HomeMy WebLinkAbout180677 12/29/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
s CHECK AMOUNT: $46.19
i•• la CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV
101 N SENATE AVE
o CHECK NUMBER: 180677
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 12/29/2009
DEPARTMENT ACCOUNT PO NUMB INVOICE NUMBER AMOUNT DESCRIPTION
,x.207 4110000 567041 -000 46.19 FULL TIME REGULAR
133438 -1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204 -2277
Toll free 1- 800891 -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 -00.0
ONE CIVIC S -Q
CARMEL IN 46032 -2584 REPORTING MONTH OCT, 2009
NET CHARGES $10,669.97
POSTING DATE NOV-08, 200
The receipt of this statement (Form 535) does: not reopen the question of.the claimant's eligibility for
unemployment insurance since, before.an.y payments were trade the employer had the opportunity
and the responsibility to report any information which could disqualify'the- claimant.
CI BENEFIT PAID FOR
SECURITY YEAFI END CLAIM RANSACTION WEEK. AMOUNT
NUMBER EMPLOYEE'S. NAME DATE LEVEL DATE, ENDING A60 CHARGED
THIS 1S NOT A,BILL.OR A REQUEST FOR MONEY DUE TO THIS DEPARTMENT. It is evstaternent of benefit charges
made to your raccount during the "repotting" 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.
NEW CHARGES FOR THE REPORTING MONTH 10/09
E 0 EDEDUWA 07/25/09 EB 10/25/09 10%17/09 1 97.5a
E 0 EDEDUWA 07 /25/09 EB 10/25/09 10/24/09 L�OI� 97.50
D M. JENSEN 08 /28/10 REG 10/15/09 09/19/09 390.00
D. M JENSEN 08/28/10 REG 10/15/09 09/26/09 390.00
M JENSEN 08/28/10 REG 10/15/09 10/03/09 390.00
M JENSEN 08/28/10 REG 10/15/09 10/10/09 390.00
�D M JENSEN 08/28/10 REG 10/26/09 10/17/09 390.00
D M JENSEN 08/28/10 REG 10/30/09 10/24/09 390.00
D L LLOYD 09/25/10 REG 10/14/09 10;/10/09 128.00
D L LLOYD 09/25/10 REG 10/21/09 10/17/09 P 1 128..00,/
D L`LLOYD 09/25/10 REG 10/26/09 10/24/09 128.00
R K PETE 07 /03/10 REG 10/12/09 10110109 II 51:56 J
R K PETE 07/03/10 REG 10/19/09 10/17/09 t 74.93
M:A MONTGOMERY, 08/14/10 REG 10/05/09 10/03/09 357:00
M A MONTGOMERY' 08/14/10 REG 10/11/09 10 357.00
X A.MONTGOMERY 08/14/10 REG 10/19/09 10/17/69 357.00
:M A MONTGOMERY 08/14/10 REG 10/26/0.9 10/24/09 357_00
M'LINGELBAUGH 09/18/10 REG 10/05;/09 10/Q 390.00
D M LINGELBAUGH 09118110 REG 10/11/09 10/10/09 3.90.00
D M LINGELBAUGH 09/18/10 REG 10/18/09 10/17/09 390.00
D M LINGELBAUGH 09/18/10 REG 10/25/09 10/24/09 390.00
C M BRODERICK 04/04/09 EB 10/06/09 10/03/09 390.00
C M BRODERiCIC 04/04/09 DEB 10/12/09 10/10/09 1�IIIJJJ 390.00
C M BRODERICK 04/04/09 EB 10/20/09 10/17/09 390.00
.0 M BRODERICK 04/04/09 ES 10/27/09 10/24/09 �l```��� 390.00
J L HOPE 08/14/10 REG 10/08/09 10/03/09 390.00
J L HOPE 06/14/10 REG 10/14/09 10/10/09 390.00
J L HOPE 08/14/10 REG 10/21/09 1.0/17/09 �J .390.00
J L HOPE 08/14/10 REG 10/28/09 10/24/09 390.00
CONTINUE ON NEXT PAGE
An in the ACQ column denotes 'a charge resulting from an acquisition of another business.
Account/Location Number: 133438 —000 Reporting Month: OCTOBER, 2009 Wage 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT P D FOR
SECURITY YEAR END CLAIM �R ANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ CHARGED
RGES FOR THE REPORTING MONTH 10/09 ll
E E SWIRSKY 07/24/10 REG 10/27/09 10/17/09 t 4.48 IV
J G KOZLOVICH JR 06/05/10 REG 10/04/09 10/03/09 378.00
J G kOZLOVICH JR 06/05/10 REG 10/12/09 10/10/09 378.00
J G KOZLOVICH JR 06/05/10 REG 10/18/09 10/17/09 378.00
J G KOZLOV.ICH JR 06/05/10 REG 10/26/09 10/24/09 378.00
TOTAL NEW CHARGES FOR THE ,REPORTING MONTH 10/09 10,669.97
TOTAL AMOUNT OF NET CHARGES 10,669.97
END OF BENEFIT CHARGE STATEMENT
C W 0,91
An *j in the ACQ column denotes a charge resulting1rom an acquisition of another business.
567041 -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
BLOCKOMS GOLF MANAGEMENT COMPANY L L C ACCOUNT
12120 BROOKSHIRE PKWY LOCATION NUMBER 567041 -000
CARMEL IN 46033 -3314 REPORTING MONTH NOV, 2009
NET CHARGES $46.19
POSTING DATE DEC 04, 2009
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
L yment_ in su ran ce..since,.. before _an.v- 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 CLAIM �T RANSACTION WEEK AMOUNT
NUMBER I EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACC) CHARGED
NEW C GES FOR THE REPORTING MONTH 11/09
S J HERBST 05/29/10 REG 11/01/09 10/31/09 21.25
7 S J HERBST 05/29/10 REG 11/09/09 11/07/09 24.94
TOTAL NEW CHARGES FOR THE REPORTING MONTH 11/09 46.19
TOTAL AMOUNT OF NET CHARGES 46.19
END OF BENEFIT CHARGE STATEMENT
An in the AC® 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
f}�7ry1� bJ0 2C6:' Purchase Order No.
fv.
/y NOON S s� �TE Terms
�V Di/3rtJRZ2)ks, Zu Qo) Z- 2D_ 27 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
ozo27 7
(=1�
ON ACCOUNT OF APPROPRIATION FOR
7 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
materials or services itemized thereon for
which charge is made were ordered and
received except
20
aturd
Cost distribution ledger classification if Ti e
claim paid motor vehicle highway fund