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202856 10/19/2011 CITY OF CARMEL, INDIANA VENDOR: 279200 Page 1 of 1 ~f ONE CIVIC SQUARE INDIANA SECRETARY OF STATE CARMEL, INDIANA 46032 NOTARY DEPARTMENT CHECK AMOUNT: $5.00 ROOM 201, STATE HOUSE CHECK NUMBER: 202856 INDIANAPOLIS IN 46204 CHECK DATE: 10/19/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 209 4347500 5.00 NOTARY -KASS Do Not Write In This Box For Office Use Onl 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 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 ($5), payable to the Secretary of State, in lheform of check or money order. (Do not send currency in the mail.) (IC 33- 16 -2 -1) PRINT OR TYPE 1. NAME ��OS�.,_ I Yourl signature tn rich comniss ion will be issued see instruct ion #3 r 2. HOME ADDRESS j -i t-I 4 1 r I e C Numbs and street C la r m e I I q(003 3 C ivy St ate ZIP code 3. COUNTY OF RESIDENCE -{fir -M /fCQn 4. Business or Employer's Name Of,��?'�e��__� 5. Business or Employer's Address 0fJL_ 0AV1 A tA f'(Z- 1'me r (fv? v333 S trect L City State ZU' code 6. HOME PHONE 3 1f7) 79 4 y OFFICE PHONE (317) 5-7 I 2 7 7.S Area Code Number Ate. 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 COUNTY OF -a SS: pun in 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 1 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 (orunder the pains and penalties of perjury). Signature of applicant Plate officer's sea] Here Subscribed and sworn or affirmed to before me, this 1A—: day of ©G O✓3_ A.D. 201 IN TESTIMONY WHEREOF, I, A, L-4 r lJ�s S Printed or typed name of pffiCer a f�17 7L� tf tf �U ,AL C for the Signature of a notar public or other o a thooad to adminiva oaths Office County of /�1W 1 0Al State of Indiana. Officers munry ofresidmrn My commission expires: �'1 j L� �L� r o2C� �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 #I0. 10. NOTARIAL BOND KNOW ALL BY THESE PRESENTS, that we as principal Name afApplicant (applicant) and of Name of Surety Stroet address, city, s we &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 ual'sco fi ssion to LbL expiratiop date of the same. Signature of phe-t. M-1 be aeknowi edged Wowin Nll Signs tore of surd y. Must beacknowledged below in 412 11. ACKN WLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. I STATE OF 1 1� 1Jp COUNTY OF l L 55: 1 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 Jp S 4U Al S h I+ C 5 and acknowledged the execution of the foregoing bond for the uses and Printed or t yped name of applicant purposes therein expressed, without condition or reservation. nn 1 Place r Officers seal here IN TESTIMONY W HEREOF, I 2A l M L (3 Ass have hereunto set my P d nted or typed nam c of officer hand and official seal, this day of OG 7 _20 Signal— arth.,iz dofr— office for the County of J CL State of L P J D r.. Office is count y of rm idrnce My commission expires: c d3 aZ (a 12. ACKNOWLEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge his/her own signature) STATE OF COUNTY OF 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.) personalty appeared Printed or typed name of indivi dual signing as surety and acknowledged the execution of the foregoing bond for the uses and purposes therein expressed, without condition or reservation. Place Officer's seal here IN TESTIMONY WHEREOF, I have hereunto set my Pn n[ed or typed name of office hand and official seal, this day of 20— a Signature of authorized officer office for the County of State of Officer's roomy afra 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. signatureofsarety Place Officer's seal here IN TESTIMONY WHEREOF, I_ P have hereunto set my Printed or typed name of oBic¢ hand and official seal, this day of 20 a S igna ure of authorized officer office for the County of State of Officers eounty ofre5 idence 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 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 -12 -11 Notary Commission for Joslyn S. Kass per the $5.00 attached "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 Notary Department, Secretary of State IN SUM OF Room 201, State House Indianapolis, Indiana 46204 $5.00 s ONE ON FOR 3209 �1 Licenses Board Members DEPT INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify.that the attached invoice(s), or 209 0 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 f, 20// a Ti Cost distribution ledger classification if claim paid motor vehicle highway fund