The URL can be used to link to this page

Home My WebLink About170793 04/16/2009 CITY OF CARMEL, INDIANA VENDOR: 362529 Page 1 of 1 ONE CIVIC SQUARE DON CLEVELAND CARMEL, INDIANA 46032 141 STONY CREEK OVERLOOK CHECK AMOUNT: $450.72 NOBLESVILLE IN 46060 CHECK NUMBER: 170793 r co CHECK DATE: 4/16/2009 DEPARTMENT ACC OUNT PO N UMBER I NVOICE NUMBE AMOUNT DESCRIPTION '902 4347500 450.72 CLEVELAND INSURANCE I e. Monthly Medical Insurance Premiums Donald H. and Barbara L. Cleveland Current for 2009 Donald: Medicare Part B $96.40 Humana Choice PPO 44.00 0(c Total Don 140.40 Barbara: Anthem COBRA 389.86 Total Monthly Expense $530.26 85% $450.72 15% 79.54 Wp x b l F I t e 4 -'r Y M 0,; 4 '4 4% k 0 If A tT 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 ii get premium-free Part A. Part B (Medical Insurance) Monthly Premium If Your Yearly I ncome 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 Plan Details Page 1 of 3 0 en espanol H Me icare Toll -free: 1 800 372 2147 `lt!!da,yr:e w hat you flee[ it n iast TTY users: 1 877 833 4486 D 11 Print This Pag I A Enlarge Text Help Return to Previous Screen Plan Details Humana Choice PPO Plans (PPO R5826 -008 Monthly Plan Premium: r$44.00 PI n Premiums for People with Extra Hel Rx C Annual P D Deductibl $0.00 Annual M Deducti $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: 35.0 0 Cop Hospitalization: $800.00 per admit https: /www.humana- medicare. com/ SeniorWizardNET /PlanDetails.aspx 3/27/2009 E ,g CHASE 04/22/09 $0.00 $596.00 Account number: I want to purchase optional Make your check payable to: Chase Payment Protector 5 o 6V Chase Card Services. Plan. I've read the Benefits Please write amount enclosed. Disclosures on back of insert. New address or e Print on back. I nitial s Date 20385 BEX Z08709 D � DONALD H CLEVELAND 141 STONY CREEK OVERLOOK CARDMEMBER SERVICE NOBLESVILLE IN 46060 -5427 PO BOX 94014 PALATINE IL 60094 -4014 Statement Date: C H A SE 03/01/09 03/28/09 Manage your account online www.chase.com/creditcards Minimum Payment: $596.00 Payment Due Date: 04/22/09 Additional contact information ACCOUNT SUMMARY conveniently located on reverse side Previous Balance Total Credit Line $30,000 Payment, Credits $600.00 Available Credit $163 Purchases, Cash, Debits +$1,372.97 Cash Access Line $30,000 Finance Charges +$73.71 Available for Cash $163 New Balance ACCOUNT ACTIVITY Date of Transaction Merchant Name or Transaction Description Amount 03/12 Payment Thank You 300.00 03119 Payment Thank You 300.00 03/01 LOWES #01191 NOBLESVILLE IN 550.00 03/02 HUMANA HEALTH PLAN,INC 8009922551 KY 44.00 03/10 INDIANA NEWSPAPERS INC 317- 444 -8056 IN i2.00 03/20 STAPLES 00105171 NOBLESVILLE IN 119.97 03/20 PICTURE THIS INDIANAPOLIS IN 237.01 03/19 LEE SUPPLY CARMEL IN 235.14 03120 LOWES #01191' NOBLESVILLE IN 34.67 03/23 GRAYS AUTOMOTIVE SERVI CARMEL IN 115.18 03/24 CAPITOL COMMONS PARKIN INDIANAPOLIS IN 25.00 FINANCE CHARGES Finance Charge Transaction Daily Periodic Rate Corresp. Average Daily Due To Fee/ Accumulated FINANCE Category 28 days in cycle APR Balance Periodic Rate Service Charge Fin Charge CHARGES Purchases V.00890% 3.25% $26,993.23 $67.27 $0.00 $0.00 $67.27 Cash advances V .05271 19.24% $0.00 $0.00 $0.00 $0.00 $0.00 Convenience check V .00890% 3.25% $577.68 $1.44 $0.00 $0.00 $1.44 Balance transfer V .00890% 3.25% $2,004.58 $5.00 $0.00 $0.00 $5.00 Total finance charges $73.71 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. DONALD H. CLEVELAND 71- 1323/749 1325 BARBARA L. CLEVELAND 4e033444a5 141 STONY CREEK OVERLOOK NOBLESVILLE, IN 46060 DAB PAY y ORDER THE ��F�L�h� //5 �,W ORDER OF T DOLLARS LJ a Hams N.A. I L 7491 Please make checks /money orders payable to Anthem Blue Cross and Blue Shield and be sure to include participant's name and account number(s) on your check or money order. The remittance slip must be returned with your payment in the enclosed envelope. Please do NOT staple checks to remittance slip. BARBARA CLEVELAND Client Name: Don Hinds Ford 00110840 141 STONY CREEK OVERLOOK Account 0608780993 NOBLESVILLE, IN 46060 Amount Due: $389.86 Coverage Period: 4/1/09 4/30/09 Due Date: 4/1/09 II�I��I�II��I��II�Iilllll�l�l��i�llll��ll�l Anthem Blue Cross Blue Shield 0501 I P.O. Box 14258 Orange, CA 92863 -1258 I I I Harris Image Check Number 1325 Page 1 of 1 *04 VGOB 14 04'1.06 https:/ /mbanxonlinebanking.harrisbank. com /onlinebanking /CheckImage.asp ?params= 25C4... 4/7/2009 Prescrib6d 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 J�G� C1've— Ig_1;7d Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) O��i 7 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 C" DSO 7 2 ON ACCOUNT OF APPROPRIATION FOR r l� Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or ��2 d jai oy K7.5od z15 72 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 O9 LAXXIS nature Cost distribution ledger classification if Title claim paid motor vehicle highway fund