317759 10/25/2017 CITY OF CARMEL, INDIANA VENDOR: L2370
ONE CIVIC SQUARE I N S C C U-ASFE
CHECK AMOUNT: $**......55.00'
:? r° CARMEL, INDIANA 46032 PO BOX 6271 CHECK NUMBER: 317759 -
+M. INDIANAPOLIS IN 46206-6271 CHECK DATE: 10/25/17
Y DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 GIBSON 55.00 OTHER EXPENSES
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THE EMPLOYEES LISTED BELOW OWE THE 2017 INDIANA ANNUAL SUPPORT FEE.
• The remittance for the Annual Support Fee must be mailed separately to the special ASFE P O Box address listed
below.
• You are not obligated to make a payment for employees/income payees listed if he/she is no longer employed by your
company. If there is an outstanding paycheck, send the amount requested from the list below while not exceeding the
CCPA limits. If an employee/income payee is not employed by your company,please complete column 3 of the list
and fax to(317)232-0290.
Please retain a copy of the completed list for your records.If additional or multiple
payments are needed,a copy of this list is to be sent with your payments.
Employer Name: CITY OF CARMEL Make Check Payable to:
DBA: INSCCU - ASFE
FEIN: 356000972 P O Box 6271
Indianapolis IN 46206-6271
Employee's Name Employee's Date of Last Day ISETS Case# Amount Amount
SSN Worked or Due Paying
Never Employed per case per case
GIPSON,BRUCE E. 304-52-6248 ASFE5585392 $55.00
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