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Home My WebLink About163527 09/04/2008 CITY OF CARMEL, INDIANA VENDOR: 00351684 Page 1 of 1 0 ONE CIVIC SQUARE CLERK OF THE COURTS ANNUAL FEES CARMEL, INDIANA 46032 P O BOX 6069 DEPT 179 CHECK AMOUNT: $230.00 INDIANAPOLIS IN 46206 -6069 CHECK NUMBER: 163527 CHECK DATE: 9/4/2008 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1180 R4355300 15914 230.00 MEMBERSHIP DUES First Notice 11207 -49 •�aq.� &9TF INDIANA, ®9 A N A SUPREME COURT Current Status: LE Active 115.00 OR NET A mmNUAL REGISTRATION STATEMENT 'yoccc8�� PAY ANNUAL ATTORNEY FEE FOR ACTIVE OR INACTIVE STATUS If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here: MR DOUGLAS HANEY 1 CIVIC SQUARE 49 HAWTHRONE DRIVE CARMEL, IN 46032 CARMEL, IN 46033 -0000 TOTAL AMOUNT DUE RETURN THIS STATEMENT WITH YOUR CHECK MADE PAYABLE TO: Postmark Date Inactive Status Address for annual fees mailed in Address for annual fees personally delivered Clerk of the Courts Annual Fees Clerk of the Courts Annual Fees 8/1-10/1 1 15.00 57.50 P.O. Box 6069 Dept. 179 402 W. Washington St., Rm. W062 10/2- 10/15 180.00 107.50 Indianapolis, IN 46206 -6069 Indianapolis, IN 46204 10/16-12/31 $230.00 $157.50 OR PAY YOUR ANNUAL FEE AND UPDATE YOUR INFORMATION AFTER 12/31 $380.00 $157,50 ON THE CLERK OF COURTS WEBSITE! (see below) INSTRUCTIONS FOR COMPLETING YOUR ANNUAL FEE STATEMENT ONLINE: To pay your annual fee and /or change your contact information with the Roll of Attorneys online, go to http /courts.in.gov /cofc and click on the link to "Attorney Registration Online. IMPORTANT: A convenience fee of $3.50 plus 2% of your total attorney fee due (including any penalty for late payment) is charged by accesslndiana for payment by credit card. REQUIRED IOLTA CERTIFICATION Please check one of the following: El I /my firm participate(s) in Indiana's IOLTA program. Compliance with Rule 1.15 was completed by creating and maintaining (an) interest bearing.trust account(s) for qualified clients' funds. [Enrollment forms and IOLTA information are available at.www.Mbf.org, or call the Indiana Bar Foundation at 317- 269 2415.] Indiana IOLTA Account Financial Institution: IOLTA Account Number: Attorney /Law Firm Name: NOTE: If you maintain multiple IOLTA accounts, please attach information on additional accounts to this I /my firm.maintain(s) an IOLTA account in a state other than Indiana. I am exempt from maintaining an IOLTA account because: I am not in the private practice of law, or my practice does not involve Indiana client trust funds, or I do not have an office within the State of Indiana. I am a judge; an attorney employed by a local, state, or federal government; on duty with the armed services; a corporate counsel; or teacher of law; and I am not otherwise engaged in the private practice of law. Participation in the IOLTA program would work an undue hardship on me and /or would be extremely impractical based on the geographic distance between my principal office and the closest depository institution participating in the IOLTA program and /or other compelling and necessitous factors. Please attach on a separate piece of paper an explanation_ of why you are seeking this undue hardship exemption. IMPORTANT! IF YOU ®O NOT COMPLETE YOUR IOLTA CERTIFICATION, YOUR STATEMENT AND CHECK WILL. BE RETURNED TO -YOU, AND YOU MAY OWE A LATE FETE Please see reverse side. AFFIDAVIT OF INACTIVITY OR RETIREMENT I wish to place or retain my Indiana law license in inactive El I wish to place my Indiana law license into retired status. I am status. I am currently in either active or inactive good currently in either active or inactive good standing status. I standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys who do not plan to return to the practice of law. I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true. I �I Date: Signature: ATTORNEY SURROGATE DESIGNATION If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company (LLC), professional corporation (PC), limited liability partnership (LLP),.another lawyer, or an organization not engaged in the private practice of law, then pursuant to Admission and Discipline Rule 23 27(b)(1) you may designate a member in good standing of the Ind B to ac t as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment. I hereby designate the following member in good standing of the Indiana bar to act as my attorney surrogate pursuant to Admission 1 and Discipline Rule 23 27 (NOTE: Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem- bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary Entity rather than a specific attorney —see Admis. Disc. R. 23 27(b)(2)): Surrogate or Entity: Bar No.: Office: Home: If I have listed a surrogate attorney above, then by signing below I certify that s /he has agreed to this designation in writing and that we both have copies of the agreement in our possessions. (NOTE: Designation invalid without this certification.) Date: Signature: OPTIONAL RACE/ETHNIC INFORMATION In an effort to obtain accurate information about diversity within Indiana's legal profession, the Indiana Supreme Court, through its Commission on Race and Gender Fairness, requests that attorneys fill out the following demographic information: GENDER: Male Female RACE: Caucasian African American American Indian /Native American Asian American Hispanic /Latino Other CONTACT US Clerk of the Su preme Court, Court of Appeals, For all IOLTA questions, please contact the Indiana Bar Foundation at 800 279 -8772 or and Tax Court IOLTA@inbf.org. 200 W. Washington St., Rm. 217 Indianapolis, IN 46204 -2795 For all questions about the Attorney Annual Fee Process, please contact the Roll of Attorneys PHO: 317- 232 -1930 Administrator at 317- 232 -5861 or roIlatty@courts.state.in.us. FAX: 317 -232 -8365 clerk@courts.state. in. us Visit the Clerk's website at http /courts.IN.gov /cofc. First Notice 18428 -49 �4 us tte8'.rF e�® I111�1 p� QYXZEFGY °`m I s'!� ®IA NA S M E C ®U R T Current Status Active g' m z 4 115.00 .:a 2 /M ®r? Y �hoccciN. N1 JAL REGISTRATION STAT NT PAY ANNUAL ATTORNEY FEE FOR ACTI VE OR INACTIVE STATUS If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here: MR THOMAS PERKINS II 3RD FLOOR 14150 EQUINE COURT ONE CIVIC SQUARE WESTFIELD, IN 46074 -0000 CARMEL, IN 46032 Please see reverse side. OE6I ZFZ L I E :OHd snaaa f- u C j -114 56LZ NI 'sllodeuelpul L 1,7 'Wa 15 u016ulus2/y\ '/X\ OOZ 6 jo•jqu! @H110I ;fin®, XejL pue Jo ZLZ8 008 le uollepunoj jee euelpul ay1 l:)eluoa aseald 'suollsanb Vilol IIP job Ifeaddy j® ;,no:) ;.on®� away ns aye jo )Iaaa:) sn l3VlN®:) layl0 oullPl /�luedslH uPDuawv uPlsy ueauawy aA11PN /uPlpul uPDuawy uP:)uawy ueDlJIV F-1 ueiseanPD :3DVa alewaj aleW F :83aN3J :uollPwaoJu! Dlydei5owap bulAnolloj aU1 lno lll3 sXauaolle 1eU1 slsanbaa 'ssaunPJ aapua9 PUP aaP�l uo uolsslwwoD sl! y6noayl 'ljnoD awaadnS Puelpul a41 'uoissajo,id le5al sguelpul uiL41!m lnoge uo!1ewjolui aleJn»e uiPlgo of :Ijo ga ue ul NO1J,VWHOAN1 :)INHJL3 /3 :)VV 11® NOIld® AFFIDAVIT OF INACTIVITY OR RETIREMENT I wish to place or retain my Indiana law license in inactive El I wish to place my Indiana law license into retired status. I am status. I am currently in either active or inactive good currently in either active or inactive good standing status. I standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys who do not plan to return to the practice of law. �i I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true. Signature: Date: �j �L ATTORNEY SURROGATE DESIGNATION If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company (LLC), professional corporation (PC), limited liability partnership (LLP), another lawyer, or an organization not engaged in the private practice of law, then pursuant to Admission and Discipline Rule 23 27(b)(1) you may designate a member in good standing of the Indiana Bar to act as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment. i I hereby designate the following member in good standing of the Indiana bar to act as my attorney surrogate pursuant to Admission and Discipline Rule 23 27 (NOTE. Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem- bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary Entity rather than a specific attorney —see Admis. Disc. R. 23 27(b)(2)): Surrogate or Entity: Bar No.: Office: Home: II� I i If I have listed a surrogate attorney above, then by signing below I certify that s /he has agreed to this designation in writing and that we both have copies of the agreement in our possessions. (NOTE: Designation invalid without this certification.) Date: Signature: j Prescribed 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 Clerk of the Courts Annual Fees Purchase Order No. P. O. Box 6069 Dept. 179 Terms Indianapolis, Indiana 46206 -6069 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 8 -3 -07 Annual Fee 2008 -2009 for: D ouglas C. Haney, Carmel Cit Att orney an Thomas D. Pt:�Ikil 1� C'ai njehAssistant City Attorney 10 15.00 per the attached Statement 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 C,Ierk of the Court Annual FaPG IN SUM OF P. O. Box 60 69 Dept. 179 Indianapolis, IN 46206 -6069 $230.00 ON ACCOUNT OF APPROPRIATION FOR Department of Law 430 -55300 Dues Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT ,a&wr I hereby certify that the attached invoice(s), or DOL aney $115.00 bill(s) is (are) true and correct and that the erkins 115.00 materials or services itemized thereon for which charge is made were ordered and received except 20 D nature Cost distribution ledger classification if Title claim paid motor vehicle highway fund