162782 08/20/2008 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP
CARMEL, INDIANA 46032 P 0 BOX 1910 CHECK AMOUNT: $50.00
CARMEL IN 46082 CHECK NUMBER: 162782
CHECK DATE: 8/2012008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
'1192 4347500 50.00 GENERAL INSURANCE
i
i
i•F
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, Indiana 46204: Telephone: 317- 232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS (85), payable to the Secretary of State, in the form of a checkor money order. (Do not send curre ncy in
the mail) (IC 33- 16 -2 -1)
PRINT OR TYPE
L I. NAME L; /1YIet
urlega signatureinuttich commission will be issued -see instruct ion 93
2. HOME ADDRESS i 0 Pci SS
Numbs tnd sneer
Ciry State ZIP code
3. COUNTY OF RESIDENCE cI rv1 I 14C it
4. Business or Employer's Name
5. Business or Employer's Address 01 2 C -S� a I AJ 0 3 2
street Ory state ZIP code
6.. HOME PHONE (3 L 4 6 .U c U OFFICE PHONE (31 -s' 21 4 2 c 1
Arm Code Number Area Code Number
7. If you have a current valid notary commission, show your expiration date:
6 1 2
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 c2 e4 i'3
County in wtuch om is aam a austeTe
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 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 the pains and penalties of
perj ury).
sigrwture of app!••i
Place Officer's Seal Here Subscribed and sworn or affirmed to before me, this
1� da
A.D. 20 IN TESTIMONY WHEREOF, 1, r
Prmt o come ofofltoer
a �.lafa.� (�G/ forthe
sistatum ofart9twy public m o icer authonmd to administer oaths ice
County of t 2 State of Indiana.
ats
coup y ofresidan a
My commission expires: M7 4, 201
NOTE: The Bond Form, starting with 1110 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in 410.
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we as principal
Name ofAppkam
(applicant) and of
NameofSmery and County as
Strmt address, city, state P coda
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 tQ the a piration,date of the same.
i
Signmure ofapplidam. Must be acknoul edgeirfiel owi CI A Sigoatvreofsmcty. Must beadmowkdged below in #12
11. ACKNOWLEDGEMENT OF I I 1k,AP T'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF E n t l l G C J"7Q COUNTY OF tY /r
ty in which admWedgerneW Ong m ade SS:
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Cler7; etc.) personally appeared
1 a Q i and acknowledged the execution of the foregoing bond for the uses and
Prrnte o ed namco f pphexnt
purposes therein expressed, without condition or reservation. I
Place Officees seal here IN TESTIMONY WHEREOF, I Sasar) have hereunto set my
2 Pnnted or d eo offer A
han d a official seal, this /Z l day of C/l 20 QO
a
Signal ortzed of tcer /office
for the County of State of
Of cdsmuntyofrauknce
My commission expires: �km 15,c l�o/ �Y
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer cannot acknowledge his/herown signature)
STATE OF COUNTY OF SS:
in which n owe anent is &G& ro
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc) personally appeared
and acknowledged the execution of the foregoing bond for the uses and
P4 ntd or typed name of indivi dual sig ing as mmty
purposes therein expressed, without condition or reservation.
Place Officees seal here IN TESTIMONY WHEREOF, I have hereunto set my
Pen or typed namaofo&➢cer
hand and official seal, this day of 20
a
Signatum of authoriz o tmr office
for the County of State of
f6cefsmunryofrestdexe
My commission expires
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
county in which ackmModgement s mg 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. signatmeorsurety
Place Officer's seal here IN TESTIMONY WHEREOF, I Pan have hereunto set my
or ryPed name officer
hand and official seal, this day of_ 1 20
a
Signattacofainhoriztdofficer of6ce
for the County of State of
O cels mtmty o res u
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 54.
cPrescrihed 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.
y y°
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
c7
Total
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
G o JuQ 177breJ6 Clk- -*&DO
PO. A601v-
-6 00
5 00 SP�ry d F,�
55. oo 7Y yla,-)7'`
ON ACCOUNT OF APPROPRIATION FOR
'16o
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
��q a q7 56:00 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
2
in e
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund