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COEPM3 PROCUREMENT CARD TRANSACTION SUMMARY (LOG) 08/1a/2010 8:39AM <br />Cardholder. MAST STROUD,KIM <br />STAPLES 00114538 <br />OFFICE MAX OPS <br />mouse <br />Card reader <br />Total Statement Summary: <br />Account Nbr. 6657 <br />$39.99 <br />62501 <br />011 <br />8920 <br />87 <br />$12.99 <br />62501 <br />011 <br />8920 <br />87 <br />I, the undersigned card holder, do hereby certify under penalty of perjury, that, to the best of my knowledge, the materials furnished, services rendered, expense Incurred, or <br />other item of indebtedness as charged in the foregoing bill is a true and correct charge against the City of Eugene; that the claim is just and due; and that payment for <br />these charges has not been requested or made from petty cash, department order or other method. <br />Statement Date: 08/17/2010 <br />/ <br />Cardhclddes Signature Date <br />For losVstolen cards, call: Reviewed an °A6y: <br />Tank k of America: 3057735 ` 5110 <br />Treasury Office: 68282--6 5027 Q Supervisor's Signature Date <br />ff> <br />Yv_ " <br />alg,lro <br />