158949 04/30/2008 r
CARMEL, INDIANA VENDOR: 279200
Page 1 of 1
ONE CIVIC SQUARE INDIANA SECRETARY OF STATE
CARMEL, INDIANA 46032 NOTARY DEPARTMENT CHECK AMOUNT: $5.00
ROOM 201, STATE HOUSE
CHECK NUMBER: 158949
INDIANAPOLIS IN 46204
CHECK DATE: 4/30/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 2.50 OTHER EXPENSES
651 5023990 2.50 OTHER EXPENSES
5 1 S h
I
6
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: Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that 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 ($5) 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 LISA L KEMPA
Your legal name in which commission will be issued see instruction #3
2. HOME ADDRESS 5159 Pine Hill Drive
(Number and Street)
Nob lesville IN 4
(City) (State) (Zip Code)
3. COUNTY OF RESIDENCE Hamilto
4. Business Name City of Carmel IN
5. Business Address One Ci Sq uare C armel IN 46032
(Street) (City) (State) (Zip Code)
6. HOME PHONE 317 -571 -2443 BUSINESS PHONE 317 -571 -2443
(Area Code) Number (Area Code) Number
7. If you have a current, valid notary commission show your expiration date:
05/29/2008
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 �Jlj D) 4 /V -A
I do so solemnly swear (or affirm) that l 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 bj the
Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of perjury).
X
Signat re of appli (Ft)
LISA L KEMPA
Subscribed and sworn or affirmed to before me, this a 2 yl e� day of r- A.D.
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal.
in and for the County of j State of Indiana.
(Signature of a notary public of other
officer authorized to administer oaths)
My commission expires:
Page 3 of 4
S- 6080 /DA 3/01
American States Insurance Company Bond No. 6570119
INDIANAPOLIS, INDIANA
26 -0504 DOUG WALKER SON AGENCY INC INDIANAPOLIS, IN
Agency Agency City State
10. NOTARIAL BOND
KNOW ALL MEN BY THESE PRESENTS, That we LISA L KEMPA
(Name of Applicant)
as principal (Applicant) and AMERICAN STATES INSURANCE COMPANY of 500 North Meridian Street, Indianapolis, Indiana
46207 and Marion County as 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
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 principal commission to the expiration date ��S INS q;
P "�G
of the sa eI
n /J�/ U or
Signature of Principal, Must be ack owledged below in #11) (Signature of Surety, Must be acknowledged below in
LISA L KEMPA Tim Mikolajewski Senior Vice- President, Surety 'iND1ANP'
11. ACKNOWLEDGMENT OF PRINCIPAL'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGMENTS.
STATE OF AV)) /qA), COUNTY OF ��11`1 I L? Z� SS:
Before me the undersigned, an officer authorized to take the acknowledgment of deeds (Notary Public, County Clerk, etc.)
personally appeared before me LISA L KEMPA and
(Principal)
acknowledged the execution of the foregoing bond for the uses and purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal,
this day of ADO
(Signature of a notary public other authorized officer) ffice)
in and for the County of d j j J-D State of A,O j 9 -A
My commission expires d S
12. ACKNOWLEDGMENT SURETY'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGMENTS
STATE OF I NDIANA
COUNTY OF Ma rion SS:.
Before me the undersigned, an officer authorized to take the acknowledgment of deeds (Notary Public, County Clerk, etc.)
personally appeared before me Tim Mikolajewski and
(Surety)
acknowledged the execution of the foregoing bond for the uses and purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal,
this 21st day of April 2008
iD a Notary Public
(Signature of a notary public or other authorized officer) (Office)
in and for the County of BOONE State of INDIANA
My commission expires 2 -14 -2016
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.
S- 6080 /DA 3/01 Page 4 of 4 WEB PDF
Etas
AMERICAN STATES INSURANCE COMPANY
NOTARY PUBLIC ERRORS AND OMISSIONS POLICY
POLICY NO. E 0 6570119
AMERICAN STATES INSURANCE COMPANY will pay on behalf of LISA L KEMPA
of 5159 Pine Hill Drive Noblesville IN 46062
(Address)
(hereinafter called the insured), all sums which the insured shall become obligated to pay by reason of liability for breach of duty
while acting as a duly commissioned and sworn Notary Public, claim for which is made against the insured by reason of any
negligent act, error or omission, committed or alleged to have been committed by the insured, arising out of the performance of
notarial service for others in the insured's capacity as a duly commissioned and sworn Notary Public.
POLICY PERIOD: This policy applies only to negligent acts, errors or omissions which occur during the policy period and then
only if claim, suit or other action arising therefrom is commenced during the policy period, and is not barred by the applicable
Statute of Limitations pertaining to the insured. The Policy Period commences on the effective date of the insured's commission
as a Notary Public and terminates upon the expiration of the Insured's commission as a Notary Public unless cancelled earlier
as provided in this policy. This policy is not valid for more than one commission term.
LIMITS OF LIABILITY: The liability of this company shall not exceed in the aqqreqate for all claims under this insurance the
amount of Five Thousand Dollars And Zero Cents 5,000
In addition to the limit of liability and in accordance with the other provisions of this policy, this company will pay costs and
expenses paid and incurred in investigating, contesting or settling liability in an amount not to exceed, in the aggregate, one -half
of the limit of this policy.
INSURED'S DUTIES IN THE EVENT OF OCCURRENCE, CLAIM, OR SUIT:
(a) Upon knowledge of any occurrence which may reasonably be expected to result in a claim or suit, written notice
containing particulars sufficient to identify the Insured and also reasonably obtainable information with respect to the time,
place and circumstances thereof, and the names and addresses of the potential claimant and of available witnesses, shall
be given by or for the Insured to the Company or any of its authorized agents as soon as practicable, but in no event
longer than forty- five(45) days after discovery.
(b) If claim is made or suit is brought against the Insured, the Insured shall immediately forward to the Company every
demand, notice, summons or other process received by him or his representative.
(c) The Insured shall cooperate with the Company and, upon the Company's request, assist in making settlements, in the
conduct of suits and the Insured shall attend hearings and trials and assist in securing and giving evidence and obtaining
the attendance of witnesses. The Insured shall not, except at his own cost, voluntarily make any payment, assume any
obligation or incur any expense except with the prior written consent of the Company.
EXCLUSIONS: Coverage under this policy does not apply to any dishonest, fraudulent, criminal or malicious act or omission of
the insured.
CO- INSURANCE: If the insured has other insurance against a loss covered by this policy, the company shall not be liable
under this policy for a greater proportion of such loss, cost and expenses than the limit of liability stated in this policy bears to
the total limit of liability of all valid and collectible insurance against such loss.
CANCELLATION` This policy may be cancelled by the Company by mailing thirty (30) days written notice to the Insured and
may be cancelled by the Insured by surrender thereof to the Company or any of its agents or by mailing to the Company
thirty (30) days written notice and this policy shall be deemed cancelled and the Policy Period terminated upon
such return or at the expiration of said thirty (30) days. A pro rata return premium shall be allowed on cancellation.
Dated, signed and sealed this 21 st day of April 2008
AMERICAN STATES INSURANCE COMPANY
Address Claims to: �S INSU, ��P
AMERICAN STATES INSURANCE COMPANY
PO Box 34526 9S L v By
Seattle, WA 98124 -1526 ��Za r� Tim Mikolajewski Senior Vice- President, Surety
/NDIANP'
S 6835/DA 6/03 Safeco and the Safeco logo are registered trademarks of Safeco Corporation
WEB PDF
THIS ENDORSEMENT CHANGES THE. POLICY. PLEASE READ IT CAREFULLY.
INDIANA CHANGES CANCELLATION AND
NONRENEWAL
This endorsement modifies insurance provided under the following:
Notary Public Errors Omissions Policy
A. The Cancellation Policy Condition is replaced by the following:
1. Cancellation of Policies In Effect
a. 90 Days Or Less
If this policy has been in effect for 90 days or less, we may cancel this policy by mailing or
delivering to the Insured written notice of cancellation at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium;
(2) 20 days before the effective date of cancellation if you have perpetrated a fraud or material
misrepresentation on us; or
(3) 30 days before the effective date of cancellation if we cancel for any other reason.
b. More Than 90 Days
If this policy has been in effect for more than 90 days, or is a renewal of a policy we issued, we may
cancel this policy by mailing or delivering to the Insured written notice of cancellation at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium;
(2) 20 days before the effective date of cancellation if you have perpetrated a fraud or material
misrepresentation on us; or
(3) 45 days before the effective date of cancellation if:
(a) There has been a substantial change in the scale of risk covered by this policy;
(b) You have failed to comply with reasonable safety recommendations.
(c) Reinsurance of the risk associated with this policy has been cancelled.
B. The following is added to the Policy Conditions and supersedes any provision to the contrary.
NONRENEWAL
1. If we elect not to renew this policy, we will mail or deliver to the Insured written notice of nonrenewal at
least 45 days before:
a. The expiration date of this policy, if the policy is written for a term of one year or less; or
b. The anniversary date of this policy, if the policy is written for a term of more than one year.
2. We will mail or deliver our notice to the Insured's last mailing address known to us. If notice is mailed,
proof of mailing will be sufficient proof of notice.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
S- 6896/GE 7/03 Safeco and the Safeco logo are registered trademarks of Safeco Corporation
XFT
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
279200
SECRETARY OF STATE Purchase Order No.
NOTARY DEPARTMENT Terms
ROOM 201 Due Date 4/22/2008
INDIANAPOLIS, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
4/22/2008 042808 $2.50
hereby certify that the attached invoice(s), or bill(s) is (are) true and
orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer
VO�ICHER 081580 WARRANT ALLOWED
ti
278200 IN SUM OF
SECRETARY OF STATE
NOTARY DEPARTMENT
-'ROOM 201
'INDIANAPOLIS, IN 46204
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
042808 01- 6360 -08 $2.50
1
Voucher Total $2.50
Cost distribution ledger classification if
claim paid under vehicle highway fund
f
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: Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 232 -6542
To: THE GOVERNOR OF INDIANA
1 respectfully request that I 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 ($5) 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 LISA L KEMPA
Your legal name in which commission will be issued see instruction #3
2. HOME ADDRESS 5159 Pine Hill Drive
(Number and Street)
Nob lesville IN 46062
(City) i (State) (Zip Code)
3. COUNTY OF RESIDENCE Hamilto
4. Business Name City of Carmel IN
5. Business Address One Civic Square C arme l IN 46032
(Street) (City) (State) (Zip Code)
6. HOME PHONE 317 -571 -2443 BUSINESS PHONE 317 -571 -2443
(Area Code) Number (Area Code) Number
7. If you have a current; valid notary commission show your expiration date:
05/29/2008
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 do so 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 p ins and penalties of perjury).
X o�Ar
Signat /re of appli ant)
f/ LISA L KEMPA
Subscribed and sworn or affirmed to before me, this day of �1- A.D.pp8
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal.
in and for the County of State of Indiana.
(Signature of a notary public ot other
officer authorized to administer oaths)
My commission expires: e
Page 3 of 4
S- 6080 /DA 3/01
American States Insurance Company Bond No.6570119
INDIANAPOLIS, INDIANA
26 -0504 DOUG WALKER SON AGENCY INC INDIANAPOLIS, IN
Agency Agency City State
10. NOTARIAL BOND
KNOW ALL MEN BY THESE PRESENTS, That we LISA L KEMPA
(Name of Applicant)
as principal (Applicant) and AMERICAN STATES INSURANCE COMPANY of 500 North Meridian Street, Indianapolis, Indiana
46207 and Marion County as 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
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 principal commission to the expiration date P��S INSDR
of the sane:
n
0
X SEAL a
(Signatr re oS Principal, Must be ackollowledged below in #11) (Signature of Surety, Must be acknowledged below in #12)
LISA L KEMPA Tim Mikolajewski Senior Vice- President, Surety DIANP'
11. ACKNOWLEDGMENT OF PRINCIPAL'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGMENTS.
STATE OF ���j�}� COUNTY OF 1 t nI SS:
Before me the undersigned, an officer authorized to take the acknowledgment of deeds (Notary Public, County Clerk, etc.)
personally appeared before me LISA L KEMPA and
(Principal)
acknowledged the execution of the foregoing bond for the uses and purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal,
this 11� day of r: i I OC
(Signature of a notary public other authorized officer) ffice)
in and for the County of rN State of i A/0 j/1
My commission expires d j vc`
12. ACKNOWLEDGMENT SURETY'S SIGNA' BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGMENTS
STATE OF IND IANA
COUNTY OF Ma ri o n SS:
Before me the undersigned, an officer authorized to take the acknowledgment of deeds (Notary Public, County Clerk, etc.)
personally appeared before me Tim Mikolajewski and
(Surety)
acknowledged the execution of the foregoing bond for the uses and purposes therein expressed, without condition or reservation.
IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal,
this 21st day of April 2008
i a Notary Public
(Signature of a notary public or other authorized officer) (Office)
in and for the County of BOONE State of INDIANA
My commission expires 2 -1 4 -2
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.
S 6080/DA 3/01 Page 4 of 4 WEB PDF
ME@
AMERICAN STATES INSURANCE COMPANY
NOTARY PUBLIC ERRORS AND OMISSIONS POLICY
POLICY NO. E 0 6570119
AMERICAN STATES INSURANCE COMPANY will pay on behalf of LISA L KEMPA
Of 5159 Pine Hill Drive Noblesville IN 46062
(Address)
(hereinafter called the insured), all sums which the insured shall become obligated to pay by reason of liability for breach of duty
while acting as a duly commissioned and sworn Notary Public, claim for which is made against the insured by reason of any
negligent act, error or omission, committed or alleged to have been committed by the insured, arising out of the performance of
notarial service for others in the insured's capacity as a duly commissioned and sworn Notary Public.
POLICY PERIOD: This policy applies only to negligent acts, errors or omissions which occur during the policy period and then
only if claim, suit or other action arising therefrom is commenced during the policy period, and is not barred by the applicable
Statute of Limitations pertaining to the insured. The Policy Period commences on the effective date of the insured's commission
as a Notary Public and terminates upon the expiration of the Insured's commission as a Notary Public unless cancelled earlier
as provided in this policy. This policy is not valid for more than one commission term.
LIMITS OF LIABILITY: The liability of this company shall not exceed in the aqqreqate for all claims under this insurance the
amount of Five Thousand Dollars And Zero Cents 5,000
In addition to the limit of liability and in accordance with the other provisions of this policy, this company will pay costs and
expenses paid and incurred in Investigating, contesting or settling liability in an amount not to exceed, In the aggregate, one -half
of the limit of this policy.
INSURED'S DUTIES IN THE EVENT OF OCCURRENCE, CLAIM, OR SUIT:
(a) Upon knowledge of any occurrence which may reasonably be expected to result in a claim or suit, written notice
containing particulars sufficient to identify the Insured and also reasonably obtainable information with respect to the time,
place and circumstances thereof, and the names and addresses of the potential claimant and of available witnesses, shall
be given by or for the Insured to the Company or any of its authorized agents as soon as practicable, but in no event
longer than forty- five(45) days after discovery.
(b) If claim is made or suit is brought against the Insured, the Insured shall immediately forward to the Company every
demand, notice, summons or other process received by him or his representative.
(c) The Insured shall cooperate with the Company and, upon the Company's request, assist in making settlements, in the
conduct of suits and the Insured shall attend hearings and trials and assist in securing and giving evidence and obtaining
the attendance of witnesses. The Insured shall not, except at his own cost, voluntarily make any payment, assume any
obligation or incur any expense except with the prior written consent of the Company.
EXCLUSIONS: Coverage under this policy does not apply to any dishonest, fraudulent, criminal or malicious act or omission of
the insured.
CO- INSURANCE: If the insured has other insurance against a loss covered by this policy, the company shall not be liable
under this policy for a greater proportion of such loss, cost and expenses than the limit of liability stated in this policy bears to
the total limit of liability of all valid and collectible insurance against such loss.
CANCELLATION` This policy may be cancelled by the Company by mailing thirty (30) days written notice to the Insured and
may be cancelled by the Insured by surrender thereof to the Company or any of its agents or by mailing to the Company
thirty (30) days written notice and this policy shall be deemed cancelled and the Policy Period terminated upon
such return or at the expiration of said thirty (30) days. A pro rata return premium shall be allowed on cancellation.
Dated, signed and sealed this 21 st day of April 2008
AMERICAN STATES INSURANCE COMPANY
Address Claims to: S INSU, P��' B
AMERICAN STATES INSURANCE COMPANY 0
PO Box 34526 y a y
Seattle, WA 98124 -1526 �yy r� Tim Mikolajewski Senior vice President, Surety
/NDIANP
S 6835/DA 6/03 Safeco and the Safeco logo are registered trademarks of Safeco Corporation
WEB PDF
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
INDIANA CHANGES CANCELLATION AND
N®NRENEWAL
This endorsement modifies insurance provided under the following:
Notary Public Errors Omissions Policy
A. The Cancellation Policy Condition is replaced by the following:
1. Cancellation of Policies In Effect
a. 90 Days Or Less
If this policy has been in effect for 90 days or less, we may cancel this policy by mailing or
delivering to the Insured written notice of cancellation at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium;
(2) 20 days before the effective date of cancellation if you have perpetrated a fraud or material
misrepresentation on us; or
(3) 30 days before the effective date of cancellation if we cancel for any other reason.
b. More Than 90 Days
If this policy has been in effect for more than 90 days, or is a renewal of a policy we issued, we may
cancel this policy by mailing or delivering to the Insured written notice of cancellation at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium;
(2) 20 days before the effective date of cancellation if you have perpetrated a fraud or material
misrepresentation on us; or
(3) 45 days before the effective date of cancellation if:
(a) There has been a substantial change in the scale of risk covered by this policy;
(b) You have failed to comply with reasonable safety recommendations.
(c) Reinsurance of the risk associated with this policy has been cancelled.
B. The following is added to the Policy Conditions and supersedes any provision to the contrary.
NONRENfWAL
1. If we elect not to renew this policy, we will mail or deliver to the Insured written notice of nonrenewal at
least 45 days before:
a. The expiration date of this policy, if the policy is written for a term of one year or less; or
b. The anniversary date of this policy, if the policy is written for a term of more than one year.
2. We will mail or deliver our notice to the Insured's last mailing address known to us. If notice is mailed,
proof of mailing will be sufficient proof of notice.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
S- 6896/GE 7/03 Safeco and the Safeco logo are registered trademarks of Safeco Corporation
XFT
g
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
279200
INDIANA SECRETARY OF STATE Purchase Order No.
NOTARY DEPARTMENT Terms
STATE HOUSE Due Date 4/22/2008
INDIANAPOLIS, IN 46204,
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
4/22/2008 042808 $2.50
I hereby certify that the attached invoice(s), or bill (s) is (are) true and
orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer
i
'VOUCHER 085375 WARRANT ALLOWED
r
j "'279200 IN SUM OF
INDIANA SECRETARY OF STATE
NOTARY DEPARTMENT
STATE HOUSE
INDIANAPOLIS, IN 46204,
Carmel Wastewater Utility
"ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
042808 01- 7360 -08 $2.50
SP
Voucher Total $2.50
Cost distribution ledger classification if
claim paid under vehicle highway fund