HomeMy WebLinkAbout194660 02/16/2011 CITY OF CARMEL, INDIANA VENDOR: 355319 Page 1 of 1
ONE CIVIC SQUARE MICHAEL KLITZING CHECK AMOUNT: $631.00
CARMEL, INDIANA 46032 1550 REDSUNSET DRIVE
BROWNSBURG IN 46112
CHECK NUMBER: 194660
CHECK DATE: 2!1612011
DEPARTMENT AC COUNT PO NUMBER INVOIC NUMBER AMOUNT DESCRIPTION
1125 4355200 REIMB 180.00 SUBSCRIPTIONS
1125 4358300 REIMB 451.00 OTHER FEES LICENSES
Indiana
P
143 West Market Street Indianapolis, IN 46204 C tel: (888) 526-1687 M web: www.peri.in.gov
December 7, 2010
Lynn Russell
Carmel Clay Parks and Recreation Do
1.235 Central Park Dr. E.
Carmel, In 46032
Public Employees
Retirement Form
Dear Lynn Russell:
1977 Police Officers'
an d Firefighters' Pension Thank you for your interest in Joining the Public Employees' Retirement Fund.
and Disability Fund Please find attached the actuarial survey form needed to determine the cost of
participation.
Prosecuting Attorneys'
Retirement Funo The cost of this survey will be $325.00, plus $2.00 per employee listed and
I-egi5lalors' Retirement must be returned to PERF with your completed Actuarial Survey form by
S February l,2011. If we have not received both the completed survey forrn and
payment for the cost of the survey by the February 1, 2011 deadline, we cannot
State Excise Police, process your information for the July 1, 2011 coverage date. The cost of
Gaming Confroi participation is determined by the results of the actuarial study and will be
Officers, Gaming Agents expressed as a percentage of gross payroll. The results of the actuarial study will
and Conservation be returned to you by March 31, 201. 1.
Enforcement officers
Retirement Plan Under Indiana Code 5-10.3-6-1 (b) "A governing body may include in its
1.477 and 1985 judges Ordinance or Resolution adopted under subsection (a) a determination of the date,
Retirement Fund from which prior service for its employees will be computed." The Fund's
Actuary will give you a cost based on service credited from the date of hire in the
full-time position and for service credit beginning July 1, 2011. Please note on
the enclosed Actuarial Survey form whether you want other service credit options
included in the actuarial study, (i.e. 5 years maximum past service credited).
PERF covers positions, not employees; therefore, on the Actuarial Survey form
please list all employees for each position you intend to cover. The position must
be classified as full time by the governing body, and the employee must work a
minimum of 1,000 hours per year. A school corporation employee must work a
minimum of 600 hours per year. Any position not meeting these requirements
does not qualify for membership in the PERF program.
impEm I so=
December 7, 2010
Page 2
Under PERT rules a school bus driver can receive credit for only that service as
bus driver when the school owned 100% of the school bus. Do not include any
service time when the bus driver drove a bus that was not 100% school owned.
Only those persons working for you on the effective date of your PERF coverage
(January 1 or July 1) will receive prior service credit with you, provided the
position is covered. Indiana Code 5- 10.2 -3 -1 (d) entitles a member, who has past
service in a position that was not covered by PERF, to receive credit for that
service if the position becomes covered after December 31, 1984, while that
member holds that position or another position with the same employer.
All statutes governing PERF are found in Indiana Code 5 -10.2 and 10.3. You
should be aware that IC 5- 10.3 -6 -8 requires a two year written notice of
withdrawal before any entity can tenninate PERF coverage after coverage has
been initiated. We suggest you visit our web site at www.perfdn.a for
additional information.
The PERF Board of Trustees' meeting will be scheduled in June to approve new
PERF employers joining July 1, 2011. Your governing body must meet in time to
ensure you complete the required Resolutions that must be received in our office
no later than May 1, 2011. Resolutions will be provided with the participation
cost results of your survey.
Sincerely,
Public Employees' Retirement Fund
Employer Services Department
2 ='71 5569
MICHAEL W. KLITZING 710
1550 REDSUNSET DR.
BROWNSBURG, IN 46112 DATE z l
P�K
PAY TO THE w
ORDER OF
DOLLA RS
Im ,R
CHA5E
JPMorgan Chase Bank, NA, r R. M.
Chtcago,lBinois 60670
www.Chase.com
MEMO Lcf'M C.I l-��i I
�a07 b0000 L3 2 2316 IEB5569
Indiana
ACTUARIAL SURVEY FORM
mby
Employer Information Type of Survey e.w
Employer Name:
Address- #411 1;116 tit Street Month Year
Date of Enlargement/ New
Address(cont.): Unit
Account Number:
Contact Name:
Y.
Phone No.: .17= 571.4019:�:�::
Fax No:
,.Email address:
Employee Name (Please Print)
If position will not be Filed on or before January or Present
No, July 1, please Leave name blank. SSN4 Complete Position Title Gender Date ofBirth Date of Hire Annual Salary
Present
Salary
]12 r y
:14CA statit::-X
2 Purcltasin :Cooid+nator... 813111 31172071
6 k4
5 Shaw'A H
aft:
1 T2/227 :11112011
7 17112011-
8 X '30L 1
9 X-� :M I :':5/250jM: 11112011
610
10 t4iit&a -AQ X7 610 J: j1l/2Q11
8
12
11 I 2011
13 rl: R. u's i d
14 :Coljjtne yL
15
402
16 Jfvliocta: Sifilin lesin g
::AA/201 1::
,17 4AW.
7 :11112021
Enter Past five (5) years salary on Page 2 for all employees
Actuary will provide service cost results for all past service credited and no past service.
Please note below if you would like additional options.
Notes:
—y i7r! 0
Revised 3118108
oee�i�ut� Pagel of 2
PEi�F
ACTUARIAL SURVEY FORM
Alt atiaded4i6S::ntust:be:ff:lled; iaaiy; E;ritploj er.:
Employer Information Type of survey New Unit
Employer Name: C:ertnellClay:Board:tif:Facls afid
.....I
Address: 1411:: E: 1: 1. 6:: theStreet Month Year
Date of Enlargement/ New
Address(cont.): Unrt Julya. 2�
13
Account Number:
Contact Name: L. nI1:RuSSe11
Y
Phone No.: 3:17= 573: 40:19
31 T
Fax No:
Email
Email address:
Employee Name (Please Print)
If position will not be filled on or before January or Present
No. July 1, please leave name blank. SSN# Complete Position Title Gender Date of Birth Date of Hire Annu#,balary
1 Joshaa 1'a .lor: 146rti:eulturalist
2 A1ar[d:�Ve §cernieier:
Diiector: M' ::::5
3 San
fflce Adnritilstrafor::::: F 9/4/.
2 j
4 Liiitla: AcoSta:::::
AdaItiIistrativ:c �sslsiatic: 'F: 1
>]d- I .1/ 6 1
Sifc: u ere ^isoi::::::: F 12110 >::111.1 20
5 Amx B9lifaiif S
6 3e6sica:Balliii er< Asst ::Siic:Sii ervisoi
E:::: »6126f1
7 ;letitiite� Blown:::::::::• ilsslstatif ana' e
F .:::..3/307 171130.1:l:::::::
8 7iffa'ti Buckin' Hate: Sttc;SU 'erwtor F 8/81;1 l ll' /2011:
9 C� nthia Canada:: Sate: Su ervisoi :1 11;129_ 1/11 :1::
10
ka:
�1ssf::Site:Sti ::::E;:... :9128. ":1;11:/2011::;:::
e sfca... ants
1 I 11 [ca :tiri l7ecker..:: `'Site:Sti' erviso'r' 8......
Asst :Site:Su' sill o'r::' :':'':'D1:' 42/2571 1!2011::::
1_ la.iries:Dg1ie11:;::
5...........
13 Ceo' iariria: Edwards:
Site:Su'.CM$017: :I a:j197 ::1/1:12011:::::
14 3eilgifeFlr tnniorts
5ife:Su t3rwt §or:::::::::: I? :::::::.7119 1 /r /2QY G;:
I S
Asst::Siic:Su 'crwislir: E':::: T12b7: <7/t12011;:
i ::Sife:So ervi §or:::: :7/T51 11112Q11
Sha�otitie...... 1
17
18 Bear amid: 3ohusoii:
Enter Past five (5) years salary on Page 2 for all employees
Actuary will provide service cost results for all past service credited and no past service.
Please note below if you would like additional options.
Notes:
All:eM 10 ees;cur�entlypBrtiCipate;iJnt 0 the; City:of:Carrhel:;:Will;continue to:patticipate:under Gity_of Carrhel;:thiaUgh:6130/20.
Revised 3/18108
9roaiitamlo Pagel of 2
ACTUARIAL SURVEY FORM
All:shaded areas, m... l.....l... Y :Etiiployer.
Employer Information Type of Survey NeW UC11t
.Employer Name: Caeitlel /Clan hoard of:Parbs and:Recreattnn
Address: 141:1 E 116, th Street f Enlargement/ New Month Year
Date o
Address(cont.): Unit W
Account Number:
Contact Name: l ynn. Russell
Phone No.: 3a7= 573: 4019:
Fax No: 3'17- 571: =136
Email address: LttJ5Ses11 c(ilC�trrtielCl�V(y2rk.GOrtt
Employee Name (Please Print)
If position will not be filled on or before January or Present
No. July 1, please leave name blank. SSN# Complete Position Tide Gender Date of Birth Date of Hire Annual Salary
1 Aslzle'a<<in stori FxssC- Sltx:S[i ervisor:::: ::7%29f 1111201'l
2 N$tslie:l ive.. Slte St;.' ervisor k 9121T 111 72011:::::
3 Ke[se :1Vl ler ..As5CS1te:Su ervisor. F 218%1 1Y1120I1 A
4 Jacdb:Moore Asst Site Su ervis8r: \I 612511 1412011:.
5 F1fil,ees i3rtiie:l?iuman 'Site:Su 'er4iso'r F. 4/27P 1Y112011 A
6 3essiea.Richacds Asst'S Su 'ervisor: E: 10121 %1 11I(2011::.::
7 Vicki.Rubio Asst:Sifc:Su ervisor F 87157 :IJ1 /2U31::'
8 V.alcska Siititiititids. Site $n: er vxsor :E 5124/. ::171120:11:: S
9 Dod IasSixel[in AsstSite:Su ",crvtsor `'N[; 41207. 1 /11201:1::::: :S
7 AsstSitc.S'ri cr�isor:, F: .::6WM "'1!I /2021: '1
Recreat►on:Su ervisdr F :6/207:
12 Lindsay AtiunsPn
:lrecreat olr$a ervtstrr :F.. 5/.7JI 171/2Ql I
13 �Kurris 32aun1' arfliFr: I2ceroakiolR Nlana er:. 1 ::71x31'1 7!1:120ta
14 Su0n Bcaara itecceation:>)lvisianl :dita ci G: 511Of1. ::1E1/2022:.:
15 Sarab:Carltrt
to S' ec ►al E�'encs:Su ervisor f ::q /207:►. 1/172Q:11:
16 :NI cb6ll6Com n::'.: :F.00d Service §:1vl ltia er E 1:0/21172. 1�172QG1:;
17 8 1W .a Cstriie Kea•vcne A uatics 1�1anO er::. 313071
I p' I e' e' Recreatio»:Su etvlsor 111:::::::1111$11 :1111202]
llaOw L b. r p
Enter Past five (5) years salary on Page 2 for all employees
Actuary will provide service cost results for all pest. service credited and no past service.
Please note below if you would like additional options.
Notes:
Revised 3/18108
Indiana Pagel of 2
PFRF
ACTUARIAL SURVEY FORM
Alt sh d d:arehs roust tte ffilled ,n b.j mp]oyer
Employer Information Type of Survey 1Ve:
Employer Name: Carrne'VCla:y Board of Parks and Wer eat i6
Address: 141a E 1:16 th Street f Enlargement/ 1\ew
Date o Month Year
Address(cont.): Unit ,Ia[lY
Account Number:
Contact Name: L ynn. Russt?II
Phone No.: 317373._40:19
Fay No:
Email address: Ltti55ollatl7ielclaVgatks. corn
Employee Name (Please Print)
If position will not be filled on or before January or Present
No. July t, please leave name blank. SSN4 Complete Position Title Gender Date of Birth Date of Hire Annual Salary
aiilliant Loval6 R9aiittenctYnce T.ectii►ician' M 6Ti4ll ahf ?01:1
z ErlcNletif:
SHbii:Lessait Stt ervi sor:: M. :2128/1 1(3/2011::::
3 1aanlNercao t54anio Nlalnteneadce TeeluiIClalt :N1 ?04A SY11201'1
4 �fiiaa AssE.I ZCrtatan Sri ery St)r: h7: :G /3f1 iJMon:::::
5 "i'3mata PowrU Assf"Recreatbit:Su ervisor F 7/2111 11112011:
6 3amei Rattsford:::: lt49intencance:Teclroician.. 341: 8124( :1/1/2011::::
7 ministcative Asst.: F 412f19 '1J113011
ATOrid ..5 adti
8 B'rookeThFflm ei
;Inclu3ioir -Sri ervisoi:: •.E: 813711 111x2011:::::
Ass t
1lydce "Catlin 'er ;Recresttoo Su ervisor M;: 10130 ax1120L1
9
10 l ind &a Wdfard. fitness Sti ersuoK::: 'F: 21i9L1- 1;!1/2011::::;::
I1
I2
14
15
]6
17
18
Enter Past five (5) years salary on Page 2 for all employees
Actuary will provide service cost results for all past service credited and Wpast service.
Please note below if you would like additional options.
Notes:
Y P.
rough: 61301201.1.
ntl Blti
AMMA
All t?tr? l0 ees cltrre of 8tA tirttler the Ci3 Of CBtmel. Wi}I ciiritintie t ar..t. eY@ under Clt of Garmt 1 th
Revised 3118/08
Carme 9 Clay
marks &Recreation
Employee Expense Reimbursement Request
Date of Fund Account Account
Receipt Vendor listed on receipt Line Budget Description Amount Purpose of Expense
Online employee scheduling
1/26/2011 When to Work 101 4355200 Subscriptions $180.00 service (1 /27/11 2126111)
Actuarial Survey to transfer
payment into PERF to new
1/28/2011 PERF 101 4358300 Other Fees Licenses 451.00 payroll service
All receipts should be attached in the same order as listed above.
No sales tax will be reimbursed. TOTAL T $631.00
I',- M Employee Name (print) Michael W.Klitzing 19 9l
�v
Address 1550 Redsunset Drive 2011
Check
payable to: City, St, Zip Brownsburg, IN 46112 BY:
Signature: if Approved by:
Date: j �Z�f Date:
Business Services Division, Revised 7 -7 -08
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.
355319 Klitzing, Michael Terms
1550 Redsunset Dr Date Due
Brownsburg, IN 46112
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
1/28/11 Reimb Online em to ee schedulin 1127 2/26/11 180.00
1/28111 Reimb Transfer Pavment into PERF to new Pavroll service 451-00
Total 631.00
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.
355319 Klitzing, Michael Allowed 20
1550 Redsunset Dr
Brownsburg, IN 46112
In Sum of
631.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE N0. ACCT #fTITLE AMOUNT Board Members
Dept
1125 Reimb 4355200 180.00 1 hereby certify that the attached invoice(s), or
1125 Reimb 4358300 451.00 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
13 -Jan 2011
Signature
631.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund