191952 11/22/2010 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV CHECK AMOUNT: $2,168.71
101 N SENATE AVE
CHECK NUMBER: 191952
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 11/22/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 106.88 OTHER EXPENSES
1125 4110000 498.69 FULL TIME REGULAR
1301 4110000 1,563.14 FULL TIME REGULAR
133438 -1. INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll free 1- 800.891.6499 Marion County 232 -7436
STATEMENT OF BENEFIT CHARGES (FORM 535)
CONFIDENTIAL RECORD PURSUANT TO IC 22- 4 -19 -6, IC 4 -1 -66 page 1
CITY OF CARMEL ACCOUNT/
ATTN CLERK TREASURER LOCATION NUMBER 133436 -000
ONE CIVIC SQ REPORTING MONTH OCT, 2010
CARMEL IN 46032 -2584
NET CHARGES 2,168.71
POSTING DATE NOV 2010
The receipt of this statement (Porte 535) does not reopen the question of the claimant's eligibility for
unemployment insurance since, before any payments were made the employer had the opportunity
and the responsibility to report any information which could disqualify the claimant.
SOCIAL PA0 FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME I DATE LEVEL DATE ENDING ACC] CHARGED
THIS IS NOT A BILL OR A REQUEST FOR MONEY OUE TO THIS DEPARTMENT. It is a statement of benefit charges
made to your account during the "reporting" month. At the end of the "posting" month, you will receive a Reimbursable
Bill (Form 1€167) for these charges and any previous liability still outstanding.
NEW CHARGES FOR THE REPORTING MONTH 10 /10 r)
L M BREWER 12/12/Q9 EB 1.0/05/10 10/02/10 fi 14.32
TOTAL NEW CHARGES FOR THE REPORTING MONTR 10 /10 2,166.71
TOTAL AMOUNT OF NET CHARGES 2,168.71
a
f�
END OF BENEFIT CHARGE STATEMENT 10
An in the ACQ column denotes a charge resulting from an acquisition of another business.
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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 Purchase Order No.
146500 Indiana Dept. of Workforce Development Terms
10 North Senate Ave., SE 106 Date Due
Indianapolis, IN 46204 -2277
Invoice Invoice scription ate Number ar noj invoice(s) or bill {s)) PO Amount
D 1115110 133438 Benefit char
498.69
PAY ALL OL)T Michael ,11120/08
Total 498.69
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
Voucher No. Warrant No.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
498.69
ON ACCOUNT OF APPROPRIATION FOR
101- General Fund
PO# or INVOICE NO, ACCT AMOUNT Board Members
Dept TITLE
1125 133438 4110000 498.69 1 hereby certify that the attached invoice(s), or
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
18 -Nov 2010
Signature
498.69 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund