206532 02/22/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
Q� ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $365.69
S s� CARMEL, INDIANA 46032 DEVELOPMENT AT ACCT RECV
101 N SENATE AVE CHECK NUMBER: 206532
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 212212012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 R4110000 30305 676277 -000 365.69 UNEMPLOYMENT
676277 -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
CARMEL CLAY BOARD OF PARKS ACCOUNT(
AND RECREATION LOCATION NUMBER 676277 -000
1411 E 116TH ST REPORTING MONTH JAN, 2012
CARMEL IN 46032 3455
NETCHARGES $365
POSTING DATE FEB 05, 2012
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
p y ^c^, before an! ments _were -made the the ap rt n
ouit
Uiieiii" to iTiCr'r� iii3arui�.:.� f I? y and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBE EMPLOYEE NAME DATE LEVEL DATE ENDING I ACQ 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 01;12
G M ELLIS 08/25/12. REG 12/20/11 12/17/11 4.69
TOTAL NEW CHARGES FOR THE REPORTING MONTH /12 365.69
TOTAL AMOUNT OF NET CHARGES 365.69
xr se BENEFIT CvnRCE STATEMENT
tIi1L :+1 BENEFIT
Purchase t-y- d I
Description PR
P.O. FEB 16 2012
G.L. o oco
Budget
Line Descr BY
Purchaser ate
Approval Date
An in the ACQ column denotes a charge resulting from an acquisition of another business.
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,
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)) PO Amount
215112 676277 Unemployment charges Parks Acct Jan'12 30305 365.69
Total 365.69
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.fi
20�
Clerk Treasurer
Voucher No. Warrant No,
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of$
365.69
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
30305 676277 4110000 365.69 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
17 -Feb 2012
Signature
365.69 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund