169322 03/04/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CHECK AMOUNT: $2,272.00
CARMEL, INDIANA 46032 DEVELOPMENT
PO BOX 847 CHECK NUMBER: 169322
4,roii 'o
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 3/4/2009
DEPARTMENT ACCOUNT PO N UMBER INVOICE NUMBER AMOUNT DESCRIPTION
,1125 4110000 133438 2,272.00 FULL TIME REGULAR
I
I
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 JAN, 2009
CARMEL IN 46032 2584
NET CHARGES $7,417.53
POSTING DATE FEB -03, 2009
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 made the employer had the opportunity
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END (�RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE I 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. �t2
NEw r'i?.RGES FOR THE REPORTING MONTH 01/09
S L MINNICK 12/26/09 REG 01/22/09 01/10/09 244.00
S L MINNICK 12/26/09 REG 01/22/09 01/17/09 244.00
S L MINNICK 12/26/09 REG 01/25/09 01/24/09 244.00
E 0 EDEDUWA 07/25/09 REG 01/04/09 01/03/09 390.00
E 0 EDEDUWA 07/25/09 REG 01/11/09 01/10/09 390.00
E 0 EDEDUWA 07/25/09 REG 01/18/09 01/17/09 390.00
0 EDEDUWA 07/25/09 REG 01/25/09 01/24/09 390.00
i C FEY 08/01/09 REG 01/25/09 01/24/09 eW'Z' 75.53
V A DOLAN 03/21/09 REG 01/07/09 01/03/09 390.00
V A DOLAN 03/21/09 REG 01/14/09 01/10/09 390.00
V A DOLAN 03/21/09 REG 01/22/09 01/17/09 390.00
V A DOLAN 03/21/09 REG 01/29/09 01/24/09 390.00
M R EDWARDS 10/31/09 REG 01/04/09 12/27/08 160.00
M R EDWARDS 10/31/09 REG 01/12/09 01/03/091Q 135.00
M R EDWARDS 10/31/09 REG 01/12/09 01/10/09 160.00
M R EDWARDS 10/31/09 REG 01/19/09 01/17/09 160.00
M R EDWARDS 10/31/09 REG 01/26/09 01/24/09 175.00
K S BRENNAN 08/01/09 REG 01/04/09 12/27/08 390.00
K S BRENNAN 08/01/09 REG 01/09/09 01/03/09 390.00
K S BRENNAN 08/01/09 REG 01/15/09 01/10/09 b o 390.00
K S BRENNAN 08/01/09 REG 01/23/09 01/17/09 390.00
K S BRENNAN 08/01/09 REG 01/29/09 01/24/09 39 0
L S BAILEY 04/04/09 REG 01/05/09 12/27/08 .1 60,t 126.00
L S BAILEY 04/04/09 REG 01/07/09 01/03/09 156.00
L S BAILEY 04/04/09 REG 01/21/09 01/10/09 156.00
L S BAILEY 04/04/09 REG 01/21/09 01/17/09 156.00
L S BAILEY 04/04/09 REG 01/29/09 01/24/09 156.00
TOTAL NEW CHARGES FOR THE REPORTING MONTH 01/09 7,417.53
CONTINUE ON NEXT PAGE
An in the ACQ column denotes a charge resulting from an acquisition of another business.
L1UI -F bbd vc� 1Cx -I� =7� •�v I�{bL I�`{O,D� doffs:, 3c Ov C'ey�5us: -75.53
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
'y 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.
166089 Indiana Dept. of Workforce Development Terms
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
2/3/09 133438 Benefit charges Jan'09 2,272.00
PAYALL OUT.OF101: ,er,Mi6hae1,111 72010,8;
Total 2,272.00
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
1 20
Clerk- Treasurer
till
Voucher No. Warrant No.
166089 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
I n Sum of
2,272.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept# TITLE
1125 133438 4110000 2,272.00 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
26 -Feb 2009
Signature
2,272.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund