168312 02/03/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
f ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $6,763.49
CARMEL, INDIANA 46032 DEVELOPMENT
•ti a� PO BOX 647 CHECK NUMBER: 168312
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 2/3/2009
DEPART ACCO PO NUMBER INV OICE NUMBER AMOUN DESCRIPTION
101 5023990 1,290.37 OTHER EXPENSES
'1125 4110000 988.00 FULL TIME REGULAR
1192 4110000 3,900.00 FULL TIME REGULAR
4111000 585.12 PART -TIME
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
t
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
CARMEL IN 46032 -258 1 -22 -09 A09 :04 IN REPORTING MONTH DEC, 2008
NETCHARGES $6 ,763.49
POSTING DATE JAN 09, 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 disquality the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM TRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE I ENDING I 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.
,7
NEW CHARGES FOR THE REPORTING MONTH 12/08
I E 0 EDEDUWA 07/25/09 REG 12/21/08 12/20/08 195.12
E O EDEDUWA 07/25/09 REG 12/29/08 12/27/08 390.00 V
E HAAS 08/08/09 REG 12/02/08 11/29/08 182.00 5�5
E HAAS 08/08/09 REG 12/09/08 12/06/08 34.4
V A DOLAN 03/21/09 REG 12/03/08 11/15/08 390.00
V A DOLAN 03/21/09 REG 12/02/08 11/29/08 390.00
V A DOLAN 03/21/09 REG 12/09/08 12/06/08 390.00 LL
V A DOLAN 03/21/09 REG 12/17/08 12/13/08 ALb,Q()390.00
V A DOLAN 03/21/09 REG 12/23/08 12/20/08 390.00
V A DOLAN 03/21/09 REG 12/30/08 12/27/08 390.00
R E BURY 08/01/09 REG 12/09/08 12/06/08 137.11
R E BURY 08/01/09 REG 12/16/08 12/13/08 C r,,� 168.00 I n
R E BURY 08/01/09 REG .12/23/08 12/20/08 5 60 168.00 C1'
R E BURY 08/01/09 REG 12/30/08 12/27/08 87.71
P K JACKSON 08/22/09 REG 12/01/08 11/29/08 197.00 Lj
P K JACKSON 08/22/09 REG 12/07/08 12/06/08 5[99. \Z 197.00 C 1, 0 1 P
P K JACKSON 08/22/09 REG 12/21/08 12/13/08 119.12
M R EDWARDS' 10/31/09 REG 12/03/08 11/15/08 217.40
M R EDWARDS- 10/31/09 REG 12/14/08 11/22/08 50.00
M R EDWARDS 10/31/09 REG 12/14/08 11/29/08 50..00
M R EDWARDS 10/31/09 REG 12/14/08 12/06/08 50.00
M R EDWARDS 10/31/09 REG 12/16/08 12/13/08 65.00
M R EDWARDS. 10/31/09 REG 12/22/08 12/20/08 85.00
K S BRENNAN 08/01/09 REG 12/05/08 11/29/08 390.00
I K S BRENNAN 08/01/09 REG 12/14/08 12/06/08 390.00 LI
K S BRENNAN 08/01/09 REG 12/18/08 12/13/08 390. 00
K S BRENNAN 08/01/09 REG 12/28/08 12/20/08 390.00
L S BAILEY 04/04/09 REG 12/01/08 11/22/08 46.00
L S BAILEY 04/04/09 REG 12/11/08 11/29/08 84.00
CONTINUE ON NEXT PAGE
Ar. he ACO column denotes a charge resulting from an acquisition of another business.
Account /Location Number: 133438 —000 Reporting Month: DECEMBER, 2008 r Fage 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
NEW CHARGES FOR THE REPORTING MONTH 12/08
L S BAILEY 04/04/09 REG 12/15/08 12/06/08 67.00
L S BAILEY 04/04/09 REG 12/22/08 12/13/08 41( 137.00
L S BAILEY 04/04/09 REG 12/24/08 12/20/08 137.00
TOTAL NEW CHARGES FOR THE REPORTING MONTH 12/08 6,763.49
TOTAL AMOUNT OF NET CHARGES 6,763.49
END OF BENEFIT CHARGE STATEMENT
&LM mar
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
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 f Y (6L n/�
Y 1 L J) J��r Y Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
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
v Board Members
EP 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
materials or services itemized thereon for
which charge is made were ordered and
received except
20
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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 v Purchase Order No.
/D /V �E$�'/�I� (fit; Terms
r�
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3� sil
Total S
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
PQCu -t
ON ACCOUNT OF APPROPRIATION FOR
Board Members
Po# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Ja p7rD s; �i 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
Si nature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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.
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
1/9/09 133438 Benefit charges Dec'08 988.00
PAY.ALL OUT OF 101; er Michael 1:1%20%08` f
Total 988.00
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
20_
Clerk- Treasurer
Voucher No. Warrant No.
166089 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
of
988.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
1125 133438 4110000 988.00 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
2 -Feb 2009
Signature
988.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund