HomeMy WebLinkAbout228869 02/05/2014 CITY OF CARMEL, INDIANA VENDOR: 366934 Page 1 of 1
ONE CIVIC SQUARE WILLIAM COLLINS
CARMEL, INDIANA 46032 651 DANIEL COURT CHECK AMOUNT: $400.00
' WESTFIELD IN 46074 CHECK NUMBER: 228869
SON�
CHECK DATE: 2/5/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400 . 00 OTHER EXPENSES
City of Carmel Employee Health Benefit Plan
Health Savings Account Incentive
The retired plan participant listed below has elected Plan A for 2014 and is eligible for a bi-
annual contribution to his or her HSA account, as authorized by Resolution BPW-10-03-12-02.
Please return check to Human Resources for further processing.
Plan Participant/Payee:
William Collins
651 Daniel Court
Westfield, IN 46074
Amount: $400.00
Fund: Medical Escrow Fund (301)
Date: February 3, 2014
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
William Collins Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
400.00
0
Total
1 hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
20
Clerk-Treasurer
VOUCHER NW/03/14 WARRANT NO.
ALLOWED 20
William Collins
IN SUM OF $
651 Daniel Court
Westfield, IN 46074
$ $400.00
ON ACCOUNT OF APPROPRIATION FOR
301 Medical Fund
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
02.03.14 301 $400.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund