176188 08/19/2009 CITY OF CARMEL, INDIANA VENDOR: 00351684 Page 1 of 1
ONE CIVIC SQUARE CLERK OF THE COURTS ANNUAL FEES
CARMEL, INDIANA 46032 CHECK AMOUNT: $460.00
P O BOX 6069 DEPT 179
INDIANAPOLIS IN 46206-6069 CHECK NUMBER: 176188
CHECK DATE: 8/19/2009
DEP ARTMENT ACCOUNT PO NUM BER INVO N UMBER AM OUNT DES CRIPTION
1180 4355300 HANEY /PERKIN 230.00 ORGANIZATION MEMBER
1160 4355300 NORRIS 115.00 ORGANIZATION MEMBER
1160 4355300 STMT 115.00 ORGANIZATION MEMBER
First Notice
18428 -49
S UP R EME JQ usllep��A INDIANA SUPREME C® R QYActive
o :'F:..........,P
s? Current Status'. Active
�s
im l .4% :Z 115.00
ANNUAL REG 'STATEMEN
C CC PAY ANNUAL ATTORNEY FEE FOR ACTIVE OR INACTIVE STATUS
If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current
information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here:
MR THOMAS PERKINS II
3RD FLOOR 14150 EQUINE COURT
ONE CIVIC SQUARE WESTFIELD, IN 46074 -0000
CARMEL, IN 46032
Please provide your current phone number, facsimile number, and email address:
Phone: 5 5 r Zy Z Fax: 3 J Z'� Email: �'CL�� 2 .l (/I U t �j/
ti
'TOTAL AMOUNT DUE RETURN °1'1.115 STATEMENT WITH YOUR CHECK ))BADE PAYABLE TO:
Postmark 'Date Active Status Inactive Status Address for annual fees mailed in Address for annual fees personally delivered
Clerk of the Courts Annual Fees Clerk of the Courts Annual Fees
8/ 1 10/ i 1 1'5.00 57.50 P.O. Box 6069 Dept. 179 402 W. Washington St., Rm. W062
0/Z 10/ 15 $186.00 107.50 Indianapolis, IN 46206 -6069 Indianapolis, IN 46204
16/16 12/3.1 $230.00 S 1.57.50 OR PAY YOUR ANNUAL FEE AND UPDATE YOUR PNFORMAT1ON
AFTER 12131 $380.00 $157,50 ON THE CLERK OF COURTS WEBSITE! (See below)
INSTRUCTIONS FOR COMPLETING YOUR ANNUAL FEE STATEMENT ONLINE: To pay your annual fee and /or change your contact
information with the Roll of Attorneys online, go to http: /courts.in.gov /cofc and click on the link to "Attorney Registration Online."
IMPORTANT: A convenience fee of $3.50 plus 2% of your total attorney fee due (including any penalty for late payment) is charged by
accesslndiana for payment by credit card.
REQUI "IOL'TA C ERTIFICATION-
'lease check one of the following:
F] I /my:firrim participate(s) in Indiana's IOLTA program Compliance with Rule: 1.15 was completed by creating and maintaining (an) interest-
bearing trust account(s) for qualified clients' funds. [Enrollment forms and IOLTA ;information are'available at www.inbf.org or call the
Indiana Bar Foundation.at 317- 269 2415]
Indiana IOLTA Account FinanciaiInstitution'
IOLTA Account` Number.
Attorney /.Law.Firm Name:.'
NOTE: Ifyou maintain multiple IOLTA accounts, please attach information 'on additional accounts to this form.
I /my, irm maintain(s) an IOLTA account in ,a state other than Indiana.
JI am exemptfrom mintining an IOLTA account because:
J
'earn, not in the private practice of.law, or my practice does not involve Indiana client.trust funds, or I do not have an office_ within
the State.of Indiana,
I am a judge; an attorney employed by a local, state, or federal government 'on-duty with<fhe :armed services; a corporate counsel;
or a teacher of law; and 'I am not otherwiseengaged in the private'.practice of law:
F Participation in the IOLTA program would work an undue hardship on me; and /or Would be:extremely impractical based on the
geographic distance between my principal office and theclosest depository institution participating iri the IOLTA program and /or
other,compelling and necessitous factors Please attach on separ to pieceofpaper an explanation of; why you are seeking this
undue hardship exemption:
IMPORTANT! IF YOU NOT COMPLETEYOUR IOLTA;CER'TIFICAT116 1 YOUR STATEMENT AND
CHECK WILL,BE RETURNIED TO YOU, AN® YOU MAY OWE A_LATE FEE
.v
Please see reverse side.
AFFIDAVIT OF INACTIVITY OR RETIREMENT
I wish to place or retain my Indiana law license in inactive 1 wish to place my Indiana law license into retired status. I am
status. I am currently in either active or inactive good currently in either active or inactive good standing status: I
standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law
the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this
carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys
who do not plan to return to the practice of law.
I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true.
Date: Signature:
ATTORNEY SURROGATE DESIGNATION
If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company
(LLC), professional corporation (PC), limited liability partnership (LLP), another lawyer, or an organization not engaged in the private practice
of law, then pursuant to Admission and Discipline Rule 23 27(b)( 1) you may designate a member in good standing of the Indiana Bar to act
as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment.
j I hereby designate the following member in good standing of the Indiana bar to act as my attorney surrogate pursuant to Admission I;
and Discipline Rule 23 27 (NOTE: Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem-
bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary Entity rather than a specific attorney —see
Admis. Disc. R. 23 2 7:(b)( 2
Surrogate
i; or Entity: Bar No.:
ii
If I have listed a surrogate attorney above, then by signing below I certify that s /he has agreed to this designation in writing
and that we both have copies of the agreement in our possessions. (NOTE: Designation invalid without this certification.)i,
I
1 Date: Signature: i
i
OPTIONAL RACE/ETHNIC INFORMATION
In an effort to obtain accurate information about diversity within Indiana's legal profession, the Indiana Supreme Court, through its Commission on
Race and Gender Fairness, requests that attorneys fill out the following demographic information:
GENDER: ,!:5 sale E Female
RACE: 7 Caucasian F] African American El American Indian /Native American
Asian American Hispanic /Latino Other
CONTACT US Clerk of the Suppreme
Court, Court of 'Appeals,
For all IOLTA questions, please contact the Indiana Bar Foundation at 800 -279 -8772 or and Tax Court
IOLTA @inbf.org. 200 W Washington St.,'Rm. 216
Indianapolis, IN .462042795
For all questions about the Attorney Annual Fee Process, please contact the Roll of Attorneys PHO: 317 -232 -1930
Administrator at 317- 232 =5861 or rollatty @courts.state.in.us. FAX: 317 -232 -8365
clerk @courts.state.in.us
Visit the Clerk's website at http /courts.IN.gov /cofc.
First Notice
11207 -49
LECOEHLR
�'�e`O 1 N ®'ANA SUPREME COUR
Current Status: Active
ee •.oy,•z 1 1 5 0
U L DEGISTRATION STATEMENT
fDCCCiN�
PAY ANNUAL ATTORNEY FEE FOR ACTIVE OR INACTIVE STATUS
If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current
information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here:
MR DOUGLAS HANEY 1 38 2 S S"A l uQ
1 CIVIC SQUARE
CARMEL, IN 46032 CARMEL, IN 46033 -0000
Please provide your current phone number, facsimile number, and email ail address: j
Phone: 3�� 2t(7� Fax: 9 7 7 I Z`f Email: O( Aakw 6D C a 1 goje
TOTAL AMOUNT DUE RET ATEMENT WITH YOUR CHECK MADE PAYABLE TO:
Postmark Date Active Status Inactive Status Address for annual fees mailed in Address for annual fees personally delivered
Clerk of the Courts Annual Fees Clerk of the Courts Annual Fees
P/1 -10/1 $115.00 57:50. P.O. Box 6069 Dept. 179 402 W. Washington St., Rm. W062
10/2 -10/15 180.00 107.50 Indianapolis, IN 4---- 6- Indianapolis, IN 46204
10/16 12/31 $230.00 $157.50 OR PAY YOUR ANNUAL FEE AND UPDATE YOUR INFORMATION
AFTER 12/31 $380.00 $157.50 ON THE CLERIC OF COURTS WEBSITE" (See below)
INSTRUCTIONS FOR COMPLETING YOUR ANNUAL FEE STATEMENT ONLINE: To pay your annual fee and /or change your contact
information with the Roll of Attorneys online, go to http /courts.in.gov /cofc and click on the link to "Attorney Registration Online."
IMPORTANT: A convenience fee of $3.50 plus 2% of your total attorney fee due (including any penalty for late payment) is charged by
accesslndiana for payment by credit card.
REQUIRED IOLTA. CERTIFICATION
Please check one.of the following:
I /my firm participate(s) in Indiana's IOLTA program. Compliance with Rule 1.15 was completed by creating and maintaining (an) interest
bearing trust account(s) for qualified clients" funds. [Enrollment forms and IOLTA information are available at www.inbf.org, or call the
Indiana Bar Foundation at 317 -269- 2415.]
Indiana IOLTA Account Financial Institution:
IOLTA Account Number:
Attorney /Law Firm Name:
NOTE: If you maintain multiple IOLTA accounts, please attach information on additional accounts to this forma
I/my firm maintain(s) an IOLTA account in a state other than Indiana.
I am exempt from maintaining an IOLTA account because:
1 am not in the private practice of law, or my practice does not involve Indiana client trust funds, or I do not have an office within
the State of Indiana.
am a judge; an attorney employed by a local, state, or federal government, on duty with the armed services; a corporate counsel;
or a teacher of law; arid I am not otherwise engaged in the private practice of law.
Participation in the IOLTA program would work an undue hardship on me and /or would be extremely impractical based on the
geographic distance between my principal office and the closest depository institution participating in the IOLTA program and /or
other compelling and necessitous factors. Please attach on a separate piece of paper an explanation of why you are seeking this
undue hardship exemption.
IMPORTANT! IF YOU ®O NOT COMPLETE YOUR IOLTA CERTIFICATION, YOUR STATEMENT AND
CHECK WILL BE RETURNED TO YOU, AND YOU MAY OWE A, LATE FEE
Please see reverse side.
AFFIDAVIT OF INACTIVITY OR RETIREMENT
I wish to place or retain my Indiana law license in inactive El I wish to place my Indiana law license into retired status. I am
status. I am currently in either active or inactive good currently in either active or inactive good standing status: I
standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law
the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this
carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys
who do not plan to return to the practice of law.
I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true.
Date: Signature:
ATTORNEY SURROGATE DESIGNATION
If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company
(LLC), professional corporation (PC), limited liability partnership (LLP(, another lawyer, or an organization not engaged in the private practice
of law, then pursuant to Admission and Discipline Rule 23 27(b((1) you may designate a member in good standing of the Indiana Bar to act
as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment.
1 hereby designate the following member in good standing of the Indiana bar to act as my attorney surrogate pursuant to Admission
I; and Discipline Rule 23 27 (NOTE: Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem-
bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary Entity rather than a specific attorney —see I
Admis. Disc. R. 23 27(b)(2(): it
I Surrogate
or Entity: Bar No.:
l
If I have listed a surrogate attorney above, then by signing below I certify that s /he has agreed to this designation in writing
and that we both have copies of the agreement in our possessions. (NOTE: Designation invalid without this certification.
Date: Signature:
I Ij
OPTIONAL RACE /ETHNIC INFORMATION
In an effort to obtain accurate information about diversity within Indiana's legal profession, the Indiana Supreme Court, through its Commission on
Race and Gender Fairness, requests that attorneys fill out the following demographic information:
GENDER: 7 Male Female
RACE: n Caucasian I African American L1 American Indian /Native American
Asian American F� Hispanic /Latino Other
CONTACT US Clerk of the Sup
Court, Court of Appeals,
For all IOLTA questions, please contact the Indiana Bar Foundation at 800 -279 -8772 or and Tax Court
IOLTA @inbf.org. 200 W. Washington St., Rm. 216
Indianapolis, IN 46204 -2795
For all questions about the Attorney Annual Fee Process, please contact the Roll of Attorneys PHO: 317- 232 -1930
Administrator at 317- 232 -5861 or rollatty @courts.state.in.us. FAX: 317- 232 -8365
clerk@courts.state.in.us
Visit the Clerk's website at http /courts.IN.gov /cofc.
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
Clerk of the Courts Annual Fees
Purchase Order No.
P. O. Box 6069 Dept. 179
Terms
Indianapolis, Indiana 46206 -6069
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
8 -5 -09 Annual Fee 2009 -2010 for:
Douglas C. Haney, Carmel Cit Attorney an
per the attached Statements
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
Clerk of the Court Annual Fees IN SUM OF
P. O. Box 6069 Dept. 179
Indianapolis, IN 4620
$230.00
ON ACCOUNT OF APPROPRIATION FOR
Department of Law
430 -55300 Dues
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
DOL aney $115.00 bill(s) is (are) true and correct and that the
erkins 115.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20 0 Cl
4� 1�1 Si nature
Cost distribution ledger classification if Tit le
claim paid motor vehicle highway fund
karst Notice
19106 -49
J4�•' pg y,��T T2WL07NX
0. 8 1 N 9 A N A S U PR EM E COU Current Status: Active
IV
115.00
wit: n.
C
O
7: R
ANNUAL REGIST
PAY ANNUAL ATTORNEY FEE FOR ACTIVE OR INACTI VE STATUS
If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current
information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here:
MS NANCY HECK
1326 COOL CREEK DRIVE CITY OF CARMEL
CARMEL, IN 46033 -2315 1 CIVIC SQUARE
CARMEL, IN 46032 -0000
Please provide y ur current phone number, fac number, and email address:
Phone: /7 571 q Fax: Email:
TOTAL AMOUNT DUE RETURN THOS STATEMENT WOTH YOUR CHECK MADE PAYABLE TO.
Postmark Date Active Status Inactive Status Address for annual fees mailed in Address for annual fees personally delivered
1 15.00 57.50 Clerk of the Courts Annual Fees Clerk of the Courts Annual Fees
8 P.O. Box 6069 Dept. 179 402 W. Washington St., Rm. W062
10/2- 10/15 180.00 $107:50 Indianapolis, IN 46206 -6069 Indianapolis, IN 46204
10116 $230.00 $157.50 OR OKAY YOUR ANNUAL FEE AND UPDATE YOUR ONFORMATOON
AFTER 12131 $380.00 $157.50 ON THE CLERK OF COURTS WEBSOTE° (See below)
INSTRUCTIONS FOR COMPLETING YOUR ANNUAL FEE STATEMENT ONLINE: To pay your annual fee and /or change your contact
information with the Roll of Attorneys online, go to http: /courts.in.gov /cofc and click on the link to "Attorney Registration Online."
IMPORTANT: A convenience fee of $3.50 plus 2% of your total attorney fee due (including any penalty for late payment) is charged by
accesslndiana for payment by credit card.
REQUIRED IOLTA CERTIFICATION
Please check one of the following:
I /my firm participate(s) in Indiana's IOLTA program. Compliance with Rule 1.15 was completed by creating and maintaining (an)-interest-
bearing trust account(s) for qualified clients' funds. [Enrollment forms and IOLTA information are available at www.inbLorg, or call the
Indiana Bar Foundation at 317- 269 2415.]
Indiana IOLTA Account Financial Institution:
IOLTA Account Number:
Attorney /Law -Firm Name:
NOTE: If you maintain multiple IOLTA accounts, please attach information on additional�accounts to this form
El I/my firm maintain(s)'an ]OLTA account in a state other than Indiana
IT1 f.am exempt from maintaining an IOLTA account because:
XI am not in the private practice of law, or my practice does not involve Indiana client trust funds, or 1 do not-have amoffice within
he State of Indiana.
I am a judge; an, attorney employed by a local; state, or federal government; onduty:with the armed services; a corporate counsel;
or_a teacher of law, and I am not otherwise engaged in the private of law.
Participation in the IOLTA program would work an undue hardship on me and /or would be extremely impractical based on the
geographic distance between my principal office and the closest depository institution participating in the IOLTA program and /or
other compelling and necessitous factors. Please attach on a separate piece of paper an explanation of why you are seeking this
undue hardship exemption.
"I MPORYANTT IF YOU DO NOT COMPLETE YOUR IOLTA CERTIFICATION, YOUR STATEMENT ARID
CHECK W ILL BE RETURNED TO YOU, AND YOU MAY O A LATE FETE
Please see reverse side. 0!'�yt/f
AFFIDAVIT OF INACTIVITY OR RETIREMENT
0 1 wish to place or retain my Indiana law license in inactive 1 wish to place my Indiana law license into retired status. I am
status. I am currently in either active or inactive good currently in either active or inactive good standing status. I
standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law
the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this
carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys
who do not plan to return to the practice of law.
I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true.
I;
Date: Signature:
ATTORNEY SURROGATE DESIGNATION
If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company
(LLC), professional corporation (PC), limited liability partnership (LLP), another lawyer, or an organization not engaged in the private practice
of law, then pursuant to Admission and Discipline Rule 23 27(b)(1) you may designate a member in good standing of the Indiana Bar to act
as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment.
1 hereby designate the following member in good standing of the Indiana bar to act as my attorney surrogate pursuant to Admission I
and Discipline Rule 23 27 (NOTE: Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem-
bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary Entity rather than a specific attorney —see i
Admis. Disc. R. 23 27(b)(2)):
I
Surrogate
or Entity: Bar No.:
If 1 have listed a surrogate attorney above, then by signing below 1 certify that s /he has agreed to this designation in writing
and that we both have copies of the agreement in our possessions. (NOTE: Designation invalid without this certification.)
Date: Signature:
OPTIONAL RACE /ETHNIC INFORMATION
In an effort to obtain accurate information about diversity within Indiana's legal profession, the Indiana Supreme Court, through its Commission on
Race and Gender Fairness, requests that attorneys fill out the following demographic information:
GENDER: Male Female
RACE: Caucasian African American Fl American Indian /Native American
Asian American Hispanic /Latino F] Other
CONTACT US Cleric of the Supreme
Court, Court of Appeals,
For all IOLTA questions, please contact the Indiana Bar Foundation at 800 279 -8772 or and.Tax Curt
IOLTA @inbf.org. 200 W. Washington St., Rm. 216
Indianapolis, IN 46204 -2795
For all questions about the Attorney Annual Fee Process, please contact the Roll of Attorneys PHO: 317- 232 -1 -930'
Administrator at 317 -232 -5861 or rollatty@courts.state.in.us. FAX:317 232 8365
clerk @courts.state.in.us
Visit the Clerk's website at http: /courts.IN.gov /cok.
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
8/17/09 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.
d
Payee
Clerk of the Courts Annual Fees Purchase Order No.
P. 0. Box 6069 Dent 179 Terms
Indianapolis IN 46206 -6069 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
8/17/09 Stmt Membership for Nancy Heck $115.00
Total $115.00
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
VOUCHER NO. WARRANT NO.
8/17/09
ALLOWED 20
Clerk of the Courts Annual Fees IN SUM OF
P. 0. Box 6069 Dept 179
Indianapolis IN 46206 -6069
115.00
ON ACCOUNT OF APPROPRIATION FOR
1160 Mayor 4355300
Organiza Membership Dues
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Stmt 4355300 $115.00 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
20
i Sign S
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
First Notice
10131 -49
INDIANA S U P R E Current Status: CL Acti e
115.00
009/ 10ft A OI?qhNEY Z-/ CC 1:r �c
NNUAL REGISTRATION STATEMENT
PAY ANNUAL ATTORNEY FEE FOR ACTIVE OR INACTIVE STATUS
If your status is inactive, you MUST complete the Affidavit of Inactivity on the reverse side of this statement. You have a duty to provide current
information to the Clerk. If either address listed below is no longer valid, then please make any necessary corrections here:
�y�y
MR RRELL NORRIS CF'
101 ND A S.W. #2C 101 2ND AVENUE, S.W. #2C
CARMEL, IN 46032 -2027 CARMEL, IN 46032 -2027
M� 6
Please provide your current pho r i e er, and email address:
Phone: Fax: �/E ��✓�7 i y Email:
TOTAL AMOUNT DUE IS STATEME BT YOUR CHECK MADE PAYABLE TO:
Date Active Status Inactive St s Address for annual fees mailed in Address for annual fees personally delivered
❑PL of the Courtc -Annual Fees Clerk of the Courts Annual Fees
8/ 1 10 /'l $1 15:00 $'.'S 0 1�Oox 6069 Dep `l�� 402 W. Washington St., Rm. W062
10/2 10/15 180 07..50 Indianapolis, IN 46206 -6069 Indianapolis, IN 46204
16.-1 S 157 50
OPT PAY YOUR ANNUAL IEEE AND UPDATE YOUR ON FORMATPON
AFTER l2131 $380:00 -5o
Ogg THE CLERK OF COURTS WEBSPTE! (See below)
INSTRUCTIONS FOR COMPLETING YOUR ANNUAL FEE STATEMENT ONLINE: To pay your annual fee and /or change your contact
information with the Roll of Attorneys online, go to http /courts.in.gov /cofc and click on the link to "Attorney Registration Online."
IMPORTANT: A convenience fee of $3.50 plus 2% of your total attorney fee due (including any penalty for late payment) is charged by
accessindiana for payment by credit card.
6aE�UI I®L'TA-'CEitTI ICA'f'ION.
Please efieck one�of the:following �z 1
I /my firm partiapa.te(s) In Indiana _s IOLTA °program:. Compliance with "Rule 115 was completed by creating and maintaining (an) interest
bearing trust account(s);for qua,fified clients' :funds. [Enrollment forms and'IOLTA-inforr iation are available at wvvw.inbf.org, orcall the
Indiana 13arFoundation at 31J 269 -2415 j
Indiana 1OLTA Account Finanncial Institution pRo S�R7 C N/t
IOLTA "Ac ountNumber C'C D
Attorne Law Flrm_Name. E
y/
.NOTE.-- If you marntain multiple IOLTA accounts please attach InformaUOn. o iiddlbonal accounts to this form t• w
r
5.
iA❑ I /my firm mamtam(s)`an'IOLTA account in a state other than ndiana
1 am exempt from maintalnirig an IOLTA account because
I am not in the private practice of law or my,practice does notinvolve Indiana client- trustfunds, or I do not have an office wmthm
the:State of:lndmana
a I am a judgen attomey employed;6y a local state; or federal government; on duty with the armed services a corporate counsel;
or a;teacherof law;
and I ,am.not.otherwise engaged rn the,private practice of law.
Participation in the 1OLTA program -would work, an undue hardship on me and /or would be extremely impractical based on the
geographic distance between my principal office and the closest depository institution participating in the IOLTA program and /or
other compelling and necessitous factors. Please attach on a separate piece of paper an explanation of why you are seeking this
undue hardship exemption.
II�PORTAi�T! IF YOU DO NOT COMPLETE YOUR IOLTA CERTIFICATION, YOUR STATEMENT AND
CHECK WILL BE RETURNED TO YOU, AND YOU MAY OWE A LATE FEE
Please see reverse side.
`AF OF INACTIVITY OR RETIREMENT
I wish to place or retain my Indiana law license in inactive I wish to place my Indiana law license into retired status. I am
status. I am currently in either active or inactive good currently in either active or inactive good standing status. I
standing status. I neither hold judicial office nor engage in neither hold judicial office nor engage in the practice of law
the practice of law in Indiana. I understand that this status in Indiana. I am at least 65 years old. I acknowledge that this
carries a reduced annual registration fee of $57.50. status, which carries no registration fee, exists for attorneys
who do not plan to return to the practice of law.
I swear or affirm under penalties of perjury that the foregoing statements regarding my inactivity or retirement status are true.
Date: Signature:
I'
ATTORNEY SURROGATE DESIGNATION
If you engage in the private practice of law in Indiana and do not practice solely as an employee of a partnership, limited liability company
(LLC), professional corporation (PC), limited liability partnership (LLP), another lawyer, or an organization not engaged in the private practice
of law, then pursuant to Admission and Discipline Rule 23 27(b)(1) you may designate a member in good standing of the Indiana Bar to act
as your attorney surrogate should you become unable to practice law due to death, disappearance, disability, suspension, or disbarment.
'I hE designate the following member in good.standing of the Indiana bar to act as my attorney surrogate pursuant to Admission j
anspline R ule 23 27 (NOTE: Partners, shareholders, owners, and other non employee lawyers practicing with one or more mem-
i bers of the Indiana Bar within partnerships, LLCs, PCs, or LLPs should designate their Fiduciary thanes specific attorney —see
Admis. Disc: R: -23 27(b)(2)):
i
Surrogate
or Entity: Bar No.:
If I have listed a surrogate attorney above, then by signing below I certify that s /he has agreed to this designation in writing
and that we both have copies of the agreement in our possessions. NOTE: Designation invalid without this certification.)
Date: Signature:
I
OPTIONAL RACE /ETHNIC INFORMATION
In an effort to obtain accurate information about diversity within Indiana's legal profession, the Indiana Supreme Court, through its Commission on
Race and Gender Fairness, requests that attorneys fill out the following demographic information:
GENDER: Male Female
RACE: Caucasian African American American Indian /Native American
Asian American Hispanic /Latino Other
CONTACT .US Clerk of the Supreme.
Court, Court.or Appeals;
For all IOLTA questions, please contact the Indiana Bar Foundation at 800 -279 -8772 or e' nd .'i a x Court
IOLTA@inbf.org. 200 W. Washington St.,. Rm. 216
Indianapolis IN 46204-2795
For all questions about the Attorney Annual Fee Process, please contact the Roll of Attorneys RHO: 317- 232 =19310
Administratorat.317 -232- 5861 orrollatty @courts.state.in.us: FAX: 317- 232 -8365
clerk @courts.state.in.us
Visit the.Clerk's website at http /courts.IN.gov /cok.
Prescribed by Slate Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
8/17/09 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
Clerk of the Courts Annual Fees Purchase Order No.
P. 0. Box 6069 Dept 179 Terms
Indianapolis IN 46206 -6069 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
8/17/09 Stmt An
Total $115.00
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
VOUCHER NO. WARRANT NO.
8/17/09
f ALLOWED 20
Clerk of the Courts Annual Fees IN SUM OF
P. 0. Box 6069 Dept 179
Indianapolis IN 46206 -6069
115.00
ON ACCOUNT OF APPROPRIATION FOR
1160 Mayor 4355300
Organization Membership Dues
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Stmt 4355300 $115.00 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
20
Y 4 A
,ff11 Signature
mM,m,�w��'7't� V,
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund