169312 03/03/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $5,145.53
CARMEL, INDIANA 46032 DEVELOPMENT
PO BOX 847 CHECK NUMBER: 169312
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 3/3/2009
DEPART ACCOU PO N INVOICE NUMB AM OUNT D ESCRIPTION
101 5023990 5,145.53 UNEMPLOYMENT CHARGES
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13343E —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 s ince, before any pay ments were made the employer ha the op
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK I AMOUNT
NUMBER EMPLOYEE' NAME I DATE LEVEL DATE I ENDING JACO CHARGED
THIS 1S 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.
`I� NOD
NEW CHARGES 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 1 390.00
E 0 EDEDUWA 07/25/09 REG 01/18/09 01/17/09 390.00
E 0 EDEDUWA 07/25/09 REG 01/25/09 01/24/09 390.00
D C FEY 08/01/09 REG 01/25/09 01/24/09 C�{'1�t 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 EDWA 10131/09 __RE 01/04/09 12/27/08__ 16 0
M R EDWARDS 10/31/09 REG 01/12/09 01/03/09_110 135.00
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 01/10/09 390.00
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 01/24/09 390-00
L S BAILEY 04 /04/09 REG 01/05/09 12/27/08� 126.00
L S BAILEY 04/04/09 REG 01/07/09 01/03/09 I. 156.00
L S BAILEY 04/04/09 REG 01/21/09 01/10/09 l 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.
601- god rev I ;���ti� I L i -fo,o� f i�� �ll Cea��u5� 75.53
Account /Location Number: 133438 000 Reporting Month: JANUARY, 2009 Page
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM �T RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
TOTAL AMOUNT OF NET CHARGES 7,417.53
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)
_r. 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.
Paye el I 1
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
.D lsz e)
�d,_
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.
I� ALLOWED 20
l [�Jor �CQ IN SUM OF
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
i materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund