176584 08/26/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV CHECK AMOUNT: $5,850.52
101 N SENATE AVE
CHECK NUMBER: 176584
INDIANAPOLIS IN 46206 -0647
CHECK DATE: 8/26/2009
DEF ACC OUNT PO NU MBER _INVOICE NUMBE AMOUNT DESC RIPTION
101 5023990 2,639.22 UNEMPLOYMENT
1046 4111000 1,396.30 PART -TIME
651 4110000 1,815.00.UNEMPLOYMENT
133438` -1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll free 1 -800- 891 -6499 Marion County 232 -7436
0 STATEMENT OF BENEFIT CHARGES (FORM 535)
CONFIDENTIAL RECORD PURSUANT TO IC 22- 4 -19 -6, IC 4 -1 -66
Page 1
CITY OF CARMEL ACCOUNT/
ATTN CLERK TREASURER LOCATION NUMBER 133438 -000
ONE CIVIC SQ REPORTING MONTH JUL, 2009
CARMEL IN 46032 2584
NETCHARGES $5,850.52
POSTING DATE AUG 20 0 9
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unemployment insurance since, before any payments were n��aue the employer had the opportunity
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY
YEAREND CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
THIS IS NOT A BILL OR A REQUEST FOR MONEY DUE TO THIS DEPARTMENT. It is a statement of benefit charges
made to your account during the "reporting" month. At the end of the "posting" month, you will receive a Reimbursable
Bill (Form 1067) for these charges and any previous liability still outstanding,
NEW- GES FOR THE REPORTING MONTH 07/09
R MCGEE �b 01/16/10 REG 07/06/09 07/04/09 75.00 In
N M PARR 06/05/10 REG 07/05/09 07/04/09 181.00
N M PARR 06/05/10 REG 07/12/09 07/11/09 181.00 1("L
N M PARR 06/05/10 REG 07/19/09 07/18/09 87.49
T N TEMPLE 05/22/10 REG 07/12/09 07/11/09 47.05 lCL
T N TEMPLE 05 /22/10 REG 07/23/09 07/18/09 17.76
A R BRITTAIN II 06/05/10 REG 07/05/09 07/04/09 126.00
4 A R BRITTAIN '��`C� 06/05/10 REG 07/12/09 07/11/09 126.00 ,61-
A R BRITTAIN 06/05/10 REG 07/19/,09 07/18/09 126.00
j 3 4 A R BRITTAIN 06/05/10 REG 07/26/09 07/25/09 126.00
S J HERBST I'Z7 05/29/10 REG 07/06/09 07/04/09 155,.71
D CAMPBELL 05/15/10 REG 07/15/09 05/30/09 390.00
D D CAMPBELL 05/15/10 REG 07/15/09 06/06/09 390.00
D D CAMPBELL 05/15/10 REG 07/15/09 06/13/09 390.00
D D CAMPBELL 05/15/10 REG 07/15/09 06/20/09 390.00 �7A
D D CAMPBELL 05/15/10 REG 07/15/09 06/27/09 390.00
D D CAMPBELL 05/15/10 REG 07/15/09 07/04/09 390.00
D D CAMPBELL 05/15/10 REG 07/15/09 07/11 09 143.51
J C GUIEB I6 07/03/10 REG 07/27/09 07/25/09 303.00 p
J G KOZLOVICH JR 06/05/10 REG 07/06/09 06/27/09 303.00
J G KOZLOVICH JR 06/05/10 REG 07/06/09 07/04/09 378.00
J G KOZLOVICH JR 06/05/10 REG 07/13/09 07/11/09 378.00
J G KOZLOVICH JR 06/05/10 REG 07/21/09 07/18/09 378.00
J G KOZLOVICH JR 06/05/10 REG 07/27/09 07/25/09 378.00
OU--------
��tL 3 D TOTAL NEW CHARGES FOR THE REPORTING MONTH 07/09 5,850.52
TOTAL AMOUNT OF NET CHARGES 5,850.52
ILA 8 3' S) END OF BENEFIT CHARGE STATEMENT
An in the ACQ column denotes a charge resulting from an acquisition of another business.
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
r 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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
ASW
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.
r ALLOWED 20
t
IN SUM OF
f
5g5o,
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
p Z U f bill(s) is (are) true and correct and that the
materials or services itemized thereon for
dD 1&5 Db which charge is made were ordered and
received except
A4 20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund