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Home My WebLink About173268 06/10/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND CHECK AMOUNT: $950.12 CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK N NOBLESVILLE IN 46060 CHECK NUMBER: 173268 CHECK DATE: 6/10/2009 DEPAR TMENT ACCOUNT PO NUM IN VOIC E NUMB AMOU DESCRIPTION 902 4347500 950.12 GENERAL INSURANCE Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Jun -09 Donald: Medicare Part B $96.40 Amount due for June 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 15% 142.52 Your 2009 Monthly Premiums fGr 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' 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' $160,001- $213,000 $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. Part R i en espanol HU A A I Nied ica re Toll -free: 1 800 372 2147 (;uidarwo wlicii you need it mait TTY users: 1 877 833 4486 Print This Pag Enlarae Text L He o Return to Previous Screen Plan D Humana Choice PPO Plans PPO R5826 -008 Monthly Plan Premium: 7 44. 00 PI n Premiums for Peo with Extra Help Rx Coverage: 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: Option to see physicians in- or out- of the plan's network. 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.humana- medicare. com/ SeniorWizardNET /PlanDetails.aspx 3/27/2009 ra�ciuli Chase Online Activity for Show Me my account activity ,taternent Trans Date Post Date Type Description Transaction Number Amount 04/2412009 04/24/2009 Sale STAMPXPRESS.COM(Services and Merchandise) 55480779114207376100067 $15.24 0411012009 04f I V2009 Sa C 94912099– —04 04/01/2009 04/03/2009 Sale HUMANA HEALTH PLAN,INC(Services and 55547519092542593012365 $44.00 Merchandise) Last Statement Balance$29,836.36 Search for Select Account Details for Select a Time Period Since I... t Slater on, From To You can search up to 90 days worth of activity online. Narrow Your Search Transaction Type Ali Merchant Name or Keyword 2009 JPMorgan Chase Co. https: cards. chase. com Account /AccountActivity.aspx ?AI= 63271542 4/27/2009 o f� S000 I $0.00 L- ri A ccount number: J Make your check payable to: Chase Card Services. Please write amount enclosed. New address or e-mail? Print oo back. 13848 HEX 1.1809 1) ' DONALD H CLEVELAND 141 STONY CREEK OVERLOOK CARDMEMBER SERVICE NOBLESVILLE IN 46060 -5427 PO BOX 94014 PALATINE IL 60094 -4014 Statement Date: 4C 04/29/09 05/28/09 Manage your account online: www, chase _con>%clecliicards Minimum Payment: $0.00 Payment Due Date: 06122/09 Additional contact information - Previous Balance Total Credit Line $30,000 Payment, Credits $600.00 Available Credit $755 Purchases, Cash, Debits +$149.79 Cash Access Line $30,000 Finance Charges +$79.06 Available for Cash $755 New Balance ACCOUNT ACTIVITY Date of Amount Tran sactio n Merchan Name or Tran saction Desc ri�ltion 600.00 05/21 Payment Thank You 28.68 04/27 NITRO MODELS INC 626 -968 -9860 CA 44 00 /ice 05/02 HUMANA HE ALTH PLAN INC 8009922551 KY 05/05 �M JCPENNEY.COM 800- 221 -0827 OH 33.1 I 05/11 INDIANA NEWSPAPERS INC 317- 444 -8058 IN 12.00 05116 YMCA OF GRTR INDIANAPO INDIANAPOLIS IN 32.00 FINANCE CHARGE Finance Charge Transaction Daily Periodic Rate Corresp, Average Daily Due To Fee Accumulated FINANCE Category 30 clays in cycle APR Balance Periodic Rate Service Charge Fin Charge CHARGES Purchases V .00890% 3.25 $72.16 $0.00 $0.00 $72.16 Cash advances V .05271% 1924% $0.00 $0.00 $0.00 $0.00 $0.00 Convenience check V .00890% 3.25% $578.27 $1.54 $0.00 $0.00 $1_54 Balance transfer V .00890% 3.25 $5.36 $0.00 $0.00 $5.36 $79.06 Total finance charges Effective Annual Percentage Rate (APR): 3.25% Please see Information About Your Account section for balance computation method, grace period, and other important information. The Corresponding APR is the rate of interest you pay when you carry a balance on any transaction category. The Effective APR represents your total finance charges including transaction fees such as cash advance and balance transfer fees expressed as a percentage. IMPORTANT NEWS 'Fifth Third Bank Manage Accounts Credit Card Account Activity Page 1 of 1 ANK The things we do for dreams: ME 1p a Account Balances Account Nicknames Acco unt Activity Welcome, DONALD H CLEVELAND Tuesday June 2 2009 Account Activity I Account Sma..ry Account..S.tatements Export History um Account: Statement Period- Current Statement Posted Transactions ( Advanced Search: '10 Keyword'. Posting Date Transaction Date Debit( credit( Description Action 0 05/28/2009 $809.72 ANTHE�BCBS I 05/25/09 05/22/2009 $500.00 MAIL PAYMENT BRANCH CINCINNATI OH Transactions and other information that appear on this page have occurred since your last statement cycle date. Please select another statement period to review previous account activity. I Disclosure /E rror Resol ution Copyright 6< 2009 Fifth rhird Bank, Member FD ?C, t1 Equal H(xising {-ender, All Richn Reserved Contact_us I Service Center I Help I FAQs I Privacy &_Security https: /www.5 3 com/servlet/efsonline/ account history. html ?Trans S ortCode= DATE,REV ER... 6/2/2009 ANTHEM BCBS IN INDIVIDUAL INDI -MB1 KY0303A645 1351 Wm Howard Taft Anthem; Q d Cincinnati, OH 45206 -1775 An independent Bccnsee of the Blue Cmu und Blue Shield Anociation, Anthem Blue Cron Blue Shield is the trade omoo of the Anthem hrsunnce Companies, Inc. ®Registered muffs Blue Cmn and Blue Shield Assoculdon. 0512091VM20071 WWD 881101 IDENTIFICATION 018M62629 Due Date: 06 -01 -2009 1 11 11 1111 I I I I I I I I 1 1111111111 1 11 1 11 I I I I I I I I I I I I I I I I I I I I I I Billing Date: 05 -10 -2009 o #BWNCQXF Coverage Period From: 06 -01 -2009 0 0 0 0 #AIM0000000000DS0 #INDI -MB 1 KY0303A645 Coverage Period Through: 06 -30 -2009 Cleveland, Barbara L 141 Stony Creek Overlook Total Amount Due: $809.72 Noblesville, IN 46060 -5427 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. RS DO �DETAl r>< •Y „><,C 11UN WIMAY CKS PAYABLE TO ANTTHE ®BLUE ST APL E BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber ID From Date Through.Date Due Date 018M62629 06/01/2009 06/30/2009 06/01/2009 Amount Due Amount Paid $809.72 D '7 Unit No. 002 INDI -Mg I 5 2g N/ /G G� y ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 Si necesita ayuda en espanol para entender este documento, puede solicitarla sin costo adicional, llamando al mimero de servicio al cliente que aparece al dorso de su tarjeta de identificacidn o en el folleto de inscription. Invoice 055926071 PRIOR BH LING PERIOD COVERAGE FROM 05/01/2009 THRU 05/31/2009 Previous Total Due $809.72 Payment Received on 04/18/2009 ($809.72) Outstanding Balance as of 05 -10 -2009 $0.00 CURRENT PERIOD COVERAGE FROM 06/01/2009 THRU 06/30/2009 Plan 11 $809.72 Current Period Total $809.72 PLEASE PAY THIS AMOUNT $809.72 ib13BIIVD3/IB13_B_ ND_00008811_WO055926071 1� .sE Ae w �£:j. V. �.'�l": $Y r. xa �...e Y ,R ,;2z.P;.,e. d. Prescribed by Slate Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995) 1 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 /oiy Purchase Order No. C reek Qy Pr4Z Terms J Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Po *;7 60 Total 907 60 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 7UCHER NO. WARRANT NO. ALLOWED 20 Dom C /pv IN SUM OF 5"C) ON ACCOUNT OF APPROPRIATION FOR 90 2 Z(3 Y7sD6) Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or g�Z 06 0 5' 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 6l 8 20 0 Signature Director of Operations Title Cost distribution ledger classification if claim paid motor vehicle highway fund