179109 11/11/2009 CITY OF CARMEL, INDIANA VENDOR: 355652 Page 1 of 1
ONE CIVIC SQUARE AMERICAN CAMP ASSOCIATION
CHECK AMOUNT: $612.00
CARMEL, INDIANA 46032 5000 ST ROAD 67 NORTH
MARTINSVILLE IN 46151 -7902
CHECK NUMBER: 179109
CHECK DATE: 11/1112009
DEPARTMENT ACCOUNT PO NUMBER INVOI NUMBER AMOUNT DESCRIPTION
1046 4355300 28511 612.00 ORGANIZATION MEMBER
10/20/2009 Camp Operator 28511
CJCirTI -7e t^ -9 =C C1 0'1 S S O C I CI f I O P ®J
Camp Fee and Membership Renewal Invoice Y
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Return thts'form with corrections and remittance by ugtng thts.form and,faxIng o ,765,342,2065
t5is'f ifm "and malling;it,to:j5000,State "Road 67;LVorlh Marttnsvllle; IN�4fi151 J r
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Local Office: ACA Indiana PA Carmel Clay Parks and Recreation
Expiration Date: 2/28/2010 L �1 1411 E 116th St
1 71
Affiliation: Government, LocallGL Carmel, IN 46032 -3455
0 C i 2009
Phone: 317- 848 -7275
E -mail: bjohnson @carmelclayparks.com Web URL: http: /www.carmelclayparks.com ri,e a
#1 Camps: Accreditation services are included for up to four camps. If more than four are seeldng or maintaining
accreditation, add $100 for each additional camp.
Accreditation
Camp ID# Camp Name Status Contact
48872 Carmel Clay Parks Recreation Accredited Ben Johnson ID# 57437
Expiration Date: 02/28/2010
#1A: Please list other camps you wish to be separate Camp Affiliates of ACA or ACA Accredited Camps. Please note that camps listed here
seeking accreditation will require separate accreditation visits. Attach additional sheets if needed. Include these camps in your camp fee
calculation:
Name and Address of Camp Seeking Primary Contact for Camp (must be a member)
Accreditation
YorN
YorN
Y or N
Y or N
#1 B Camp Fee (see Camp Fee Table)
#1C Additional Accredited camps or camps seeking Accreditation add $100 for each camp after 4 f
#1D Camp Subtotal
Camp Fee Table
From column "A" select the dollar amount that represents the greater of your gross operating income or gross operating expense from all sources for the
camps listed. Column •'B" is the number of individual memberships included with your camp fees. Column '•C'• is the amount of your fees. Place the amount
from column "C" on line #1 B.
A B C A B C A B C
A [$0 $25,000] 1 $612 J [$700,001 $800,0001 2 $2,004 S [$8,000,001 $10,000,0001 8 $3,672
B [$25,001 $50,000] 1 $666 K [$800,001 $900,0001 2 $2,172 T [$10,000,001 $12,000,0001 9 $3,896
C [$50,001 $100,0001 1 $834 L [$900,001 $1,000,0001 2 $2,336 U [$12,000,001 $14,000,000] 10 $4,118
D [$100,001 $200,0001 1 $1,UO2 M 1,000;UU I $1,500,000j 3 52,616 "v i4;U0G,00'I ,1 o,00 u 0 i ll :$4,340
E [$200,001 $300,000] 1 $1,224 N [$1,500,001 $2,000,000] 3 $2,780 W [$16,000,001 $18,000,000] 12 $4,564
F [$300 001 $400,000] 1 $1,282 O [$2,000,001 $3,000,000] 4 $2,952 X [$18,000,001 $20,000,000] 13 $4,786
G [$400 001 $500,000] 1 $1,392 P [$3,000,001 $4,000,000] 5 $3,116 Z [$20,000,001 Please call the
H [$500 001 $600,0001 2 $1,778 Q [$4,000,001 $6,000,000] 6 $3,284 National Office for these rates
1 [$600 001 $700,000] 2 $1,892 R [$6,000 001 $8,000,000] 7 $3,448
#2 ACA Members affiliated with your camp or organization
#2A Members: Please place a check mark to indicate if the Individual Membership is included in your Camp Fee, or if you are paying for the
extra membership. See the Camp Fee Table for the number of included Individual Memberships. Additional Individual Memberships are
$200. Discount rates are available if you are an ACA Standards Visitor for $95, Retiree for $60, or Student Membership for $35. In this area,
please write in any other ACA members that belong to your organization that are not listed.
Included
Individual, Visitor, Retiree, or Affiliated with in Camp Operator Individual
Name Student Membership Camp Fee Paying Paying Amount
57437 Ben Johnson
ACA Indiana 48872 Expiration Date: 02/28/2010
OCT
3 t) 2009
Y
#2B New Additional Members: Please fill out the information below for other persons you wish to add to your membership list. Attach
additional sheets if needed. Please place a check mark to indicate if the Individual Membership is included in your Camp Fee, or if you are
paying for the extra membership. See the Camp Fee Table for the number of Individual Memberships. Additional Individual Memberships
are $200. Discount rates are available if you are an ACA Standards Visitor for $95, Retiree for $60, or Student Membership for $35. All new
members will receive a Member Information Update Form with their member ID card.
Included
Individual, Visitor, Retiree, or Affiliated with in Camp Operator Individual
Name and Address Student Membership Camp Fee Paying Paying Amount
Please indicate if one or more of the following apply:
Standards Visitor: Retiree: r tg!�$ Full -Time Student:
#2C`Ad .41L from #2A and .2BV. embership Subtotal
#3 Elective Dues and Contributions for ACA Liaison:
#3A Religiously Affiliated Camps Council $35.00
Open to any ACA member at a religiously affiliated camp. Offers newsletter, surveys, and networking.
#38 Not -for Profit Council $25.00
Open to any ACA member with a not for profit affiliation. Offers a newsletter and kindred meetings.
43D Elective Dues Subtotal
71 #4A ACA Annual Fund
Your contribution makes a difference in the camp world. With your important support, we spread the message that camp is
an essential part of healthy human development. Thanks for your tax deductible contribution! Suggested Contribution $250.00
#46 Invest in the Future of Youthl
Children are our future, and the skills learned and relationships fostered at camp are often life- changing stepping stones on the road to
adulthood. Yes, I'd like to contribute to send a child to camp now! Suggested Contribution $500.00
Indicate how acknowledgement must appear in letters and in publications:
Verification: Stopl Read this section) Camp Subtotal #1 D)
By submitting payment I affirm that: Membership Subtotal (#2C)
The statements made on this renewal are correct; Elective Dues Subtotal (#3D)
I meet the requirements for the membership category I Suggested Contribution Subtotal
have chosen; #4A/B)
I understand fees are renewable annually (They
cannot be refunded or transferred to another Total Remittance I
individual or to next yeaes and
For tax purposes, ACA fees may be deductible as a Individual Completing Form
business expense, but are not deductible as a C -Q CjOf4ktT
charitable contribution, with the exceptation of the
Payment Method
Check or Money Order Enclosed
Bill My: VISA MasterCard Discover
Acct No:
Expiration Date: Security Code:
The American Camp Association is a voluntary association
m far a at reserves the right is aCI.I�IIC me:��bers�ip y orria— Signature:
reason.
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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
Purchase Order No.
355652 American Camp Association, Inc. Terms
5000 State Road 67 North
Martinsville, IN 46151
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
10/28/09 28511 Membership fees 22831 F 612.00
Total 612.00
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
a
Voucher No. Warrant No.
355652 American Camp Association, Inc. Allowed 20
5000 State Road 67 North
Martinsville, IN 46151
In Sum of
1
612.00
ON ACCOUNT OF APPROPRIATION FOR
104 Program Fund
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1046 28511 4355300 612.00 1 hereby certify that the attached invoice(s), or
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
5 -Nov 2009
r` Signature
612.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund