167091 12/17/2008 CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP
i`. ice'to CARMEL, INDIANA 46032 P o BOX 1910 CHECK AMOUNT: $50.00
CARMEL IN 46082 CHECK NUMBER: 167091
CHECK DATE: 12/17/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
209 4347500 BENNETT 50.00 NOTARY BENNETT
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Do Not Write In Ibis Box For Office Use Only
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4
Commission Expiration Date ofNew 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 1 be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FITS DOLLARS ($5), payable to the Secretary of Slate, in the form of a check or money order. (Do not send currency in
the mail.) (IC 33- 16 -2 -1)
PRINT OR TYPE
1. NAME A m2 A A. Ca. 6za 1 et+
Yowlegal sipaare u7u dt cmwdssian wdl be ismd -sec msvaomn 03
2. HOME ADDRESS -5 1 h N I�, l P 2
11 ba aid seta
_TnG;Gr1/�QD�IS
city Sty ZlP coda
3. COUNTY OF RESIDENCE M 0 f 1 0 YX
4. Business or Employer's Name t +.J L Me
5. Business or Employer's Address I\ t? t 1'Y I L 561 are (,Af nn! e) i
sat I Gry Sbta ZIP sole
6.. HOMEPHONE 061e) 7 R- r�Q OFFICE PHONE 57Z c� y
am code rMumat A= Code r
7. If you have a current valid notary commission, show your expiration date:
N!�
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: N Ar
NEW:
9. NOTARIAL OATH
STATE OF INDIANA SS:
COUNTY OF
t'owly in w u C56>3+iF m61
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, so help me God (or under the pains and penalties of
perjury).
Signature of applicant
f*
ptaa oif:eets seal Freir
Subscribed and sworn or affirmed to before me, this �day of� B�
A D. 20 IN TESTIMONY WHEREOF, I, A E-Al l f4 S S
P ar a mme orolLmr
Cx 7XC�P.it Q a N 0 1 141" !f Gl Z JC for the
Signanne ore m�er p eer audeaadbadmmvae aaahs tie
County of �/�1 State oflndiana
`6.� 1 OfSoetsaamy s¢
y My commission expires f"1 r z( of 'd f::�
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.
r
r 10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that �Ne as principal
Name of ADpttcattr
1 (applicant) and of
ettne of Stttery
and County as
Beet addn:ir, city, state Zffc
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 ofNotary 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 r opal's commission t the expiratio da of the same.
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garret ofopp &at. Must be ar.Uwdedgad belawam 411 5gumeor=cry. Mart bouk— ledged below in 412
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF A Q2¢ "A• COUNTY OF �1 AM L T n �J SS:
Cramp• to Vfteb adMMAl dgemcotis baag made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk etc.) personally appeared
A M A f} Q A 13 E__ 4N L and acknowledged the execution of the foregoing bond for the uses and
rented ortyped nameof appbcafl
purposes therein expressed, without condition or reservation. p
Place o'fftcct': scat berg IN TESTIMONY WHEREOF, I t7 CZ/� //yL /t S-S have hereunto set my.
n PnntodwWpcdc
hand and o fficial seal, his da f 6'C e b
tgmm�ro oft ott;acr y afbce
forthe County of M/r Stateof -f-W l A)A
lhc.rso ofmidmeo
Mycommissionexpires: C_ Sol&
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge hivherown signature)
STATE OF
COUNTY OF
Cbtmrywwhtcb awledgtments brag made
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 ortyped aameaf indM dud aegemg as stuay
purposes therein expressed, without condition or reservation.
Place Offa:ot?s seal here IN TESTIMONY WHEREOF, I have hereunto set my
Panted o< nmmeof'affita
hand and official seal, this day of 20
a
S47ur a of and oozed afftmr al6ce
for the County of State of
Ot6cola muatyo ratdmcc
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County is which wkrmwielgement >s being amdc
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. signameof waxy
Place Offi=A seal bem IN TESTIMONY WHEREOF, I Pad or have hereunto set my
ttm typed aameof offtea
hand and official seal, this day of 20
a
tg==of mUrized oWS r
for the County of State of
Officals mtmtyo raidmae
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.
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Prescribed by sate 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.
Hylant Group of Indianapolis
bOl Uongressional Blvd., Suite WO Purchase Order No.
Terms
Carmel, Indiana 46082 -1910
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12 -9 -08 Notary Bond Amanda Bennett per the attached
Application Fai Appointment As A Nutaiy Public
in The State Of Indiana
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.
r-
ALLOWED 20
Hylant1 -�ijrn of Indoanannlis IN SUM OF
501 Congressional Blvd., Suite 3 00
Carmel, Indiana 46082 -1910
50.00
ON ACCOUNT OF APPROPRIATION FOR
DEFERRAL FEE FUND
430 -47500 General Insurance
Board Members
DEPT. INVOICE NO. ACCT #/TITLE AMOUNT I hereby certify that the attached invoice(s), or
209 $50.00 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
20 OZS
re
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund