180676 12/29/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
!i
CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV CHECK AMOUNT: $10,821.59
101 N SENATE AVE CHECK NUMBER: 180676
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 12/29/2009
D EPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 133438 -000 13.16 OTHER EXPENSES
1120 4110000 133438 -000 1,950.00 FULL TIME REGULAR
1125 4110000 133438 -000 3,297.93 FULL TIME REGULAR
-1201 4110000 133438 -000 1,950.00 FULL TIME REGULAR
`1207 4111000 133438 -000 1,720.50 PART -TIME
651 4110000 133438 -000 1,890.00 FULL TIME REGULAR
'K
133438 -1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll free 1- 600 -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 NOV, 2009
CARMEL IN 46032 -2584
NET CHARGES $1.0,821.59
POSTING DATE DEC -04, 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.
S05 BENEFIT PAID FOR
SECURITY YEAR END I CLAIM TRANSACTION I 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.
NEI FOR THE REPORTING MONTH 11/09
E O EDEDUWA 07/25/09 EB 11/09/09 10/31/09 97.50 /l
E 0 EDEDUWA 07/25/09 EB 11/12/09 11/07/09 L 7�1� 97,50
E 0 EDEDUWA 07/25/09 EB 11/17/09 11/14/09 97.
D M JENSEN 08/28/10 REG 11/04/09 10/31/09 250.00 b 1
D L LLOYD 09/25/10 REG 11/02/09 10/31/09 3� �✓128.00 l0 l�
D L LLOYD 09/25/10 REG 11 /10/09 11/07/09 95.30
R S BLAIR 09/19/09 EB 11/08/09 10/31/09 6.68 Lj
R.S BLAIR 09/19/09 EB 11/08/09 11/07/09 l�. 6.48 U
J N SPENCE 10/23/10 REG 11/18/09 11/07/09 168.00
J N SPENCE 10/23/10 REG 11/23/09 11/14/09 168.00
J N SPENCE 10/23/10 REG 11/25/09 11/21/09 168.00 I
J N SPENCE 10/23/10 REG 11/29/09 11/28/09 168.00
R K PETE 07/03/10 REG 11/30/09 11/26/09 .122.63 I0
M A MONTGOMERY 08/14/10 REG 11/04/09 10/31/09 357.00
M A MONTGOMERY 08/14/10 REG 11/10/09 11/07/09 357.00 n
M A MONTGOMERY 08/14/10 REG 11/16/09 11/14/09 357.00 K U
M 'A MONTGOMERY 08/14/10 REG 11/24/09 11/21/09 357.00
3 D M LINGELBAUGH 09/18/10 REG 11/01/09 10/31/09 390.00
D M LINGELBAUGH 09/18/10 REG 11/08/09' 11/07/09 0390.00
D M LINGELBAUGH 09/16/10 REG 11/15/09 11/14/09 1 9. 390.00
D M LINGELBAUGH 09/18/10 REG 11/22/09 11/21/09 390.00
3 D M LINGELBAUGH 09/18/10 REG 11/29/09 11/28/09 390.00
C M BRODERICK 04/04/09 EB 11/02/09 10/31/09 390.00
3 C M BRODERICK 04/04/09 EB 11/10/09 11/07/09 U
C M BRODERICK 04/04/09 EB 11/17/09 11/14/09 11 390.00
J L HOPE 08/14/10 REG 11/04/09 10/31/09 390.00
J L HOPE 08/14/10 REG 11/11/09 11/07/09 390.00
-42 -4 J L HOPE 08/14/10 REG 11/16/09 11/14/09 1� 390.00
J L HOPE 08/14/10 REG 11/24/09 11/21/09 `"1 390.00
CONTINUE ON NEXT PAGE
An in the ACO column denotes a charge resulting from an acquisition of another business.
Accouht/Location Number: 133438 000 Reporting Month: NOVEMBER, 2009 Page 2
Employer Name; CITY OF CARMEL
SOCIAL BENEFIT PA FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING I ACO CHARGED
ARGES FOR THE REPORTING MONTH 11/09
5 J L HOPE 08/14/10 REG 11/30/09 11/28/09 390,00
J M PENN 10/16/10 REG 11/04/09 10/31/09 172.00
3$° J M PENN 10/16/10 REG 11/09/09 11/07/09 172.00
53 -23- J M PENN 10/16/10 REG 11/16/09 11/14/09? 172.00
-2 J M PENN 10/16/10 REG 11/23/09 11/21/09 172.00
J M PENN 10/16/10 REG 11/30/09 11/28/09 172.00
'4 lrl -5Y27 J G KOZLOVICH JR 06/05/10 REG 11/02/09 10/31/09 378.00
J G KOZLOVICH JR 06/05/10 REG 11/09/09 11/07/09 378.00
J G KOZLOVICH JR 06/05/10 REG 11/19/09 11/14/09 U 378.00
J G KOZLOVICH JR 06/05/10 REG 11/22/09 11/21/09 1 C 378.00
J G KOZLOVICH JR 06/05/10 REG 11/30/09. 11/28/09 378.00
TOTAL NEW CHARGES FOR THE REPORTING MONTH 11/09 10,821.59
TOTAL AMOUNT OF NET CHARGES 10,621.59
END OF BENEFIT CHARGE STATEMENT
7 )-0- S
Ion 02,00
or s 1 CZ� f X10' o
An in the ACQ column denotes a charge resulting from an acquisition of another business.
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
IN Dept.of.Workforce Developmen Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
12/04/09 133438 -000 Unemployment Charge
Total
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. IZ, WARRANT NO.
ALLOWED 20
IN Dept of Workforce Developme
IN SUM OF
10 N. Senate Av
Indi anapolis, IN 46204
$1,950.00
ON ACCOUNT OF APPROPRIATION FOR
General Fund
12 01 Human Resources
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
DEPT.
bill(s) is (are) true and correct and that the
1201 133438 -000 100 $1,950.00 materials or services itemized thereon for
which charge is made were ordered and
received except
20
Si natur
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bi11 to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
146500 Indiana Dept. of Workforce Development Terms
10 North Senate Ave., SE106 Date Due
Indianapolis, IN 46204 -2277
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/4109 133438 Benefit charge Nov'09 3,297.93
PAY;ALL OUT_OF101,perM�cF,ael #11. 120108
Total 3,297.93
I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
1 20
Clerk- Treasurer
+v
;Voucher No. Warrant No.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE 106 ti
Indianapolis, IN 46204 -2277
In Sum of$
3,297.93
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
1125 133438 4110000 3,297.93 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
28 -Dec 2009
V
Signature
3,297.93 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
Pr(�ribed 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
Purchase Order No.
/'D V&ej Terms
1AA)i 141,/, LtUs f lJ CA�2fi 4� Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
j�tb f �YIG�AL Qs
;7
l'
k
n
J
P
Total� pO
ra
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same Waccordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
+r H ALLOWED 20
1AJ v F Wo k 'LN vie NM 2r�
IN SUM OF
b NO N s t4 &P- A--tj-e-
NFL,
ON ACCOUNT OF APPROPRIATION FOR
clf v o Gia �elt,0 %yea P��tLC�d(Q�
Board Members
Po# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT- I hereby certify that the attached invoice(s), or
-�,111eo 00 jclS 6 o- 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
i ature
E- F
Title
Cost distribution ledger classification if
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
4 dA64 urchase Order No.
/ZZ�l/1T� ,�2, }2 t24,t�1, Terms
zL2 o il k s/_ Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
56
Total
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.
i ALLOWED 20
IN SUM OF
U
,J fiwo S,
226' �d
ON ACCOUNT OF APPROPRIATION FOR
6 WEe"q 1 C Uv
Board Members
PO# or INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
Z?v, -5'o bill(s) is (are) true and correct and that the
p 13. I(, materials or services itemized thereon for
v j which charge is made were ordered and
received except
20 o
N
r ignat0fe
itle
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER 097042 WARRANT ALLOWED
1%16500 IN SUM OF
IN DEPT OF WORKFORCE DEVEL.
Benefit Administration
10 N. Senate Avenue
India napolis, IN 46204
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
133438000 01- 4080 -12 $1,890.00
Voucher Total $1,890.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
146500
IN DEPT OF WORKFORCE DEVEL. Purchase Order No.
Benefit Administration Terms
10 N. Senate Avenue Due Date 12/30/2009
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/3012005 133438000 $1,890.00
hereby certify that the attached invoice(s), or bill(s) is.(are) true and
:orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer