167100 12/17/2008 CITY OF CARMEL, INDIANA VENDOR: 279200 Page 1 of 1
ONE CIVIC SQUARE INDIANA SECRETARY OF STATE CHECK AMOUNT: $5.00
CARMEL, INDIANA 46032 NOTARY DEPARTMENT
ROOM 201, STATE HOUSE CHECK NUMBER: 167100
INDIANAPOLIS IN 46204
CHECK DATE: 12/17/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2200 4355300 SCOTT 5.00 ORGANIZATION MEMBER
I
I
7e,
Scott, Lisa M
From: Sue Morlock [Sue.Morlock @Hylant.com]
Sent: Monday, December 15, 2008 9:28 AM
To: 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 $50.00 check
payable to Hylant Group and return to my attention.
Thank you,
Sue Morlock
Hylant Group
P.O. Box 1910
Carmel, IN 46082 -1910
317 817 -5162
Notice: The contents of this communication are privileged and confidential. If you are not the intended recipient
of this transmission, you are hereby notified that distributing, copying, or disclosing this communication, or
reliance on the contents thereof, are strictly prohibited. If you have received this communication in error, please
notify the sender immediately, then destroy the original and all copies thereof.
i
Do Not Write In This Box For Office Use Only
Commission Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317- 232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS ($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 1 --A
nc- 0
rr
ii Yourlega s iirh a co on will be mstruamn 03
2. HOME ADDRESS (!e 14 T,!►
Numbs ands et
Ci ty I ZIP code
3. COUNTY OF RESIDENCE co
4. Business or Employer's Name I U OF CLEY End 0ELL
5. Business or Employer's Address 6 1 6y.I r�j
Street C,ry State mde
6. HOME PHONE (311) 0 OFFICE PHONE ���7) fo I �7't
Area Code Area Code Number
7. If you have a current valid notary commission, show your expiration date:
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 1. I)l 1t0f)
aunty in Wnicnom isaaxnuumir
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
qualified to 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
perjury).
Signature of applicant
Place Officer's Sea] Here Subscribed and sworn or affirmed to before me, this, day of
A.D. 200 IN TESTIMONY WHEREOF, I, .J W L
Printed or typed name of o ffi ar
a /t/o+t/ forthe
Signature notary public orathe office auftri and to administer oaths Office
aunty of State of Indiana.
o
My commission expires: o 2 G c�—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 #10.
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that we L N as principal
ame o App rcant
(applicant) and nte oC Su of
arety
and County as
Strcet address, city, stns S 2[P 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 of this bond is from the effective
date of the pr cipal's commission to the expiation date of the same.
SignaloFeof�apphcant. Must be acknod edged belowin All signature of surety Must be acknowledged below in 612
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF COUNTY OF SS:
-ty in which acknowledgement is being made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk etc.) personally appeared
L j'S sC a and acknowledged the execution of the foregoing bond for the uses and
Printed ortyped nameof applicant
purposes therein expressed, without condition or reservation.
Place Officer's seal here IN TESTIMONY WHEREOF, I °`J y L lV have hereunto set my
Panud or rypedn eof afficet
hand and official seal, this S -4— of G1�� �'9 20 d
la�4 a
Srgnat of zuthoiae4ol troer ofEce
for the County of State of
Offcers mutrty ofra rdmce
My commission expires: Qom,, 0 l�
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: 77;e officer can not acknowledge his/her own signature)
STATE OF COUNTY OF SS:
County in which ndcnowk gancnt rs 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
n nted or typed name of irdivi dual signing as surety
purposes therein expressed, without condition or reservation.
Place Officer's sea] here IN TESTIMONY WHEREOF, I have hereunto set my
Printed or typed name of office
hand and official seal, this day of 20
a
Sipsoure of authorized officer office
for the County of State of
f cers muntyo rardoxe
My commission expires
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
County in 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 of over and above all
encumbrances and exemptions. signatureof surety
Place Officer's seal here IN TESTIMONY WHEREOF, I Pdo have hereunto set my
or typed nran tot officer
hand and official seal, this day of 20
a
Signature of authorized officer office
for the County of State of
Officers mwty o m
sr ce
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 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
s I e rfWeffttmber of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/15/08 n/a Notary Public Fee Lisa Scott $5.00
$5.00
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.
ALLOWED 20
I ndk
IN SUM OF
$5.00
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
n/a n/a 200- 4355300 $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-
S ignature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund