HomeMy WebLinkAbout194637 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: 279200 Page 1 of 1
ONE CIVIC SQUARE INDIANA SECRETARY OF STATE
(9) CHECK AMOUNT: $10.00
CARMEL, INDIANA 46032 NOTARY DEPARTMENT
ROOM 201, STATE HOUSE CHECK NUMBER: 194637
INDIANAPOLIS IN 46204
CHECK DATE: 2/16/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1192 4347500 10.00 NOTARYS
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 Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, indiatla 46204: Telephone: 317 -232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request/ that I be cgipoiwed and commissioned a Notary Public. In stippori of my application, I submit herewah the required bond,
oath of office, cad fee of FIVE DOLLARS ($5), payable to the Secretary of Sycite, in theform of a check or stoney order. (Do not send currency in
thenwil.) (IC 33-16-2-1)
PRINT OR TYPE r �p
14 NAME NICROL�S p M
Your I %R I signa tare i n Much comneiss ion will be issued s cc mslruct ion 713
2- HOME ADDRESS I S� AJ PE wo y
n Number ,aid s ricer
Cay State f 60� Gi
3. COUNTY OF RESIDENCE O I0-0N j LIP code
4. [business or Employer's Name -O! OR-AfL
5. BusinessorEmployer'sAddress A C&-SO
Sim[
City Scale ZfP rode
6. HOME PHONE 317 5 33
9M OFFICE PHONE 5�1 -2N$9
Are r Code Number e \ren Code
7. If you have a current 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 i nfonnation.
OLD:
NEW:
9. NOTARIAL OATH
STATE OF INDIANA
COUNTY OF OAmj LTV SS:
ounty m u• ,c oat r 35 minrslt:r
do solemnly swear (or affirm) that l 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 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 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 the pains and penalties of
perjury).
Signature of applicam
Place officer's seal Here Subscribed and sworn or affinned to before me, this day of
A.D. 20 IN TESTIMONY WHEREOF, 1,
Prartrd or typed name arofricer
a for the
Signa rue of a notary ptrbl¢ arot her o0rca authorized io administer oaths Of7iee
County of State of Indiana.
Off cc es man ty of resider cc
My commission expires:
NOTE: The Bond Form, starting with 10 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #1 Q
IO:- NOTARIAL BOND
KIN OW ALL BY THESE PRESENTS, that we NmRot4s
as principal
tt';mlc ofApplicam
(applicant) and
of
Name of Surety
ress, city siWe h Z3 P code
and County as
Sreet a
freehold or corporate surety, are h an firmly bound unto the State of Indiana, in the penal stun of FIVE THOUSAND DOLLARS (55,000), the
payment of which, well and truly to be made, we bind ourselves, out 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 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 of this bond is from the effective
date of [lie princi I's commission to the expiration date of the same.
Signaure ofapplic.ml. Must be acAnowl edged bet mvin #il Si9nature0fsurt7y Must be acknowle dged be low in 412
II. 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 which aciknowltdgemea[ is being,
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Nolar)i Public, Count), Clerk ele.) personally appeared
N ICHOLAS F- S kf-K and acknowledged the execution of the foregoing bond for the uses and
Printed er typed name of applicant
purposes therei It expressed, without condition or reservation.
Place Officer's seal here IN TESTIMONY WHEREOF, I have hereunto Set my
Pdntedor typed
n;uneofo�cer
hand and official seal, this day of 20
a
Signature of mnhorued officer office
for the County of State of
OfGccfs cvunly afrrs rdcncc
My commission expires:
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporale) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENT& (NOTE: The officer crrn /lot acknowledge Iris //ter orvn signature)
STATE OF COUNTY OF SS:
County in winch ac{<nowtedsnncnl is bang mxlc
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Note y Parblic, Count) Clerk, etc.) personally appeared
Primed or typr:d nor me of tndivi duals rgnmg its surety 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
P n nted or typed nain e of olncer
hand and official seal, this day of 20
,a
Signmure of mtl1tonzal officer office
for the County of State of
or s tounl y of its idcncc
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County in witch acknow hdgemenl is 6cing 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 S over and above all
encumbrances and exemptions.
Signaturenf surety
Place Officer's seal here IN TESTIMONY WHEREOF, I Pri nle have hereunto set my
d or typed n;mieof olrttri W`
hand and official seal, this day of 20
,a
Signor ure of wnhonzedn itzr offrcc
for the County of State of
Ofricet'smuatyorresidrnce
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.
Do Not Write In This Box For Office Use Onl
Commission 9 Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STA'T'E 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
I tespec fnrlly request that I be appointed and commissioned a Notaty .Public. Inn sttppory of my application, I submit herewith the requiu•ed bond,
oath of office, curd fee of FIVE DOLLARS ($5), payable to the Seeretar)f of State, in thefw•m of a check or monq� order: (Do not send vto in
the mail.) (IC 33- 14 -2-1)
PRINT OR TYPE
I. NAME L Z/ 5 77J' A OA.) LJK Lt U
Your l egaI signature in Idlich commission wl be iss s ee nistrtmlion 03
2. HOMEADDRESS IOJO .GZ� AVL-
Number md street
City Stare ZIP code
3. COUNTY OF RESIDENCE
4, Business or Employer's Name LTp��
5. Business or Employer's Address f 1�
t
,C) CiIY State code
6. HOME PHONE 7�i'j) �C�6 OFFICE PHONE {_3)Z) 7
rea Code Nmnber ea Cade
A
Number
7. If you have a current valid notary commission, show your expiration date: Ar
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 SS:
COUNTY OF
ountym,v re oaullswinimistere
I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of Indiana; that i am duty
qualified to hold office under [lie Constitution and laws of the State; that I am 18 years of age or over; that 1 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 the pains and penalties of
petj ury).
Sigma ire of aypi icon
Place Officer's Seal Here Subscribed and sworn or affirmed to before me, this day of
A.D. 20 IN TESTIMONY WHEREOF, I,
Primed or typed name ofollicer
Signature of a nol:rry yuhlte oe other odieer authotimd to administer os hs a for Offico
County of State of Indiana.
Offi ccrs min ry of residrn ce
My commission expires:
NOTE: The Bond Form, starting with 10 on the back of this application, must be completed before ilia iting to the Secretary of State.
The applicant must sign again in #10.
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we Z �j L l� ,J as principal
N:vne
(applicant) and of
Name c f s we ty
and County as
Sired Liddreas. city, slate ZIPeode
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 IS 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 of this bond is from the effective
date of the principal's commission to the expiration date of the same.
Sig A reofapplicant. usibemJ edbelowin #11 Signalureefsurt-hy. Muslheacknowtedgedbelowin #12
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEN'IENTS.
STATE OF COUNTY OF SS:
Couniy in which acknow3e dganenl is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Nofary Public, County Clerk, etc.) personally appeared
Lx z qoe nt A �p- u L L T- and acknowledged the execution of the foregoing bond for the uses and
Printed ortyped name of applica,)t
purposes therein expressed, without condition or reservation.
Pla Officer; seal here IN TESTIMONY WHEREOF, I have hereunto set my
Pri nud or typed heroc of officer
hand and official seal, this day of 20
,a
Signtame of authorized officer orrice
for the Comity of State of
Orricees coumy ofrwidence
My commission expires:
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehoid or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknoru( edge Iris /her own signature)
STATE OF COUNTY OF SS:
County in whieh acknoMedgemem is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
and acknowledged the execl.ltion of the foregoing bond for the uses and
P d pled m typed name or iudivi dual signing as surely
purposes therein expressed, without condition or reservation.
Ptace Office I's seal here IN TESTIMONY WHEREOF, I_ have hereunto set my
Pnnled or typed niche of oMter
hand and official seal, this day of 1 20
,a
Signal ate or authorized of imr office
for the County of Stale of
Officers county ofrrsidnice
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County in which acknowledgement is 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-
Place Officer's seal here IN 'TESTIMONY WHEREOF, I have hereunto set my
Pn hied or typed name of orTcei
hand and official seal, this day of ,20—
signal4rt ofaaihorized n rr office
for the County of State of
Oniicces county ofrtsidenee
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
Secretary of State's Office
Notary Department
IN SUM OF
Room 201 State House
Indianapolis, IN 46204
$10.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
I hereby certify that the attached invoice(s), or
1192 I 43- 55100 $10.00
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
Monday, February. 4, 2011
L •Y!(
U 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))
02114/11 Notary dues: Nick and Beth $10.00
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