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184098 04/13/2010 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND 0 CHECK AMOUNT: $882.50 CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK a NOBLESVILLE IN 46060 CHECK NUMBER: 184098 CHECK DATE: 4113/2010 DEPARTMENT AC PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 40110 882.50 INSUR /COBRA REIMBURSE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Apr -10 Donald: Medicare Part B $96.40 Amount due for April 2010 Humana Choice PPO 73.00 Dental 59.12 Total Don 228.52 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 1,038.24 85% 882.50 Portion paid by City 15% 155.74 NMI You 2009 Monthly Premtu ms for Medficare Part A (Hospital Insurance) Monthly Premium Most people don't pay a Part A premium because they paid Medicare taxes while working. You pay up to $443' each month if you don't get premium -free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly Income Is You Pay File Individual Ta Re turn I File Joint Tax Return $85,000 or below $170,000 or below $96.40' $85,001- $107,000 $170,001 $214,000 $134.90' $107,001- $160,000 $214,0014320,000 $192.70' $160,001 $213,000 $320,001- $426,000 $250.50' above $213,000 above $426,000 $308.30' Note: If you get a monthly benefit payment from Social Security, the RRB, or the Civil Service, you must have your Part B premiums deductec from your monthly benefit payment. If you don't get any of these benefit payments and choose to sign up for Part B, you will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179 -0355. If you get a bffl frorr.'. the RRB, mail your premium payments to R.RB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197 -9024. Part C :ion Drug Plan) Monti MEOICA IE HERETO INSURAIWE 800 633 -¢2z7) plan premium. Conta 1- 8 0044EDICARE rdAME0F6EtJERCKRY You J don't get it D01VALD:. ,i I CLEVELAND age is added .to your pre" ✓1EDICW CLAIM m 6MsS SEX Part C EROVE DATE preen WI SPITAL WART A) 11-0 1f yo �E A (PART B) 11 -0'1 -200 higher. I SIGN ERE 0� HERE V P Page 1 of 4 tttt® PROFESSIONAL Account Summary for Period Previous Balance $949.03 March 7, 2010 April 6, 2010 Payments Credits $949.03 Total Credit Limit $7,000 Purchases Cash Advances $882.72 Cash Limit $3,500 Other Charges $0.00 Available Credit $6,117 FINANCE CHARGES $0.00 Portion Available for Cash $3,500 New Balance $882.72 The Cash Limit is a portion of the Total Credit Limit. 'Minimum Payment Due $17.00 Payment Due Date May 3, 2010 Good news! We will no longer assess a $19 Inactivity Fee on your account. The elimination of this fee is effective immediately and modifies section 15 of your Card Agreement. Transactions Questions? Call Us Customer Service TRAN POST DATE DATE REFERENCE NUMBER DESCRIPTION AMOUNT 1.800.972.3030 Payments &Credits 04/01 04/02 7126 MAIL PAYMENT BRANCH CINCINNATI OH $949.03 Send Payments to Fifth Third Bank Purchases, Cash Advances Other Charges PO BOX 740789 03/30 04101 00903182 ANTHEM BCBS INS PMT IN 866- 649 -2034 OH $809.72 Cincinnati, OH 45274 -0789 04/03 04 /05 00936225 HUMANA HEALTH PLAN INC 800 992 -2551 NC 73.00 Finance Charges Please see reverse side for important information Send Bi Inquiries to Days in Current Billing Period 31 Custome r S Service MD 1 MOC2G -4050 Outstanding Average Daily Monthly Corresponding Periodic Balance Balance Periodic Rate Annual FINANCE 38 Fountain Square Plaza Percentage Rate CHARGE Cincinnati OH 45263 Current Purchases' $882.72 $0.00 1.33250% 15.99% $0.00 Current Cash $0.00 $0.00 2.08250% 24.99% $0.00 Total Transaction Charges: $0.00 z 8 Total FINANCE CHARGES: $0.00 8 Finance charges incurred using 'Method 1 or 2 Method 2 `Periodic Rate may vary 3 m v Please write your account number on your check m ade payable to and mail portion below in return envelope. Street Apt.# �r�rr�r��n��rrrr��n��nn�r�n�n�n�r��rnlr�n�rrt��nr��� DONALD H CLEVELAND 0039176 City State Zip 141 STONY CREEK OVERLOOK Home Phone Alternate Phone NOBLESVILLE IN 46060 -5427 Account Number New Balance $882.72 Minimum Amount Due $17.00 Payment Due Date May 3 2010 Total Enclosed ANTHEM BOBS IN INDIVIDUAL INDI -MB1 KY0303A645 009849 1351 Wm Howard Taft Anthem G V Cincinnati, OH 45206 -1775 Au nrtlelxnllenl J---f the Blnc C- -ail BI, 1, SlothI A I.., Anthem 111uc C,— Bluo Shield is lhr...k n.— of tllc Anlhcullnvuvk•e Cou,wni., Inc. ®f2egislerr l mirky ]fiat Crnss -d Blue Shield Assrx..