174712 07/22/2009 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: ?,220.84
101 N SENATE AVE CHECK NUMBER: 174712
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 712212009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 915.58 OTHER EXPENSES
1125 4110000 1,305.26 FULL TIME REGULAR
r
er
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
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 JUN, 2009
CARMEL IN 46032 -2584
NETCHARGES $2,220.84
POSTING DATE JUL 03, 2009
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unemploymen ins since n"
before ay "payments were-made the employ.er_had_ the- op.a.ortunity_
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE I ENDING A 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.
RGES FOR THE REPORTING MONTH 06/09
S L MINNICK 12/26/09 REG 06/01/09 05/30/09 244.00 Ipq1
S L MINNICK 12/26/09 REG 06/07/09 06/06/09 72.00 ,alb
R MCGEE 01/16/10 REG 06/29/09 06/27/09 303.291 0
N M PARR 06/05/10 REG 06/28/09 06/20/09 181.00 D��P
N M PARR 06/05/10 REG 06/29/09 06/27/09 181.00
A R BRITTAIN 06/05/10 REG 06/22/09 06/20/09 126.00 v
A R BRITTAIN 06/05/10 REG 06/28/09 06/27/09 126.00
S J HERBST 05/29/10 REG 06/24/09 06/13/09 211.00'
7 4 S J HERBST 05/29/10 REG 06/24/09 06/20/09 211.00 O(i
S J HERBST 05/29/10 REG 06/29/09 06/27/09 211..00
K NEFOUSE 02/06/10 REG 06/22/09 06/20/09 71.9710
L M BREWER 12/12/09 REG 06/01/09 05/30/09 179.65
_L_M BREWER 12/.3.2/09_�REG_ 05, /OQ-- 0.6 /�ti /.OQ� 10:2:.:93.,:
TOTAL NEW CHARGES FOR THE REPORTING MONTH 06/09 2,220.84
TOTAL AMOUNT OF NET CHARGES 2,220.84
***END OF BENEFI -T— CHARGE STATEMENT
I A2 L4, o o o(-
S' �)u
6�� _(X� 2-9 Z, 6 9
An in the a ACGl 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
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
1 1 VfC(!� Purchase Order No.
'v Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s)) p
0 �O
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
ON ACCOUNT OF APPROPRIATION FOR
(6 JA W! AOW
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
�Z 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
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
r
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of 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.
146500 Indiana Dept. of Workforce Development Terms
i 10 North Senate Ave., SE106 Date Due
Indianapolis, IN 46204 -2277
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/3/09 133438 Benefit charge Jun'09 1,305.26
PAY ALL O.UT OF j,6', er MichaeL 11/20/08;
Total 1,305.26
I heieby-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.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
y 1,305.26
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
1125 133438 4110000 1,305.26 1 hereby certify that the attached invoice(s), or
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 -Jul 2009
Signature
1,305.26 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund