155770 01/23/2008 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CARMEL, INDIANA 46032 DEVELOPMENT CHECK AMOUNT: $1,583.08
10 N SENATE AVE, SE106 CHECK NUMBER: 155770
INDIANAPOLIS IN 46204 -2277
CHECK DATE: 1123/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 1,563.08 UNEMPLOYMENT
133438 —1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll free 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/
ATTN CLERK TREASURER LOCATION NUMBER 133438 -000
ONE CIVIC SQ REPORTING MONTH DEC, 2007
CARMEL IN 46032
NETCHARGES $1,583.08
POSTING DATE JAN 03, 2008
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unempioymeni insurance since, before any payments were made 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 I EMPLOYEE'S NAME I DATE I LEVEL DATE I ENDING I 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 still outstanding.
NEW CHARGES FOR THE REPORTING MONTH 12/07
MOGLIA HAWKINS 09/27/08 REG 12/28/07 12/22/07 195.04
TOTAL NEW CHARGES FOR THE REPORTING MONTH 12/07 1,583.08
TOTAL AMOUNT OF NET CHARGES 1,583.08
END OF BENEFIT CHARGE STATEMENT
An in the ACCT column denotes a charge resulting from an acquisition of another business.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
IF 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.
Paye
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
83,0
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
IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT /TITLE AMOUNT I here certify that the attached invoices
DEPT. hereby Y 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
d
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund