202855 10/19/2011 a CITY OF CARMEL, INDIANA VENDOR: 00352999 Page 1 of 1
ONE CIVIC SQUARE HYLANT GROUP CHECK AMOUNT: $50.00
CARMEL, INDIANA 46032 P 0 BOX 40925
a INDIANAPOLIS IN 46082 -4910 CHECK NUMBER: 202855
CHECK DATE: 10/19/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
209 4347500 50.00 NOTARY -KASS
Do Not Write In This Box For Office Use Only
Commission Expiration Date of New C ommi scion
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to: rotary 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 ($5), 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
J. NAME �C7SI(1 J. T 1Q SS
You rleg Iszgnature rn ch commission will be issued -sec instruct ion 43
2. HOME ADDRESS I Qc �L�i e(1 WAV a
Number and street
CC�rme rro gCO033
City State ZIP code
j�.
3. COUNTY OF RESIDENCE T 1 Qm 1 I Ln
4. Business or Employer's Name O ne 1___�______
5. Business or Employer's Address Dne Cl arCne- f �N !4(9C)3,.
street C• City state j ZIP code
6. HOME PHONE ((3 0) LY a o T 7 Q y OFFICE PHONE (_317 7= 27 7.5
Area Code Number Area Cod 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 kv 1Z Z/
U oun m whi h oath is administered
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).
IF Signature of applicant
Place Officer's Seal Here 'Subscribed and sworn or affirmed to before me, this LL day of 0C
A.D. 201 IN TESTIMONY WHEREOF, I, A, iF3AS5
Printed or typed name ofoifirc,
u J a ND 7E4 t/ 7'U��' for the
Signature of a notar public orotha o authorized to administer oaths Office
County of 69 /e l OAJ State of Indiana.
Offi refs county orresidmee
My commission expires: tC_. L A 6 (P
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 N/A J 1 V* as principal
JF Name of Applicant
(applicant) and
of
Name of Surety
Street address, city, slate &ZIP code and County as
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 p c al's co ission to expirati date of the same.
Signature of plicanl. Must be acknowledged below in H ll Signature ofsurey. Must be acknowledged below in #12
11. ACKN WLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF 1 08 COUNTY OF M 7 0 SS:
County 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
�O s), /J S t 4 5 and acknowledged the execution of the foregoing bond for the uses and
Printed or t yped na me of a pphcant
purposes therein.expressed, without condition or reservation. n 11 f�
Place 6fficeA seal here IN TESTIMONY WHEREOF, I_ 14 &2A J !y 0 V /��jS -have hereunto set my
f Printed or typed nameof of icer
hand and official seal, this day of d C To I 20
Signatture�o I orizeauthd officer office
for the County of QA) State of 1-
Officer's county of res iderce
My commission expires: ®C Td,BC.� 523 f a0 (p
12. ACKNOWLEDGEAIENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
AUTHORIZED BYLAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge his/her own signature)
STATE OF COUNTY OF SS:
County in which acknowledgement is being mode
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
Printed or typed name of individual signing as surety and acknowledged the execution of the foregoing bond for the uses and
purposes therein expressed, without condition or reservation.
Place Officers seal here IN TESTIMONY WHEREOF, I_ P have hereunto set my
Printed or typed name of offices
hand and official seal, this day of 20
a
Signature of authorized officer office
for the County of State of
Officers county of res idence
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. Signature ofsurery
Place Officer's seal here IN TESTIMONY WHEREOF, I have hereunto set my
Printed or typed name of office
hand and official seal, this day of 1 20
a
S ignature of authorized officer office
for the County of State of
Officers county ofresidence
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
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Hylant Group of Indianapolis
Purchase Order No.
301 Pennsylvania parkway #201
Terms
Carmel, Indiana 46280
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
10 -12 -11 Notary Bond for Joslyn S. Kass per the attached $50.00
Application For Appointment As A Notary Public
in I he 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.
ALLOWED 20
HVlant Group of Indianapolis IN SUM OF
301 Pennsylvania Parkway #201
Carmel, Indiana 46280
50.00
ON ACCOUNT OF APPROPRIATION FOR
DEFERRAL FEE FUND 209
430 -47500 Genprnll
I
Board Members
D EPT INVOI[ I hereby certify that the attached invoice(s), or
209 �c� bill(s) is (are) true and correct and that the
l� materials or services itemized thereon for
which charge is made were ordered and
received except
20/
0%e'4 1Z0"
nature
Cost distribution ledger classification if Titl
claim paid motor vehicle highway fund