167099 12/17/2008 NANA VENDOR: 279200 Page 1 of 1
INDIANA SECRETARY OF STATE CHECK AMOUNT: $5.00
s NOTARY DEPARTMENT
ROOM 201, STATE HOUSE CHECK NUMBER: 167099
INDIANAPOLIS IN 46204
CHECK DATE: 12/17/2008
i
)UNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
3300 BENNETT 5.00 OTHER FEES LICENSES
a�
Do Not Write In This Box For Office Use Only
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
1 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 FIVE DOLLARS (85), payable to the Secretary of Stale, 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 t't YVI2 A Cc- �1?U t? t t1 efi'F
Yomlegal sigtattva to v2u dt cormmscan vnll be Issued -sm mteat:ma tr3
2. HOME ADDRESS L h N 2
be atdsuect
�C1G�iGtrl� SN Loa l
Cit
3. COUNTY OF RESIDENCE Mr CL 1 D t N,
4. Business or Employer's Name
5. Business or Employer's Address O-A4►L S61 JI�re ,�ACfY�� -1
SMeat Ow Sma Z!P mde
6.. HOMEPHONE (961e) 7z1 g -,SC> OFFICE PHONE (3 -6q(- y7�
ara Code Ntmtb dude vtmiber
7. If you have a current valid notary commission, show your expiration date:
Nl 1 20
g. 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.
O LD: N Its,
NEW: N I
9. NOTARIAL OATH
STATE OF MIANA
SS:
COUNTY OF
ounty m a 2Etii�+TF state
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
qualifiedto hold office under the Constitution and laws of the State; that I am IS 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).
i si®rottae of appiteaat
place Off=eS s` eal b;i Subscribed and sworn or affirmed to before me, this _day of D 6 c z
A.D.20�_. IN TESTIMONY WHEREOF, I, NL= 6A
i P ad or dmtne ofe6mr
r l 0 Q a N l (�Y fU !!'7.l �S' for the
i L� Sigteaae of a try of tea atffioomd to admmWer oaths f mac
i County of �1 y F„ y t9 c State oflndiana.
`APR T t)r5mtsawmyof ma
My commission expires �_Z
NOTE.'- -The Bond Form, starting with #10 on the back of this application, must be completed before marling to the Secretary of State.
The applicant must sign again in 410.
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we as principal
Name of Applicam
(applicant) and of S of
ame u,ery
and County as
u¢e, addmss, ciq, stmn a Wcodc
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 t cipal's commission t the expiration date of the same.
garai orapplica¢t• Must be aclno4edged belmia rill 5gaatmeorsway. Muse bnaek lodged below is 412
It. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS. n
STATE OF piaA)A' COUNTY OF rl �1� l L TON SS:
Cuunq m zinc admm4cdgt+ncot is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk etc.) personally appeared
13 F,^ and acknowledged the execution of the foregoing bond for the uses and
Prmtedortypednamco app
purposes therein expressed, without condition or reservation.
Place OCfiee�s seal titxe IN TESTIMONY WHEREOF, I CZ/4 �NL •�!t S-S have hereunto set my
Purest ar gpcd nameel
hand and official seal, his da f L/ E C C_ Lam- 20 Q g
jp
,g„mamue�o�tu office
for the County of 1 14 4142 Al
State of W190A)
EEenrs ofrc,dmcc
My commission expires: (7 't ,0 osus C o af
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS_ (NOTE. The officer cannot acknowledge hWherown signature)
STATE OF COUNTY OF SS:
O¢m,rylo acknowledgernent fs bmgmade
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 namnaf irdih dud siguug as swag
purposes therein expressed, without condition or reservation.
Place officcee seal here IN TESTIMONY WHEREOF, I P have hereunto set my
¢nted or nm,00roffsea
hand and official seal, this day of 20
a
siiv=ii or mdwued officer office
for the County of State of
Of icersommtyo rssdis,ce
My commission expires:
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
oumy is which ec wfadtpmeat 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 of over and above all
encumbrances and exemptions. sigaamreors,ae
Place orikets seal here IN TESTIMONY WHEREOF, I P have hereunto set my
anmd or typed nnaeof oHFca
hand and offic rat seal, this day of 20
a
,g=ins of n
mthoz offior
for the County of Ot State of
officers minty o raidmea
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.
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
Notary Department, Secretary of State
Purchase Order No.
Room 201, State House
Terms
Indianapolis, Indiana 46204
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12 -9 -08 Notary Commission for Amanda Bennett per the $5.00
attached pp ica ion or Appointment As A Notary
Public in The State Of Indiana"
Total
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
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
G ALLOWED 20
IN SUM OF
Room 201, State House
Indianapolis, Indiana 46204
$5.00
ON ACCOUNT OF APPROPRIATION FOR
DEFERRAL FEE FUND
430 -58300 Other Fees and Licenses
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
209 $5.00 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 49,f
Ignature
Cost distribution ledger classification if
Titl
claim paid motor vehicle highway fund