HomeMy WebLinkAbout194622 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
0 ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $100.00
CARMEL, INDIANA 46032 P 0 Box 40925
aN INDIANAPOLIS IN 46082 -4910 CHECK NUMBER: 194622
CHECK DATE: 2/16/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1192 4355300 100.00 ORGANIZATION MEMBER
Do Not Write In This Box For Office Use Only
Commission Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Relnrn to: Notary Department, Secretaiy of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 -232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notaty Public. In supporT of my application, I submit here>vith the required board,
oulh of office, rrnd fee of FIVE DOLLARS ($5), payable to the Secretcu�y of State, in theform of a check or rno+te} order (Do not send currency ill
the mail.) (IC 33 I6 2 1)
PRINT OR TYPEE 7� j� I
I. NAME r Z t /AJIU
Yourlegal signalurcii�iiichcomntission k• beisued -sce ioslruclion Nl
2. HOME ADDRESS �Io� �J'�rz �LLIDA) /L
1 .4'D.��y Q Mnn ber and snecl
Cny Slme
3. COUNTY OF RESIDENCE ZIP code
4. Business or Employer's Name
5. Business or Employer's Address LJfU L�l� 3
smrcrl
C ity Stale� "LIP code
6. xoMEI�IION> 7fs�S) ��r p,� OFFICE PHONE 3iZ) 7 L c
Area Code Number Area Code Number
7. If you have a current valid notary commission, show your expi rat ion date:
L �,20
8. If you are now a notary public and your name or county has changed since your last application, please give both old and new information.
OLD:
NEW:
9. NOTARIAL OATH
STATE OF INDIANA
COUNTY OF 1 Cryry��t1 5S:
t oiyhmnicrii muster
do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of lndiana; that I am duly
qualified to (told office under the Constitution and laws of the State; that 1 am 18 years of age or over; that I am of good moral character and integrity;
that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have
carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the ditties of NOTARY
PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of
perj u ry).
zt
Signs ure or appl icair
Placuof' icer's seat here Subscribed and sworn or affirmed to before me, this day of
A.D. 20 IN TESTIMONY WHEREOF, I,
Primed ormyped name oron'irer
a for the
S ignaune or a nom ary public. or of her oRcer aulhori zed to adrnwsl cr oaths 9lfice
County of State of Indiana.
Orfi a>'s coun ly orresidenee
M commission expires:
NOTE: The Bond Form, starting with 410 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #110.
10. NOTARIAL BOND
KNOW ALL BY THESE P RESENTS, that we b LDM ~l
I as principal
Mane ofAppl,cani
(applicant) and of
Nu me of S wely
5vent address, c Hy, stWC ZIP code and County as
freehold or corpora(e surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), the
payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents.
WITNESS our signatures as acknowledged below. THE CONDITION OF THE ABOVE OBLIGATION IS AS FOLLOWS.
TO -WIT.
WHEREAS, the above bound principal has applied for appointment by the Governor of the Statc of Indiana as a
Notary Public, in and for the State of Indiana, for a eight -year term.
Now, if the said principal shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to
law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective
date of the principal's commission to the expiration date of the same.
sigLF eru�plreanl. Xusl be ac ed bet ow I ;l Signa lure of surei y. Musi be tick nowledgcd below in d 12
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF COUNTY OF SS:
County in winch .111, m iedgcnen1 is bnng m:�e
Before nre the undersigned, an officer authorized to take tile acknowledgement of deeds (Notary l'irblic, County Cleric, etc.) personally appeared
ut )i.�� k= 7
Printed ortyped name of apphctutl
and acknowledged the execution of the foregoing bond for the uses and
Purposes therein expressed, without condition or reservation.
Place Officers seal here IN TESTIMONY WHEREOF, I have hereunto set my
Pnnled or typed n.ene of o(11ter
hand and official seal, this day of 20
a
Sign:u un: oC ;mthorized of leer office
for the County of State of
Offcer's county ofrts idc�tce
My commission expires:
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge leis /her own signahrre)
STATE OF COUNTY OF Cot SS:
Cott in whreh aeknou ^lcdgctncui is being made.
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary PubliC, Coaatl}) Clerk, etc.) personally appeared
Pdlned on yped name of indivi duo signBtn a5 surely and acknowledged the execution of the foregoing bond for the uses and
purposes therein expressed, without condition or reservation.
Place Officer's seal here IN TESTIMONY WHEREOF, I_ have hereunto set my
Pnnted ar typed n:nne of officer
hand and official seal, this day of 20
a
Stgn;u un; orautlmnud officer office
for the County of State of
Offiects county orrmidence
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County in wucb acknowledge me nl as being made
The undersigned surety, being duly sworn or affirmed, says that he /she is the owner in fee simple of Real Estate in
County, of the fair Cash Value of over and above all
encumbrances and exemptions.
Signa lure of surety
Place OFFicer's seal here IN TESTIMONY WHEREOF, 1_ have hereunto set my
P n Hied or typed mm� a of officer
hand and official seal, this day of
Sigmu we of :unhonzedofficer office
For the County of State of
onieets cnunly orrratdence
My commission expires:
For the statR€te pertaining to surety company bonds, see Indiana Code 27 -1 -22. For the statutes pertaining to Officer's Bonds and
Oaths, see Indiana Code 5 -4.
Do Not Write In This Box For Office Use Onl
Commission l# Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF :INDIANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 -232 -6542
To: THE GOVERNOR OF INDIANA
1 respeclfidl)r recIvesl (hall be appoiuled and commissioned ca Nolaay Public. M sulylvil Of'?')' application, submit herewith the required board,
oath of office, and fee of FIVE. DOLLARS ($5), payable to lh e Secretmj of Stale, in 1/re of a check or money order (Do not send currency ira
the mail-) (X33-16-2-1)
PRINT OR TYPE
I. NAME N r lcoLkS Y MrmLm
Your I ega I signature i n whi ch commiss ion will be issued see instruct ion 43
2- HOME ADDRESS is/ AJ P6 W-41
Mun ber Intl s tree t
ZAP cny �Siate Y6o32de
3. COUNTY OF RESIDENCE
4. Business or Employer's Narrle
5. Business or Employer's Address )vi a�R�- I��iQR1�lEL
Strcct City giate ZIP code
6. HOMEPHONE 3r 7 5
�N umber OFFICE PHONE (31?
Area Code N rea Code Number'
7. If you have acurrent valid notary commission, show your expiration date:
20
8. If you are now a notary public and your name or county has changed since your last application, please give both old and new information.
OLD:
NEW:
9. NOTARIAL OATH
STATE OF INDIANA t
COUNTY OF Mmi cTvP1 SS:
onmymw ;c oat ns; nvnistercd
do solemnly swear (or affirm) that 1 will support the Constitution of the United States, and the Constitution of the State of Indiana; that I am duly
qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over; that l am of good moral character and integrity;
that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have
carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the duties of NOTARY
PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under €he pains and penalties of
Perjury)-
?�t Ft
Signature of applicant
PlaceOfiicei's Seal Hcre Subscribed and sworn or affirmed to before me, this day of_
A.D. 20 IN TESTIMONY WHEREOF, I,
Primal or typed name of ofear
a forthe
Sigmfln ofanotary public or other oll ice andtori �cd to administrr oat hs OCGcc
County of State of Indiana.
0 ffi cc fs mun ry afresiden ct
My commission expires:
NOTE: The Bond Form, starting with 410 on the back of this application, nulst be completed before mailing to the Secretary of State.
The applicant must sign again in 410.
X 10. ;NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we I�tC�tO1 R$ M�SF l �{Q as principal
Mi ofApplicanl
(appl leant) and
of
Name of$umly
and County as
S Irrc1 a ddress, c uy, s rule .l'• 7, l P code
freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5.000), the
payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents.
WITNESS our signatures as acknowledged below. THE CONDITION OF THE ABOVE OBLIGATION [S AS FOLLOWS,
TO -WIT.
WHEREAS, the above bound principal has applied for appointment by the Governor of the State of Indiana as a
Notary Public, in and for the State of Indiana, for a eight -year term.
Now, if the said principal shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to
law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term ofthis bond is from the effective
date of the princ i I's commission to the expiration date of the same.
Signahrre of applicmn. Mud be xAno4 odgcd bclowin till Stgnalure of surely Musl be acknowledged 6clOw in ifl2
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF COUNTY OF SS:
Cpunry in which acknowledgnncnl rs 6cing m tic
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Nalaly Public, County Clerk, etc.) personally appeared
N ICOLAS F M I S OLF-ft and acknowledged the execution of the foregoing bond for the uses and
Panted or Typed name of applicant
purposes therein expressed, without condition or reservation.
Place Of ricers seal here IN TESTIMONY WHEREOF, I have Itcretutto set my
P n nierl ortypedmm�e of offl c,
hand and official seal, this day of 20
Signature of nud;nrized officer office
for the County of State of
OfGcerseaunry ❑fires idcice
My commission expires:
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge Iris /her own signature)
STATE OF COUNTY OF SS:
Cuumy in which acknow le dgenum rs hmng mule
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, Couno1 Clerk, etc.) personally appeared
Pri nkd S as sun: ry
and acknowledged the execution of the foregoing bond for the uses and
or lypcd name pf indn•r du.r!
Purposes therein expressed, without condition or reservation.
Place Officers seal here IN TESTIMONY WHEREOF, I_ }ta.ve hereunto set my
Ponied or typed tramepf p1I'rcer
hand and official seal, this day of 20
,a
signalure of muhorized officer office
for the County of State of
Officer's oountyofresidaue
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OFA FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County m u•hech ;cYnow ltdgement rs 6emg made
The undersigned surety, being duly sworn or affirmed, says that he /she is the owner in fee- simple of Real Estate in
County, of the fair Cash Value of over and above all
encumbrances and exemptions.
Signahire or surly
Place Officers seal here IN TESTIMONY WHEREOF, 1 have hereunto set my
P n med or typed Warn c pf offrc er
hand and official seal, this day of 20
a
Srgnmure of muhorrzcd officer office
for the County of State of
Of hers county Wresidence
My commission expires:
For the statute pertaining to surety company bonds, see Indiana Code 27 -1 -22. For the statutes pertaining to Officer's Bonds and
Oaths, see Indiana Code 5 -4.
VOUCHER NO. WARRANT NO.
ALLOWED 20
Hylant Group
Sue Morlock IN SUM OF
501 Congressional Blvd.
Carmel, IN 46032
$100.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS Department
PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members
1192 43- 553.00 $100.00 I hereby certify that the attached invoice(s), or
bills) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
nday, February 1 011
i l t 1l
3
Director, DOCS
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
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.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
02/14/11 Notary public fees: Nick and Beth $100.00
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