HomeMy WebLinkAbout228866 2/5/2014 - F CITY OF CARMEL, INDIANA VENDOR: 00353016 Page 1 of 1
ONE CIVIC SQUARE BOB PELZER
CARMEL, INDIANA 46032 14350 WEEPING WILLOW COURT CHECK AMOUNT: $300.00
CARMEL IN 46033
CHECK NUMBER: 228866
CHECK DATE: 2/5/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 300 . 00 HSA
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:
Robert Pelzer
14350 Weeping Willow Court
Carmel,IN 46033
Amount: $300.00
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
Robert Pelzer Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02103114 02.03.14 Savings Ac-ca-unt Incentive $300.00
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
20Clerk-Treasurer
VOUCHER N002103114 WARRANT NO.
Robert Pelzer ALLOWED 20
IN SUM OF $
14350 Weeping Willow Court
Carmel, In 46033
$ $300.00
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 $ 00.00 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