155761 01/23/2008 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: 155761
CHECK DATE: 1/23/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1 *192 4347500 NOTARY 50.00 GENERAL INSURANCE
t
i;
Do Not Write In This Box For Office Use Onl
r
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 respec fully request that I be appointed and commissioned a Notary Public. In support ofmy application, I submit heretvith the required bond,
oath of office, and fee ofFIYE DOLLARS ($5), payable to Ili e Secretary of State, in theform of a checkor money order. (Do not send currency in
the mail.) (IC 33- 16 -2 -1)
PRINT OR TYPE
I. NAME
Vo alai alurei ommisstonw' ei
ssued "soeimUtietionfl3
2. HOME ADDRESS 1 i nxbi 1 'nC�
I Number and street
City State ZIP mde
3. COUNTY OF RESIDENCE
4. Business or Employer's Name
5. Business or Employer's Address dress On V I C c Z
2 Samt city Sate -de
6. HOME PHONE (ol) �tf'7' I V OFFICE PHONE
LL
Arm Cdde I Number Area Code Ntuaber
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 information.
OLD:
NEW:
9. NOTARIAL OATH
STATE OF INDIANA SS:
COUNTY OF
County in witien lo is odm inisteral
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 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, help me God (or under the pains and penalti of
perjury).
IV
Sigutme o applicant
PtaceofLcces Seal Here Subscribed and swom or affirmed to before me, this day of 'J t-( c7 1 z,
�.D. 20 IN TE IMONY WI�REOF, I,
Pr ntodo typed rte ofoQ err
C forthe
Sigiiotun: ofanotaryyu lie or other olricer. orisd dminister oaths Office
County of State of Indiana
Of6ars warty ofresiJma
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 #10.
y
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we as principal
Name oCApplieant
of
(applicant) and Name of Surety
and County as
street address, city, star &ZIP 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 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 ove obligation to be null and void, 0the se to remain in full force and virtue in law. The term of this bond is from the effective
date of the p i cipal's commission the piration date f the same.
ignature ofapp cant. test be acknowldged bdowtn Ntl Signature of surd y. Must beadtnawledgedbelowin Hit
tii. AC OWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
c
STATE OF �tGf r cz vl c COUNTY OF #"Z iL1 1 (�O %l SS:
County in which adrnow m is ledgeme being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk etc) personally appeared
yo o C and acknowledged the execution of the foregoing bond for the uses and
Printed "typed name 01 apphesd
purposes therein expressed, without condition or resery ation.
Place OfficcA seal here IN TESTIMONY WHEREOF, I S I C l E have hereunto set my
Printed or typed name of offic
had and official seal, t is day of ._S ari f 20
Sig2lue of riz tar A i N o e
for the County of State of fT; ey
O ccesmuntyofresidea c
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 cannot acknowledge hisArer own signature)
STATE OF COUNTY OF SS:
County in which adtnowiedganent is being mode
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
Panted or typed mine of individuals igsing as surty
purposes therein expressed, without condition or reservation.
Place Officer's seal here IN TESTIMONY WHEREOF, I have hereunto set my
Printed or typed nerve of officer
hand and official seal, this day of 20
a
Signature of oulhorizd officer office
for the County of State of
0f4cets musty ofres idrnce
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 trade
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. sigmtnreora rely
TESTIMONY WHEREOF, I have hereunto set my
Place Office is seal here IN pnntd or typed namcofoQice,
hand and official seal, this day of 20
a
sigmdum orawhorized officer office
State of
for the County of
0(Geeys musty of resrdmce
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 Coda 5 -4.
BIYLANT
www.hylant.com
GROUP
December 12, 2007
City of Carmel
Department of Community Services
One Civic Square
Carmel, IN 46032
ffrn7y: Coy
ue:
Enclosed is the Notary Public application you requested. Please complete items 1
through 8 and sign where indicated by the "X" on items 9 and 10. A notary public
needs to complete items 9 and 11.
Please return the completed application to me along with two checks, $5.00 made
payable to the Secretary of State and $50.00 made payable to Hylant Group.
(Please note these charges apply per notary bond.) Upon receipt of the completed
application in our office, we will forward onto the company for issuance.
Please feel free to contact me if you have any questions.
Sincerely,
HYLANT GROUP
'W
Sue Morlock
.Senior Client Service Specialist
Enclosure
301 Congressional Boulevard, 4300 P.O. Box 1910 Carmel, INI 46082-1910
1- 800 -678 -0361 Local: 317- 817 -3000 Fax: 317- 817 -3151
Risk Management insurance 401 B enefits,
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
00 y Purchase Order No.
Terms
0c) J�'l��Q�� 1'G Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total �J Q 0
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
I
N SUM OF
'5 Con ass l onao 6W JCo
0 60y- l q O
50 0 v L1 f rte°
ON ACCOUNT OF APPROPRIATION FOR
&L5
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
(Q 7� d 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
/8 201
P ig e d
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund