178568 10/27/2009 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
CARtv1EL, INDIANA 46432 DEVELOPMENT ATTN. ACCT RECV CHECK AMOUNT: $7,392.24
101 N SENATE AVE CHECK NUMBER: 178588
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 10!2712009
DEPARTMENT AC COUNT PO NUMB INV NUMBER AMOUNT DES CRIPTION
101 5023990 711.18 OTHER EXPENSES
1120 4110000 1,950.00 FULL TIME REGULAR
1125 4110000 1,790.89 FULL TIME REGULAR
1207 4110000 1,428.17 FULL TIME REGULAR
651 4110000 1,512.00 FULL TIME REGULAR
r o
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 S4
CARMEL IN 46032 -2554 REPORTING MONTH SEP, 2009
NETCHARGES $7,392.24
POSTING DATE OCT-09 F 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 respUnsiniiity io report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING AC O 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.
NEW CHARGES FOR THE REPORTING MONTH 09/09 L
R M MAIER 12/26/09 REG 09/20/09 09/19/09 267.87 0 5
M A MONTGOMERY 08/14/10 REG 09/09/09 09/05/09 357.00
M A MONTGOMERY 08/14/10 REG 09/14/09 09/12/09 357.00
M A MONTGOMERY 08/14/10 REG 09/22/09 09/19/o9 357.00 4 t�/
M A MONTGOMERY 08/14/10 REG 09/30/09 09/26/09 357.00
S J HERBST 05/29/10 REG 09/13/09 09/12/09 r 0.17
S L VAN DYKE 10/31/09 REG 09/06/09 08/29/09 227.00
1 4= 1 S• L VAN DYKE 10/31/09 REG 09/20/.09 09/05/09 a 216,.31 V '2
BRODERICK 04/04/09 EB 09 of 69 08/29/09 390.00
C M BRODERICK 04/04/09 EB 09/08/09 09/05/09 390.00 1�(
C M BRODERICK 04/04/09 EB 09/14/09 09/12%09 390.00
.0 M BRODERICK 04/04/09 EB 09/22/09 09/19/09 390.00
C M BRODERICK 04/04/09 EB 09/2
U-li nOrr;" 08/14/10 REG 09/17/09 08/29/09 390.00
J L HOPE 08/14/10 REG 09/17/09 09/05/09 390.00
J L HOPE 08/14/10 REG 09/17/09 09/12/09 390.00
J L HOPE 08/14/10 REG 09/24/09 09/19/09 390.00
L HOPE 08/14/10 REG 09/30/09 09/26/09 390.00
S BAI 04 04 09 EB 09 /06/09 09/05/09 113.00
5 J G KOZLOVICH JR 06/05/10 REG 09/06/09 09/05/09 378.00
J G KOZLOVICH JR 06/05/10 REG 09/13/09 09/12/09 378.00
J G KOZLOVICH JR 06/05/10 REG 09/21/09 09/19/09 378.00
1 -5 �J G K JR 06/05/10 REG 09/30/09 09 /26/09 378.00
TOTAL NEW CHARGES FOR THE REPORTING MONTH 09/09 7,664.35
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 08/09
315 -08 -2658 K NEFOUSE 02/06/10 REG 09/21/09 08/01/09 s 106.85CR 0?
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: SEPTEMBER, 200 -9 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ CHARGED
1
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 08/09
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 08/09 106.85CR
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 06/09
315 -08 -2658 K NEFOUSE 02/06/10 REG 09/21/09 06/20/09 71.97CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 06/09 71.97CR
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 05/09
315 -08 -2658 K NEFOUSE 02/06/10 REG 09/21/09 05/02/09 93.29CR��
_TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 05/09 93.29CR
TOTAL AMOUNT OF NET CHARGES 7,392.24
END OF BENEFIT CHARGE STATEMENT
Cebu
14
CAU--) 1 1.3. v D
m aqc)
6Y
l
c h,
'a
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
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
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
Signature 0
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund