164769 10/16/2008 CITY OF CARMEL INDIANA VENDOR: 279200 Page 1 of 1
a Cry
f ONE CIVIC SQUARE INDIANA SECRETARY OF STATE
CARMEL, INDIANA 46032 CHECK AMOUNT: $5.00
NOTARY DEPARTMENT
'"hce cod:. ROOM 201, STATE HOUSE CHECK NUMBER: 164769
INDIANAPOLIS IN 46204
CHECK DATE: 10116/2008
DEPAR ACCO PO NU IN VOICE NUM BER AMOUNT DESCRIP
209 J 4358300 5.00 OTHER FEES LICENSES
I
.w,
S
447 {OIL e�C Z
Do Not Write In This Box For Office Use Only
Commission# Expiration Date ofNew Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF M ANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317-232-6542
To: THE GOVERNOR OF INDIANA
J respectfully request that 1 be appointed and commissioned a Notary Public. In support of my application, 1 submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS ($S), payable to the Secretary of State, in theform of a check or money order. (Do not send currency in
the mail.) (IC 33- 16 -2 -1)
PRINT OR TYPE
1. NAME A. ELAINE BASS
Yowlegal signature is utu d, eom+aission will be iaued -see amebioa k7
2. HOME ADDRESS 8832 Powder Wa
N=bw asdsaen
Indianapolis Dana 4h75ti
c,y tade
3. COUNTY OF RESIDENCE Marion
4. Business or Employer's Name City of Carmel
5. Business or Employer's Address One Civic Square Carmel Indiana 46 332
Street cry Shm Z@ m de
6.. HOMEPHONE (317 845 -5182 OFFICE PHONE (317 571 -247
Area Code Nre„bzr Ana umber
7. If you have a current valid notary commission, show your expiration date:
October 23 20 _Q2
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 HAMILTON
puny m WNCh 00h is aftmwer
I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of lndiana; that I am duty
qualifiedto hold office under the Constitution and laws of the State; that I am 18 years of age or over, that l am of good moral character and irmeginy;
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)- a.
r—
si tore o appti
P1acc ofseees Sea] Here Subscribed and sworn or affirmed to before me, thiso� day of i
A t.20 IN TESTIMONY WHEREOF, 1, Carla J. Newcomer
Pr6nad or "d of ofl'ieer
~��r a Notary Public for the
SiB,eax of an pub& aro,baofficc audnnmd m adminzaa mrhs cfrwc
County of Boone Stateoflndiana.
officers cam y o£residares
My commission expires Ma r c h 12, 2016
NOTE: The Bond Form, starting with 4110 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #10.
Y
10. NOTARIAL BOND
KNOW ALL BY THESE PRESENTS, that me A. Elaine Bass as principal
Nrme of ApplKnm
(applicant) and of S of
tune u[ery
and County as
tress addrea, city, son Z& 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 ofNotary Public, in all things according to
law, then the above be null and void, otherw ise to remain ur full force and virtue in law. The term of this bond is from the effective date of the pri7iF to the exp' date of the same.
Si o appliemt. dawin 1 &gnsnusofsme7c Must Dearkaowkdged below is 612
11. ACKNOWLEDGEMENT OF APP ICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF COUNTY OF SS:
Counw in u4tc admwdedgaaeat a hang made
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Cle rk etc.) personally appeared
A. Elaine Bass and acknowledged theexecutionof the foregoing bond forthe uses and
dortypednarneotapp
o app
purposes therein expressed, without condition or reservation. /r
Place OffiteA seal hem IN TESTIMONY WHEREOF, I ax 1 4 'itj Cl� Cl�f� have hereunto set my
�F an or ypcd nm[oa o me
h an nd official seal, this n day of 't R JC 1 2 0 0
Signer izel �T
forth County of l 0 State of �t'104.d-u-P`-
eafs menty ofrs[dmee
My commission expires: —�I
12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS. (IVOTB. The officer cannot acknowledge hivher'own signature)
STATE OF COUNTY OF SS:
county in wlueh acknowledgamentIS hmgmade
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
Panto! orryped nsn[eof indwi dud s[guag as stray
purposes therein expressed, without condition or reservation.
Place of@eets seal hue IN TESTIMONY WHEREOF, I have hereunto set my
Pnnled ar nancofoffica
hand and official seal, this day of 20
a
s'[gntma of xmWeized off ar of &a
for the County o f State of
Officafsm[mtyo res[dmcc
My commission expires
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF is vddeh SS:
otudy s: wlpigtement is Le[og atade
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. siq[awcof lady
Place Officest seal heft IN TESTIMONY WHEREOF, I Panted or typed have hereunto set my
nameof o6tter
hand and official seal, this day of 1 20
a
g[a= of authorized coke,
for the County of State of
officers m[a[ty o raidace
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))
10 -2 -08 Notary Commission for A. Elaine Bass per the $5.00
attached
Public In The State E)f Indiana"
Total sr; nn
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
Notary Department 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
200
&;���atu�ree
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund