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Home My WebLink About177059 09/15/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND i',�4'•, CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK CHECK AMOUNT: $807.60 NOBLESVILLE IN 46060 CHECK NUMBER: 177059 CHECK DATE: 9/15/2009 DEPARTMENT AC COUNT PO N UMBE R I NVOICE NUMBER AMOUNT DESCRIPTION 902 4347500 807.60 COBRA INSURANCE r: Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Sep -09 Donald: Medicare Part B $96.40 Amount due for September 2009 Humana Choice PPO 44.00 Total Don 140.40 Approved by Ron Carter Barbara: Anthem 809.72 Total Monthly 950.12 85% 807.60 Portion paid by City 15% 142.52 ANTHEM BCBS IN INDIVIDUAL INDI -MBI KY0303A645 003037 1351. Wm Howard Taft Affier 0 9. Cincinnati, OH 45206 -1775 An independent lk enscc of the Bl— Cross aad 131— Sludd Association. Anthem BI— Cross III- Si dd is dte trade of We And, —ltu Con,>anies, Inc. 011 gp t d nwks BWe Cross and Blue Shield Association. IDENTIFICATION 018M62629 091109 I V BL21226 IN] ND 3037 01 Due Date: 09 -01 -2009 ��1��1�� Billing Date: 08 -10 -2009 #BWNCQXF Coverage Period From: 09 -01 -2009 0 #AIM0000000000DS0 #INDI -MB I KY0303A645 Coverage Period Through: 09 -30 -2009 Cleveland, Barbara L Lq 141 Stony Creek Overlook Total Amount Due: $809.72 Noblesville, IN 46060 -5427 SEE REVERSE SIDE FOR BILLING DETAILS. Questions about your bill or interested in other payment options? Did you know you can make your payment over the phone? For assistance, please call the Customer Service phone number listed on the back of your Identification Card. Choosing to mail in your payment? Please allow 7 to 10 days to ensure timely processing of your payment. Please remember to list your 9 -digit Identification Number on your check, include the lower portion of this page and mail to the address specified. If you have already mailed in your payment, thank you for your continued membership with us. IMPORTANT NOTICE: If you have received a reminder notice from Anthem Blue Cross and Blue Shield regarding a past due payment, this bill includes all amounts that you owe to keep your policy in force. To avoid any lapse in coverage, the Total Amount Due listed on this bill must be received by the Due Date. Anthem Blue Cross and Blue Shield's issuance of this bill does not waive its contractual right to automatically terminate your coverage for failure to pay premiums in a timely manner. Payments recently mailed may not be reflected. DETACH AND RETURN THIS SECTION WITH YOUR PAYMENT DO NOT STAPLE MAKE CHECKS PAYABLE TO ANTHEM BLUR; CROSS BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber I1) From Date Through Date Due Date 018M62629 09/01/2009 09/30/2009 09/07 /2009 Amount Due Amount Paid $809.72 R05 7 Z Unit No. 002 INDI -MB I 7 —Gg 9;7 1. �j 7c�7� IIIIIIIIIIIIIIILIIIIIII11111 ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262970901200900000809720028 Si necesita ayuda en espanol Para entender este documento, puede solicitarla sin costo adicional, llamando at numero de servicio at clien.te yue aparece at dorso de su tarjeta de identification o en el folleto de inscription. Invoice 058783638 PRIOR BILLING PERIOD COVERAGE FROM 08 /01/2009 THRU 08 /31/2009 Previous Total Due $1,619.44 Payment Received on 07/29/2009 ($809.72) Payment Received on 07/18/2009 ($809.72) Outstanding Balance as of 08- 10- 2009 $0.00 CURRENT PERIOD COVERAGE FROM 09/01/2009 THRU 09/30/2009 Plan l l $809.72 Current Period 'Total $809.72 PLEASE PAY THIS AMOUNT $809,72 ibl3BINT)2/1813 B IND 00003037 000058783638 Fifth Third Bank I Manage Accounts Credit Card Account Activity Page 1 of 1 F=IFTH THIRia SANK' The Aings vve do for d r e ams: J a Account Balances Account Nicknames i Account Activity Welcome, DONALD H CLEVELAND Tues Se ptember 1, 2009 Accou Activi I A ccount Summary Account Statements Account: Statement Period Current Statement I Posted Transactions k ( Advanced Search: Keyword Posting Dat Transaction Date Debit Credit L Description 08/31/09 08/27/2009 $809.72 ANTHEM BCBS INS PMT IN 866 649 -2034 OH 08/26/09 08/25/2009 $920.92 MAIL PAYMENT BRANCH CINCINNATI OH Transactions and other information that appear on this page have occurred since your last statement cycle date. Please sell statement period to review previous account activity. I Disclosure /Error Resolution Copyright 2009 Fifth Third Bank, Member FDIC, n Equal Housing Lender, All Rights Reserved Contact Us I Service Center I Help FAOs I Privacy Security https: /www.53.com/servlet/efsonline/ account history .html ?TransSortCode= DATE,REV ER... 9/1/2009 CMS -500 (07/08) NOTICE O F MEDICARE PREMIUM PAYMENT DUE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES (CMS) BILLING NOTICE DATE: 05/27/2009 YOUR CLAIM NUMBER I 314-52-2281D5 Use Visa /MasterCard /American Express /Discover or make check /money order payable to "CMS Medicare DEB0104008 -T712 "3 -DIGIT 460 Insurance." Send payment with the bottom portion of DONALD H CLEVELAND this notice in the enclosed envelope to: 141 STONY CREEK OVERLK NOBLESVILLE IN 46060 -5427 Medicare Premium Collection Center P.O. Box 790355 St. Louis, MO 63179 -0355 Hospital Medical Total Insurance Insurance Amount Part A Part B Current amount due for 07/01/2009 09/30/2009 $674.80 $674.80 Past due amount S //A, �,S Total Amount Due $674.80 Part A: TERMINATION DATE: Part B: TERMINATION DATE: PAYMENT DUE BY: 06/25/2009 Last payment received: $289.20 on 10/21/2008 To ensure timely processing, payments must be received by 06/25/2009 Any payments received after this date will be included in your next notice. SEE OTHER SERE FOR, IMPORTANT [NFORMAT[O Please teat at clotted Eire and return bottom portion with Payment 'V* n If your name or address has changed or is incorrect, s notice. DONAL DONALD H. CLEVELAND 71-1323/749 1383 141 ST( BARBARA L. CLEVELAND 48033"485 NOBLE; 141 STONY CREEK OVERLOOK NOBLESVILLE, IN 46060 DATE AMOUNT Pi PAYTOTFIE __I yi- ORDFR Or �hc h 7�. d'(7 J' 1 25/2009 VISAIMAST DOLLARS q :ARE INSURANCE LI mW, Harns N.A. l1�tLL��.l. II EXP. DATE r� ENTER SIGNATUE MEMO i'P/ -Yl�� j {over) Year 2005 Manffi[y Premiums for Medicare Part A (Hospital Insurance) Monthly Premium Most people don't pay a Part A premium because they paid Medicare taxes while working. You pay up to $443'F each month if you don't get premium -free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly Income Is You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below $96.40' $85,001 $107,000 $170,001- $214,000 $134.90" $107,001- $160,000 $214,001- $320,000 $192.70' $160,0014213,000 $320,001- $426,000 $250.50' above $213,000 above $426,000 $308.30' Note: If you get a monthly benefit payment from Social Security, the RRB, or the Civil Service, you must have your Part B premiums deducted from your monthly benefit payment. If you don't get any of these benefit: payments and choose to sign up for Part B, you_ will get a bill. If you choose to buy Part A, you will always get a bill for your premium. You can mail your premium payments to the Medicare Premium Collection Center, P.O. Box 790355, St. Louis, MO 63179 -0355. If you get a bill from the RRB, mail your premium payments to RRB, Medicare Premium Payments, P.O. Box 9024, St. Louis, MO 63197 -9024. � W en espanol j] Toll -free: 1 800 372 2147 TTY users: 1 877 833 4486 iZ Print This Pag I A Enlarge Tex f I L He1a Return to Previous Screen Plan De Humana Choice PPO Plans PPO R5826 -008 Monthly Plan Premium: $44.00 PI n Premiums for Peo le with Extra Help R x Co Annual Part D Deductible $0.00 Annual Medical Deductible: $0.00 Maximum Medical Out -of- $5,000.00 Pocket: Prescription Drug Coverage: Amount you pay per prescription Type of Drug Stage 1 Stage 2 Stage 3 Stage $0 -$295 $296- Over 4` $2700 $2700 Over $4350 Preferred $7 $7 100% 5% Generic Preferred $40 $40 100% 5% Brand Non Preferred $65 $65 100% 5% Brand Specialty 33% 33% 100% 5% Physician Detail: c Option to see physicians in- or out- of the plan's network. c No referrals required. You pay more for out -of- network services. Doctor Office Visits: Primary Care Physician: $15.00 Copay Specialist: $35.00 Copay Hospitalization: $800.00 per admit https: /www.hum ana- medicare. comJSeni orWizard]\TET/Pl anDetails.aspx 3/27/2009 t t New address or e-mail? Print on back. I nitials Date 45691 BEXZ24009D DONALD H CLEVELAND 141 STONY CREEK OVERLOOK CARDMEMBER SERVICE NOBLESVILLE IN 46060 -5427 PO BOX 94014 PALATINE IL 60094 -4014 Statement Date: CH S E O 07/29/09 08/28/09 �j Manage your account online: w_ ww.ch _a se.com/creditcards Minimum Payment: $407.00 Payment Due Date: 09/22109 Additional contact information conveniently located on reverse side ACCOUNT SUMMARY Account Number: Previous Balance $18,932.07 Total Credit Line $30,000 Payment, Credits S1,277.78 Available Credit $9,628 Purchases, Cash, Debits +S2,661.40 Cash Access Line $30,000 Finance Charges +556.24 Available for Cash $9,628 New Balance 520,371.93 ACCOUNT ACTIVITY Date of Transaction Merchant Name or Transaction Description S Amount 08/16 Payment Thank You 1,200.00 08121 THE HOME DEPOT 2017 NOBLESVILLE IN -77.78 07/27 THE HOME DEPOT 2017 NOBLESVILLE IN 1,192.72 .07/29 THE HOME DEPOT 2017 NOBLESVILLE IN 246.80 07/27 WM SUPERCENTER SE2 NOBLESVILLE IN 4.00 08/01 HUMANA HEALTH PLAN,INC 08009922551 KY 44.00 08/02 SOFTWARE 1 -866 ZOOMBLI 08669666254 WA 49.85 07/31 WM SUPERCENTER SE2 NOBLESVILLE IN 15.00 08/03 WAL -MART #0923 SE2 NOBLESVILLE IN 5.71 08/10 INDIANA NEWSPAPERS INC 317 444 -8058 IN 18.05 08/10 SOUTHERNMOST HOTEL R KEY WEST FL 178.88 08/08 WAL -MART #0923 SE2 NOBLESVILLE IN 14.55 08110 WAL -MART #0923 SE2 NOBLESVILLE IN 47.00 08/16 YMCA OF GRTR INDIANAPO INDIANAPOLIS IN 32.00 08123 DELTA 00623139599633 ATLANTA GA 389.40 0105101 U IND ATL 2 U ATL EYW 3 U EYW ATL 4 U ATL IND 08/23 DELTA 00623139599622 ATLANTA GA 389.40 0105101 U IND ATL 2 U ATL EYW 3 U EYW ATL 4 U ATL IND 08/23 INFUSION RESTAURANT FISHERS IN 22.91 08/23 WM SUPERCENTER SE2 NOBLESVILLE IN 11.13 f'resc:ribed 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. P Payee (/on Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 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 IN SUM OF I J�Uhy �Y�e^� a Pd /f�o� FO 7 6cJ ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or gDZ °I U(a Y3 y75� E''U7,Go 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 3j 20 0p Signature Director of Operations Cost distribution ledger classification if Title claim paid motor vehicle highway fund