HomeMy WebLinkAbout169454 03/04/2009 CITY OF CARMEL, INDIANA VENDOR: 279200 Page 1 of 1
p ONE CIVIC SQUARE INDIANA SECRETARY OF STATE
CARMEL, INDIANA 46032 NOTARY DEPARTMENT CHECK AMOUNT: $5.00
ROOM 201, STATE HOUSE CHECK NUMBER: 169464
INDIANAPOLIS IN 46204
CHECK DATE: 314/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIP
1192 4341999 5.00 OTHER PROFESSIONAL FE
4 r
F,W: Notary Application Page 1 of 1
Stewart, Lisa M
From: Sue Morlock [Sue.Morlock @Hylant.com]
Sent: Tuesday, February 24, 2009 10:26 AM
To: Stewart, Lisa M
Subject: FW: Notary Application
Attachments: notary app_20090121124154.pdf
Lisa,
Attached is the Notary application you requested.
<<notary app_20090121124154.pdf>>
Please complete items #1 through #8 and sign on items #9 and #10. A notary public needs to complete items #9
and #11.
Please return the completed application along with a $5.00 check payable to the Secretary of State and a $50.00
check payable to Hylant Group and return to my attention.
Thank you,
Sue Morlock
817 -5162
Notice: The contents of this communication are privileged and confidential. If you are not the intended
recipient of this transmission, you are hereby notified that distributing, copying, or disclosing this
communication, or reliance on the contents thereof, are strictly prohibited. If you have received this
communication in error, please notify the sender immediately, then destroy the original and all copies
thereof.
G� n
V
f,
2/24/2009
State Forth 40889(R7/ 1.03)
Approved by Smte Board of Accounts .1997 TODD ROIUTA
SECRETARY OF STATE
NOTARY PUBLIC APPLICATION*
Including:
Request to be appointed a Notary Public
Notarial Oath
Notarial Bond
Instructions
IC 33- 16 -2 -1: (as amended)
Sec. 1 (a) Any applicant for a commission as a notary public shall possess the following qualifications:
(1) be at least eighteen (18) years of age; and
(2) be a legal resident of the State of Indiana.
(b) A notary public shall be appointed and commissioned by the Governor. A notary public shall hold
office for eight (8) years. A notary public, when so qualified, shall be authorized to act within the State of Indiana. A person may
request an application to become a notary public from the Secretary of State. The application shall be prescribed by the Secretary of
State and shall include the applicant's county of residence, oath of office, and official bond. The application shall also contain any
additional information necessary for the efficient administration of this chapter. The applicant shall personally appear, with an
application, before an officer authorized by law to administer oaths who shall administer an oath of office to the applicant The
applicant shall secure an official bond, with freehold or corporate security, to be approved by the Secretary of State in the sum of five
thousand dollars ($5,000). The official bond shall be conditioned upon the faithful performance and discharge of the duties of the
office of notary public, in all things according to law, for the use of any person injured by a breach of the condition. The completed
application shall be forwarded to the Secretary of State. The Secretary of State shall forward each commission: issued by the Governor
to the applicant or the applicant's surety company.
Notary Department
Secretary of State's Office
Room 201 State House
Indianapolis, Indiana 46204
317 232 -6542
This application should also be filled out by current notaries public desiring to extend their commission
for another term. There is no separate renewal form or procedure.
IT IS A CRIME TO PERFORM ANY OF THE DUTIES OF A NOTARY PUBLIC UNTIL COMMISSIONED BY THE
GOVERNOR. IT IS IMPORTANT THAT YOU POSSESS A CURRENT, VALID COMMISSION BEFORE ACTING AS A
NOTARY PUBLIC. THE FILING OF THIS APPLICATION OR THE TAKING OF THE OATH CONTAINED AS PART OF
THIS APPLICATION DOES NOT AUTHORIZE YOU TO ACT AS A NOTARY PUBLIC
Do Not Write In This Box For Office Use O nly
Commission# Expiration Date of New Commission
APPLICATION FOR APPOINTMENT AS A NOTARY PUBLIC IN THE STATE OF INDIANA
Complete and Return to: Notary Department, Secretary of State, Room 201, State House
Indianapolis, Indiana 46204: Telephone: 317 232 -6542
To: THE GOVERNOR OF INDIANA
I respectfully request that I be appointed and commissioned a Notary Public. In support of my application, I submit herewith the required bond,
oath of office, and fee of FIVE DOLLARS 5), payable to the Secretary of State, in the form of a check a money order. (Do not send currency in
the mail) (IC 33- 16 -2 -1)
PRINT OR(( TYPE
i t n A
1. NAME I\ 1. f FL 1" 0 1 E
Yousltaal s, Mein uitidtmmnBsion wb he ismed -sae iastruclion B3
2. HOME ADDRESS_ 10 V�G �SL ��t, 0
Himbe mad stmal
N D i A L,-t S I N 1 2-20
Cny side
3. COUNTY OF RESIDENCE I A p
4. Business or Employer's Name `I y Cl
S. Business or Employer's Address (y C G 6 L A V 01 1 I KA 0
City St. Z
[7 Strmt to ,I I I P
1 mdc
6. HOME PHONE 2 D� OFFICE PHONE_( �JI t z Z� 0
At® Code Minhcr An:a Cade Ruing
7. If you have a current valid notary commission, show your expiration date:
N/ A 20
8. If you are now a notary public and your name or county has changed since your last application, please give both old and new information.
OLD: N
NEW:
9. NOTARIAL OATH
STATE OF INDIANA SS:
r�l C f r
COUNTY OF awry u, W w o to
I do solemnly swear (or affirm) that I will support the Constitution of the United States, and the Constitution of the State of Indiana; that I am duly
qualified to hold office under the Constitution and laws of the State; that I am 18 years of age or over; that 1 am of good moral character and integrity;
that I am a resident of Indiana; that my answers to questions on this application are true and complete to the best of my knowledge; that I have
carefully read all of the instructions which came with this application, and that I will faithfully and impartially discharge the duties of NOTARY
i PUBLIC if so commissioned by the Governor, according to the best of my skill and ability, so help me God (or under the pains and penalties of
j
perjury).
s patare of am I ani
Place Officers Seal Her Subscribed and sworn or affirmed to before me, this :;tiU� day of
i
A.D. 20' IN TESTIMONY WHEREOF, I, raud -r
me
1 r1 P ortyped na ofoffiewr
e�,� Z t tea' t r, for the
pp
sie ofanota<y ublic orotha offiaa audtodmd to adinimsta oaths O(fiu
County of f4 t- Its "i State of Indiana.
.I Offi oaf fman ry ofresaim ae
j My commission expires:
NOTE: The Bond Form, starting with 10 on the back of this application, must be completed before mailing to the Secretary of State.
The applicant must sign again in #10.
10. NOTARIAL BOND 3
KNOW ALL BY THESE PRESENTS, that we i C as principal
ane o A ,con
of
(applicant) and Name of Sunny
and County as
Strata .%city,&we &ZIPeede
freehold or corporate surety, are held and firmly bound unto the State of Indiana, in the penal sum of FIVE THOUSAND DOLLARS ($5,000), the
payment of which, well and truly to be made, we bind ourselves, our heirs, executors and administrators, firmly by these presents.
WITNESS our signatures as acknowledged below. THE CONDITION OF THE ABOVE OBLIGATION IS AS FOLLOWS,
TO -WIT.
WHEREAS, the above bound principal has applied for appointment by the Governor of the State of Indiana as a
Notary Public, in and for the State of'Indiana, for a eight -year term_
Now, if the said principal shall truly and faithfully perform and discharge the duties ofsaid office of Notary Public, in all things according to
law, then the above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective
date of the prineipal's remission to the expiration date of the same.
JC §gnaeaeefepp9icait. MunbaaknovJedgedbdominHll 5t aturaarsway. ASim beatknowledgOdbnluwingt2
11. ACKNOWLEDGEMENT OF APPLICANT'S SIGNATURE BY A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED BY
LAW TO TAKE ACKNOWLEDGEMENTS.
STATE OF SS:
3 l e r4a1 6� COUNTY OF z 4. T7"t
t� whteh actnowkdgemnt�emg mock
Be ore me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc.) personally appeared
"I r 601 :'!..,c_ and acknowledged the execution of the foregoing bond for the uses and
Prao ortyped a—mor Appacm
purposes therein expressed, without condition or reservation.
Place Claera seat her IN TESTIMONY WHEREOF, I i� have hereunto set my
Pn artypednuneofa6ictr
band and 6fficial seal, this t day of r r��,`�i /y>"� 20 y-
a
S atn,e or oxhonud rtnr o ce
T-
for the Co ty, of l l` 1I I Srnteof "'L
ort;cees aunty resti�
My commission expires: A _i S
12. AC"OWLIEDGEMENT OF SURETY'S SIGNATURE (Freehold or Corporate) BY A NOTARY PUBLIC OR OTHER OFFICER
l',.uTHORCZED 13Y LAW TO TAKE ACKNOWLEDGEMENTS. (NOTE: The officer can not acknowledge his/her own signature)
STATE OF COUNTY OF SS'
County m tc a pwkdgwent n ng mare
Before me the undersigned, an officer authorized to take the acknowledgement of deeds (Notary Public, County Clerk, etc) personally appeared
and acknowledged the execution of the foregoing bond for the uses and
Pdntedorlypednamo t Aduatsq;atnil surety
purposes therein expressed, without condition or reservation
Plate Officers seathere IN TESTIMONY WHEREOF, I PnnwdoFMrdnauaaoffka have hereunto set my
hand and official seal, ibis day of 20
a
S,gnaum of officer office
for the County of State of
5cersanntey rm exe
My commission expires
13. SUPPORTING AFFIDAVIT TO BE USED IN SUPPORT OF A FREEHOLD SURETY.
STATE OF INDIANA, COUNTY OF SS:
o+mH in which acknowledgement to bemg iscede
The undersigned surety, being duly sworn or affirmed, says that he /she is the owner in fee simple of Real Estate in
i County, of the fair Cash Value of S oven and above all
encumbrances and exemptions. signatweorsarety
Place Offm s seal here IN TESTIMONY WHEREOF, I have hereunto set my
Hated a typed Dane oFOff to
hand and official seal, this day of 20
a
S�g,atum o ar z ofr,¢r Office
for the County of State of
Ofi ce 5m9 ty rmr 9,eC
My commission expires:
For the statute pertaining to surety company bonds, see Indiana Code 27 -1 -22. For the statutes pertaining to Officer's Bonds and
Oaths, see Indiana Code 5 -4.
I
NO'T'ARY APPLICATION INSTRUCTIONS
I. Application for Notary Public may be obtained from the Secretary of State, the Clerk of the Circuit Court, or a
bonding company. Applications can be photocopied if all parts of the application remain on the front and back of
one piece of paper.
2. The application must be filled out completely. The application must be typewritten or printed.
Do not leave any blanks. If any item is not applicable to you, please indicate that fact with 'the
words "not applicable" or "none" or "NA
3. In giving your name in item #1 on the application, you should print or type your name the way you will sign your name as a
notary public. Your first or middle name maybe initialed, but we suggest either your first full name or your second full name
or both, whichever you prefer. For example: John S. Smith, J. Samuel Smith, or John Samuel Smith; but not J. S. Smith.
Your commission will be issued in the name given in item #1 and when performing a notarial act you should always sign
your name the way it appears on your commission. This requirement is for identification purposes and is for your protection.
