193005 12/21/2010 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
1 ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $2,151.43
+4 CARMEL, INDIANA 46032 DEVELOPMENTATTN: ACCT RECV
101 N SENATE AVE CHECK NUMBER: 193005
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 12/21/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 NOV2010 69.42 OTHER EXPENSES
1125 4110000 NOV2010 2,082.01 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 133438 --000
ONE CIVIC SQ
CARMEL IN 46032 -2584 REPORTING MONTH NOV, 2010
i NETCHARGES $2,151.43
E
POSTING DATE DEC 05, 2010
The receipt of this statement (Form 535) d'oe's'ii'ot 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 BENEFIT PAID FOR
SECURITY YEAR END CLAIM TRANSACTION WEEK AMOUNT
NUMBER I EMPLOYEE'S NAME I DATE LEVEL DATE 1. ENDING 1 ACQ CHARGED
THIS IS NOT A BILL OR A REQUEST FOR MONEY DUE 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 1067) for these charges and any previous liability still outstanding.
NEW CHARGES FOR THE REPORTING MONTH 11/10
L M BREWER 12/12/09 EB 11 /15/1.0 11/13/10/ 0.92
y� TOTAL NEW CHARGES FOR THE REPORTING MONTH 11/10 2,151.43
TOTAL AMOUNT OF SET CHARGES 2,151.43
The following charge(s) are POTENTIAL credits to your account. A determination was made and you were found not
liable for these charges. But because you have chosen to make payment in lieu of contributions for Unemployment
Insurance, your account cannot be credited for these charges unless or until the claimants) refund the overpayment.
Your account will be credited as the claimant refunds the overpayment in full or in monthly installments.
D A HUGHES 08/20/11 REG 10/16/10 286.00
An in the ACQ column denotes a charge resulting from an acquisition of another business.
Account /Location Number: 133438 000 Reporting Month: NOVEMBER, 2010 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING A CHARGED
The following charge(s) are POTENTIAL credits to your account. A determination was made and you were found not
liable for these charges. But because you have chosen to make payment in lieu of contributions for Unemployment
Insurance, your account cannot be credited for these charges unless or until the claimant(s) refund the overpayment.
Your account will be credited as the claimant refunds the overpayment in full or in monthly installments.
D A HUGHES 08/20/11 REG 10/23/10 248.14
END OF BENEFIT CHARGE STATEMENT*
r
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., SE106 Date Due
Indianapolis, IN 46204 -2277
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
1215110 133438 Benefit charge Nov'10 2,082.01
PAY ALL,OtIT_OF 101 rper Mlchae1,1'1720 /08'..
Total 2,082.01
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
i
Voucher No. Warrant No,
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
2,082.01
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE.
1125 133438 4110000 2,082.01 l hereby certify that the attached invoice(s), or
ij 1,61 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
16 -Dec 2010
Signature
2,082.01 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund