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Home My WebLink About171794 04/29/2009 CITY OF CARMEL, |NO|ANA »swmon� 36e529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND CAnMEL.|ND�Nx4On32 ,m STONY CREEK mEnux� CHECK AMOUNT: $826.72 wooLsuv/us/w 4606 CHECK NUMBER: 171794 CHECK DATE: wumuooy ospAnTmswT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT osooR|pTmm 902 4230200 15.24 OFFICE SUPPLIES 902 4239099 3.98 OTHER MZSCELIA00lJS 902 4347500 807.60 H INS-CLEVELAND, Use Your 2% SIG CARD REBATE M ENARDS CARM L 1. 2'.1 '_)O E. GreyVic)i-irid Pas Carmel, 'M KEEP. YOUR RECIFIP] RETURN POLICY VARTES BY PROPUM TYPE Allowable ral!1ins For items on, this rec'eipt vJ1 he the form 01 an 9 s1hore credit vou,-,!r if thl- return is done after 079199 Hill 1111111111111111111111111111111111111111111 Sale "'ailsaction 1.1-3 3 APPLTANFIE CP; 370 c ow Fl TAX AT 7% TOTAL SALE 4.K CAS1 I Km DA6E TOTAi- 04 JEy =l N.Am" YOU, YOUR Qd k6 2 3056C Cf; 6223" 1 1 2 :53M '30E'13 i Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995) ACCOUNTS PAYABLE VOUCHER 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 '//o117 CKr°r-1,_4�� Purchase Order No. Terms /�o 5c�i 141 Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 7 21 09 Total I 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 /,tJ ��G ON ACCOUNT OF APPROPRIATION FOR 902350�� Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or ,9Q2 7- '��35'o9f 3 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 27 20 0 1 9 Signatur Cost distribution ledger classification if Title claim paid motor vehicle highway fund Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland May -09 Donald: Medicare Part B $96.40 Amount due for May 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 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* 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 en espanol JJ A I M ed ica re Toll -free: 1 800 372 2147 1tla(Y[? N70 W[ItI7 you need it man TTY users: 1 877 833 4486 F Print This Pag Enlarge Text I Help Return to Previous Screen Plan Details Humana Choice PPO Plans (PPO R5826 -008 Monthly Plan Premium: n Premi for People with Extra Help Rx Cover Annual Part D Deducti $0.00 Annual Medical D eductible: $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. Copay Specialist: 35.00 Copay Hospitalization: $800.00 per admit https: /www.humana- medicare. com/ SeniorWizardNET /PlanDetails.aspx 3/27/2009 Page 1 of 1 Chase Online Activity for Show Me my account activity i Trans Date Post Date Type Description Transaction Number Amount 04124/2009 04/24/2009 Sale STAM PX PRESS. COM (Services and 55480779114207376100067 $15.24 Merchandise) 094 94 442999 payweAt pa yma' a Tha k ivaw 999 .9@ 9445/2969 04i 1742809 Sale YlVIGA 9F GRT-R I NBIANAPG(E)ther) 65416 $q26.08 "TV 1 012009 i�}A NEi4/� SPAPERS (Other .Q410WAQ9 Ain y mentY Payr�eat T4aaek You(9t 499699627899968599i5876 388.88 84AM42W9 --0481 •/2809 F A� �"Q.QOAE -M -E FEE( $98.80 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 CREDIT CARD (...1033) Select a Time Period [..St tatr, t i: Ott From To You can search up to 90 days worth of activity online. Narrow Your Search Transaction Type Ail Merchant Name or Keyword 2009 JPMorgan Chase Co. https: cards. chase. com Account /AccountActivity.aspx ?AI= 63271542 4/27/2009 Fifth Third Bank Manage Accounts Credit Card Account Activity Page 1 of 1 The things w e do for dreams ai' ck' aa5:' ✓cr --R• Account Balances Account Nicknames Account Activity Welcome, DONALD H CLEVELAND Wednesday, April 22, 2009 Account Activity I Account Summa I A ccount. Statements E x Account: Statement Period: Current Statement Posted Transactions ( Advanced Search: Keyword Posting Date Trans Dat Debit Credit Description @4"2199 SAPPORO JAPANESE STEAK INDIANAPOLIS IN 94, ^700 AMERICAN COLLECTORS IN CHERRY HILL N) 04/20/09 04/17/2009 $809.72- ANTHEM BCBS INS PMT IN 866 649 -2034 OH Transactions and other information that appear on this page have occurred since your last statement cycle date. Please s statement period to review previous account activity. Disclosure /Error Resolution Copyright Oc 2.009 Fifth Third Bank, Member FDIC, 122 Equal Housing Lender, All Rights Reserved Contact Us Service Center I Help I FA s I Privacy Security https: /www.5 3 com/servlet/efsonline /account- history.html ?Trans S ortCode= DATE,REV E... 4/22/2009 ANTHEM BCBS IN INDIVIDUAL INDI -MB 1 KY0303A645 1351 Wm Howard Taft Anthem.419 Cincinnati, OH 45206 -1775 An independent licensee of the Blue Cron and Blue Shield Assodation. Anthem Blue Cmss Blue Shield is the trade omm of o' the Anthem In—nce ConTe im. Inc. ®Registered necks Blue Cross and Blue Shield Associaeou. 041509 M11, 19627 MIND 63901 IDENTIFICATION 018M62629 Due Date: 05 -01 -2009 Billing Date: 04 -14 -2009 °o #BWNCQXF Coverage Period From: 05 -01 -2009 #AIM0000000000DS0 #INDI -MB 1 KY0303A645 Coverage Period Through: 05 -31 -2009 Z 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. DETACH AND RETURN THIS SECTION WITH YOUR PAYMENT -DO NOT STAPLE MAKE CHECKS PAYABLE TO ANTHEM BLUE CROSS BLUE SHIELD Cleveland, Barbara L AND MAIL TO THE ADDRESS BELOW Subscriber ID From Date Through Date Due Date 018M62629 05/01/2009 05/31/2009 05/01/2009 Amount Due Amount Paid $809.72 Unit No. 002 INDI -MB I IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ANTHEM BCBS IN INDIVIDUAL PO Box 105674 Atlanta GA 30348 -5674 1 4001954140000018226262970501200900000809720020 Si necesita ayuda en espanol para entender este documento, puede solicitarla sin costo adicional, llamando al ncimero de servicio al cliente que aparece al dorso de su tarjeta de identificaci6n o en el folleto de inscripci6n. Invoice 055144151 CURRENT PERIOD COVERAGE FROM 05/01/2009 THRU 05/3112009 Plan 11 $809.72 Current Period Total $809.72 PLEASE PAY THIS AMOUNT $809.72 ib13BINDUIB13 B IND 00000639 000055144151 Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland May -09 Donald: Medicare Part B $96.40 Amount due for May 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 Cleveland, Don H From: sales @stampxpress.com Sent: Thursday, April 23, 2009 1:23 PM To: Cleveland, Don H Subject: Thank you for ordering StampXpress.com receipt for order 101452 wy a E x X P "I fl, I f 3 E� �II i I i� S li �5i� €d 1 ?�gW ?!„k ti`I w Current Status: Paid /Unshipped Order Number: 101452 Payment Method: Order Time: 4/23/2009 10:22:34 AM $15.24 Billed To: Ship To: Donald Cleveland Donald Cleveland Carmel Redevelopment Commission Carmel Redevelopment Commission 30 W Main St., 30 W Main Suite 220 Suite 220 Carmel, IN 46032 Carmel, IN 46032 United States United States 3175712795 3175712795 Fax:3175712789 dcleveland @carmel.in.gov Promotional Code(s): none Special Instructions: none Qty SKU Product Name Unit Price 1 DUAL PAD 20 Dual Pad Printer 20 Black Ink $6.25 In Process 1 DUAL PAD 30 Dual Pad Printer 30 Black Ink $8.99 In Process SubTotal: $15.24 Director of Operations Tax: $0.00 Shipping: $0.00 Director of Redevelopment Handling: $0.00 Gift Wrap: $0.00 Grand Total: $15.24 Please retain for your records. 1 WWW.STAMPXPRESS.COM PACKING SLIP# 2033108 P.O. BOX 14133 PINEDALE, CA 93650 A CCT# j DATE TERMS BIN /CNT 030003000 04/ 24/2009 5034 -2 Ref 101452 LILL TO 1 SHIP TO US Mail First Class DONALD CLEVELAND DONALD CLEVELAND CARMEL REDEVELOPMENT COMMISSION CARMEL REDEVELOPMENT COMMISSION 30 W MAIN SUITE 220 30 W MAIN SUITE 220 CARMEL, IN 46032 ;CARMEL, IN 46032 559- 233 -7894 T QTY I STK Orderld DESCRIPTION LIST DISC PRICE I T 1 IS20DUAL PRINTER 20 DUAL PAD BLACK 032493 Director of Operations /0 6 99 1 S30DUAL PRINTER 30 DUAL PAD BLACK 032494 Director of Redevelopment 161807 I I I I We appreciate your business TOTAL i Package Weight: 5.00 oz USMAIL-FIRSTCLASS Pres`crib'ed 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. C4 "'C57 1 Payee Purchase Order No. 57' 'T CV p 111� 6a1_1 /1 11 Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) p� �2Ya9 y2 yo 2 �r� s S�z Total I 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 G IN SUM OF ON ACCOUNT OF APPROPRIATION FOR T go Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 0 2 0S0 S y'75iXr X07.60 bill(s) is (are) true and correct and that the �oz d y2'fo 9 23UzoU %5;2 materials or services itemized thereon for which charge is made were ordered and received except 2009 JJ Signature [�l' °c 7 t/ Cam aler/' 9/ S Cost distribution ledger classification if Title claim paid motor vehicle highway fund Director of Operations