4. If you are making reapplication, it is important for you to complete item #7 on the application and show your ex-
piration date so that when your new commission is issued there will be no lapse or overlap. (If your commission has recently
expired, do not show your old expiration date in #7. Show an expiration date only if your commission is still in effect when
you complete the application.) Reapplications should not be sent to the Secretary of State's office earlier than sixty (b0) days
before the expiration date.
5. After the first seven items of the application have been filled out, take the application to an officer authorized by law to
administer oaths (e.g another notary public, the Clerk of the Circuit Court, etc_). The oath of office (item 09 of the
application) will be administered to you by that officer. Be sure to read instructions #6, 7, 8, 9 and 10 below.
PLEASE NOTE: BEFORE TAKING THE OATH IT IS IMPORTANT TO DETERMINE IF YOU ARE QUALIFIED TOBE
A NOTARY PUBLIC.
A. INDIANA LAW STATES THAT IT SHALL BE AN INDISPENSABLE QUALIFICATION FOR PERSONS TO HOLD ANY
OFFICE WITHIN THE STATE OF INDIANA, EITIJER BY ELECTION OR APPOINTMENT, THAT SUCH PERSONS
SHALL NEVER HAVE BEEN CONVICTED OF ANY CRM AGAINST THE LAWS OF THE UNITED STATES WHERE
THE SENTENCE IMPOSED EXCEEDED SIX (6) MONTHS (IC -3 -1).
B. NO PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER THE UNITED STATES OR UNDER
THIS STATE, AND PROHIBITED BY THE CONSTITUTION OF THIS STA'T'E FROM HOLDING MORE THAN ONE
SUCH LUCRATIVE OFFICE, SHALL SERVE AS A NOTARY PUBLIC, AND HIS ACCEPTANCE OF ANY SUCH
OFFICE SHALL VACATE HIS APPOINTMENT AS SUCH NOTARY; BUT THIS PROVISION SHALL NOT APPLY TO
ANY PERSON HOLDING ANY LUCRATIVE OFFICE OR APPOINTMENT UNDER ANY CIVIL OR SCIIOOL CITY
OR TOWN OF THIS STATE. (IC 33- 16 -2 -7)
C. EVERY PERSON ELECTED OR APPOINTED TO ANY OFFICE UNDER THIS CONSTITUTION SHALL, BEFORE
ENTERING ON THE DUTIES THEREOF, TAKE AN OATH OR AFFIRMATION TO SUPPORT THE CONSTITUTION
OF THIS STATE, AND OF THE UNITED STATES, AND ALSO AN OATH OF OFFICE. (Indiana Constitution; Article
15, Section 4)
6. An official bond, with freehold or corporate security, must be secured in the sum of $5,000. The applicant' must
sign in item 1110 and have his signature acknowledged in #11. (Freehold security must be approved by the Secre-
tary of State and item 413 of the application is only completed in the case of a freehold bond. A freehold bond is
when someone other than the applicant, who owns land worth at least $5,000, is the surety.) Corporate security
can be obtained by taking the application to a bonding company for completion. Insurance companies and agents
are often qualified to provide corporate security. Items #10, 11 and 12 of the application make up the bond.
7. In the case of a corporate security, a power of attorney showing that the individual signing for the bonding company
has authority to execute the bond should be attached to the application when it is submitted to the Secretary of
State.
8. The completed application, including the oath of office and bond, should be forwarded to the Secretary of State with
a fee of five dollars ($5), payable to the Secretary of State, in the form of a check or money order. Do not send cur-
rency in the mail.
9. The Secretary of State will forward your commission to you (or to your surety company, if requested to
do so by enclosing a self addressed return envelope with the application.)
10. Please tearoff and keep these instructions.
i
I
.j
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))
02/24/99 Notary fees Rachel $5.00
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Secretary of State's Office
IN SUM OF
Notary Department
Room 201 State House
Indianapolis, IN 46204
$5.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel DOCS Department
PO# Dept. INVOICE NO, ACCT# /TITLE AMOUNT Board Members
1192 43- 419.99 $5.00 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
Monday, March 02, 2009
Director, 6CS
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund