167090 12/17/2008 "R. CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $50.00
CARMEL, INDIANA 46032 P 0 BOX 1910
CARMEL IN 45082 CHECK NUMBER: 167090
CHECK DATE: 12/1712008
D EPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2'200 .4355300 SCOTT 50.00 ORGANIZATION MEMBER
ti
Scott, Lisa M
From: Sue Morlock [Sue.Morlock @Hylant.com]
Sent: Monday, December 15, 2008 9:28 AM
fo: Scott, Lisa M
Subject: FW: Notary Bond Application
Attachments: pitts notary_20080805123742.tif
pitts notary_20080805123742.tif>>
Please complete items #1 through #8 and sign on items #9 and #10. A notary public needs to complete items #9 and
#11.
Please return the completed application along with a $5.00 check payable to the Secretary of State and a $50.00 check
payable to Hylant Group and return to my attention.
Thank you,
Sue Morlock
Hylant Group
P.O. Box 1910
Carmel, IN 46082 -1910
317- 817 -5162
Notice: The contents of this communication are privileged and confidential. If you are not the intended recipient
of this transmission, you are hereby notified that distributing, copying, or disclosing this communication, or
reliance on the contents thereof, are strictly prohibited. If you have received this communication in error, please
notify the sender immediately, then destroy the original and all copies thereof
i
Do Not Write In This Box For Office Use Only
Commission Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, 1 submit herewith the required bond,
oath of office, and jee of FIVE DOLLARS ($S), payable to the Secretary of State, 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 .`X-t- )Co tt
G� 1 Yourlegal sigtaNre in uhi dt c will be i ed stt insaatl ion #3
2. HOME ADDRESS J 1PZ l�?C -u�f I Jt
-y
c i Z` a code
3. COUNTY OF RESIDENCE
4. Business or Employer's Name' VI C6,ayle, I
5. Business or Employer's Address l fA.f�
veet Ciw Z7 `t -1 Scut 7 j, mde
6. HOME PHONE I) 0 OFFICE PHONE t 1
Area C6de umber Area `(.obi: umber
7. If you have a current valid notary commission, show your expiration date:
1 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 bf�VYIt 1
ciymwhi omits inn rid
I do solemnly swear (or affirm) that 1 will support the Constitution of the United Statcs, and the Constitution of the State of Indiana; that I am duly
qualifiedto 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
Pert ury).
Sige�w'e of appllean[
Place Officer's Seat Here Subscribed and sworn or affirmed to before me, this L day of
A.D. 20()_.. IN TESTIMONY WHEREOF, I, .Jv Q Y L �7� �7 /e f
Prmt d o r typed name of 0 f err
a /moo forthe
Signature anOtmy public arothw uTrm uudw6wd to adminiAer oaths Office
ounty of State of Indiana.
OR6 eersmuntyofres>d.cc
My commission expires: 0 O
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 1110.
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we c �J�[ as principal
Name o Ap�,oant
(applicant) and of
ame of Sutery
and County as
Snmtaddtcs.cq, stae& 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 above obligation to be null and void, otherwise to remain in full force and virtue in law. The term ofthis bond is from the effective
date of the pr ipal's commission to the ex i ation date of the same.
Signmur usl be acknowledged bell ow i n 1111 Signatureofsurdy. Musibeacknowledgedbelowin Rl2
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENT S.
STATE OF v -----.,COUNTY
COUNTY OF /J l SS:
unry in which aeknow edganent is bang made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
SC in 17 4 and acknowledged the execution of the foregoing bond for the uses and
Primed er t yptd n�cmt
purposes therein expressed, without condition or reservation.
Plate Officers seal here IN TESTIMONY WHEREOF, I "`1 v r have hereunto set my
Printed or type�rr�e
hand and official seal, this d�ay�o£ 20 d
a
sign�,ne:af�,y o cer otFtt
for the County of CL State of
Of cefs musty arc ldalte
My commission exp
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BY LANV TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer-can not acknowledge his /her-own signature)
STATE OF COUNTY OF SS:
County in which nrlutowledganrnt 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 execution of the foregoing bond for the uses and
Pnnlod or typed name of indivi duel signing as surety
purposes therein expressed, without condition or reservation.
Place Officers seal here IN TESTIMONY WHEREOF, I- Printed or have hereunto set my
Typed sane of Olrtta
hand and official seal, this day of 20
a
signature of authorized officer flice
for the County of State of
f cer5 muntya rvSidmce
My commission expires
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County m 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 o£ over and above all
encumbrances and exemptions. signaarraor sattty
Place officer's seal here IN TESTIMONY WHEREOF, I have hereunto set my
Pun or typed stance odtte
hand and official seal, this day of 20
a
ignel ure of authorized officer office
for the County of State of
A fites'smuntyn rest mce
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.
W 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
Hylant Group
Purchase Order No.
P.O. Box 1910
Terms
Carmel, IN 46032 -1910
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/15/08 nla Notary Public Fee Lisa Scott $150.00
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.
z
ALLOWED 20
Hylant rOQP IN SUM OF
P.O. Box 1910
Carmel, IN 46032 -1910
$50.00
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
nla n/a 2200 4355300 $50.0(1 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
a 20
1
dn
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund