167243 12/23/2008 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CHECK AMOUNT: $4,097.99
CARMEL, INDIANA 46032 DEVELOPMENT
PO BOX 847 CHECK NUMBER: 167243
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 12/23/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
.101 5023990 819.99 UNEMPLOYMENT
1125 4110000 548.00 PART -TIME
1192 4110000 2,730.00 FUEL TIME REGULAR
,3.
A
133438 —1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 1D NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll tree 1 -800 -891 -6499 Marion County 232 -7436
STATEMENT OF BENEFIT CHARGES (FORM 535)
CONFIDENTIAL RECORD PURSUANT TO IC 22- 4 -19 -6, IC 4 -1.66
Page 1
CITY OF CARMEL ACCOUNT/
ATT.N CLERK TREASURER LOCATION NUMBER 133438 —000
ONE CIVIC SQ
CARMEL IN 461732 25.84 REPORTING MONTH NOV, 2008
NET CHARGES $4,097.99
POSTING DATE DEC -05, 2008
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unemployment insurance since, before any payments were trade. the employer had the opportunity
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ CHARGED
THIS IS NOT A BILL OR A REQUEST FOR MONEY DUE TO THIS DEPARTMENT. It is a statement of benefit charges
made to your account during the "'reporting" month. At the end of the "posting" month, you will receive a Reimbursable
Bill (Form 1067) for these charges and any previous liability sti ll outstanding.
NEW CHARGES FOR THE REPORTING MONTH 11/08
L S BAILEY 04/04/09 REG 11/26/06 11/15/08 30.00
TOTAL NEW CHARGES FOR THE REPORTING MONTH 11/08 4,097.99
TOTAL AMOUNT OF NET CHARGES
DC o,0U
An in the ACCT column den61dsFdN�h2WgFA;l ri?*6jVn AAc Rti6W6f another business.
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
166089 Indiana Dept. of Workforce Development Terms
10 North Senate Ave., S6106 Date Due
Indianapolis, IN 46204 -2277
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1215108 133438 Benefit charges Nov'08 548.00
PAYA.LL,OUT'OF 101; er Mlclael 11'/20108,.
Total 548.00
1 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
T Clerk- Treasurer
S
Voucher No, Warrant No.
166089 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
,r
548.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO #or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
1125 133438 4110000 548.00 hereby certify that the attached invoice(s), or
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
18 -Dec 2008
Signature
548.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
Prescribe�!,3jj State Board of Accounts ACCOUNTS PAYABLE_ VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
i 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.
I Payee
7 1)1l-' l Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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.
1 ALLOWED 20
IN SUM OF
10 kd
Wd s k) 0%
SOM
ON ACCOUNT OF APPROPRIATION FOR
(0116 uj-�
azq4d&(!�
0 b Board Members
Po# or INVOICE NO. ACCT /TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
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
Signatu e
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund