173268 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
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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
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Transaction Type Ali
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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