HomeMy WebLinkAbout228868 2/5/2014 CITY OF CARMEL, INDIANA VENDOR: 00350917 Page 1 of 1
ONE CIVIC SQUARE KIM ROTT
sCHECK AMOUNT: $400.00
CARMEL, INDIANA 46032 1303 HOLLYCREST DRIVE
BLOOMINGTON IL 61701 CHECK NUMBER: 228868
CHECK DATE: 2/5/2014
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
301 5023990 400 . 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:
Kimberly Rott
1303 Hollycrest Drive
Bloomington, IL 61701
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
Kimberly Rott Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
$400.00
02103114 2.03.14 Healt Savings AGGGunt Incentive
Total
I 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 NW03/14 WARRANT NO.
ALLOWED 20
Kimberly Rott
IN SUM OF $
1303 Hollycrest Drive
Bloomington, IL 61701
$ $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 $ oo.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