— IDENTI+ICATIOiN #:018M62629 hJ 11JU IVBL240d'I INWI7 '1A59 ul Due Date: 04 -01 -2010 IIIIIIIiI11111rIrlLrrllrllrlrllrll did IIIlrllrllrllrllll oil ll Billing Date: 03 -10 -2.010 #BWNCQXF Coverage Period From: 04 -01 -2010 0 #AIM0000000000DS0 #INDI -MB L KY{)303A645 Coverage Period Through: 04-30-2010 CIO Cleveland, Barbara L 141 Stony Creek Overlook Total Amount Due: $809,72 Noblesville, IN 46060 -5427 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in making your payment over the phone? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your payment. Please list your 9 -digit Identification Number on your check, include the lower portion of this page and mail to the address specified. If you pay by check, Anthem Blue Cross and Blue Shield charges a "Non- Sufficient Funds" (NSF) fee of $20 for returned, unpaid checks. IMPORTANT NOTICE: 11' you have received a reminder notice from Anthem regarding a past due payment, this bill includes all amounts that. you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amount. Due listed on this bill must be received by the Due Date. Anthem's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay premiums in a timely manner. Payments recently madcd may not be reflected. D A R ETURN "PHIS SECTION WITH Y-OUR-PAYMENT -.DO NOT STAPLE MAKE CHECKS PAYABLE TOANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barbara 1, AND MAIL TO THE ADDRESS BELOW Subscriber 11) From Date Through Date Due Date 018M62629 04101/201.0 04/30/2010 [14/(11 /211111 Amount Due Amount Paid p $809.72 30 72— Unit No. 002 INDI -MB I I rlllrlLlr1111rrIrrllr llrlLlrrllrllrlrllllllllrllrlrrllrllrl ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 40019541400000182262629704012010 00000809720025 Si necesila ayuda en espahol Para en.lender este documenlo, puede solicilarla,, a sin costa adicional, llamanclo al numero de servicio al clienle yue aparece al dorso de su tarjeta de idenli caci6n o en el folle de inscripci6n. Invoice 065548282 PRIOR BILLING PERIOD COVERAGE FROM 03/01/2010 THRU 03/31/2010 Previous Total Due $809.72 Payment Received on 02/25/2010 ($809.72) Outstanding Balance as of 03 -10- 20,10 $0.00 CURRENT PERIOD COVERAGE FROM 04/(11 /2010 THRU 04/30/2010 Plan 1.1 $809.72 Current Period Total $809.72 PLEASE PAY THIS AMOUNT $809.72 ibl3li1Nl ?I/llil3 ©INl) 00009899 000065548282 • Manage Accounts Credit Card Account Activity Page 1 of 1 Account Balances Account Nicknames AN 9 Acc ount Activity Welcome, DONALD H CLEVELAND Thursday, April 82010 Account Activity 1 Account. Summary Account Statements Export History Account: Statement Period: Current Statement Posted Transactions ( Advanced Search: Keyword: Posting Date Tr ansaction Date Depit( Credit(_), Description Action 04/07/10 04101/2010 $72.53 CBSA MINNEAPOLIS MN Transactions and other information that appear on this page have occurred since your last statement cycle date. Please select another statement period to review previous account activity. I Disclosure /Error _Reso Copyright 2010 Member FDIC, L�t Equal Housing Lender, All Rights Reserved Contact us I Service Center I Help I FAQs I Privac Securit https: /www.5 3.com/servlet/efsonline/ account- history.html ?Trans S ortCode= DATE,REVER... 4/$/2010 hCttt Associates Insurance Em la ee Bene tt S ecialL tc Health -Li e- Disabilit� Annuities -4011 Is 2929 E. 9h` Street, Suite "C's Indianapolis, IN 46240 Phone 317 574 3805 Fax ,317 574 3809 Check us out at our Web Site: InsYruuphealth.com March 5, 2010 Dear Don Cleveland, Your Present P remietm Rates: DENTAL $52.90 /mouth VISION $13.41 /month Total $55.31 /month April 1., 2010 Renewal Rates DENTAL $59.12 /month YXSIDN= $i3.41lmonth Total $72.53 /month Call ifyou have any questions. Thank yotc Sincerely, 4 Hunt Associates Insurance Financial Services Employee Benefit Specialists 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. n Payee /dh Cf"� /C/' /C�/ Purchase Order No. 1'l Terms L/G o 6 o Date Due Invoice Invoice Description Amount Date L Number (or note attached invoice(s) or bill(s)) FEZ _.SD d t' r Total f�i2 -SO 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 ,VOUCHER NO. WARRANT NO. nn ALLOWED 20 IN SUM OF ON ACCOUNT OF APPROPRIATION FOR 9a2� Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 9" :Z yv /�o y3��s��2.5o bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Director of R-AmmInnm—f ignature Cost distribution ledger classification if Title claim paid motor vehicle highway fund