206573 02/27/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $6,640.74
CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV
101 N SENATE AVE CHECK NUMBER: 206573
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 2/27/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1115 R4350900 133438 467.32 OTHER CONTRACTED SERV
1160 4110000 133438 1,560.00 FULL TIME REGULAR
1207 4111000 133438 1,835.00 PART -TIME
2201 4110000 133438 433.00 FULL TIME REGULAR
1125 R4110000 30305 133438 2,345.42 UNEMPLOYMENT
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 SQ REPORTING MONTH JAN, 2012
CARMEL IN 46032 -2584
NETCHARGES $6,640.74
POSTING DATE FEB 05, 2012
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
t�tteftipluyiy,z��t sc:ra��ce- s D— O !'g r%tk%1 ants -were madP_the_emplover -had the opportunity
and the responsibility to report any information which could.disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAREND CLAIM WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING 1 AC0 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
K PHILLIPS 111, 06/02/12 REG 01/08/12 01/07/12 77.32
v
TOTAL NEW CHARGES FOR THE REPORTING MONTH 01/12 6,737.48
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: JANUARY, 2012 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAREND CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 10 /11
M EDWARDS 10/31/09 REG 01/20/12 12/20/08 68.56CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 12/08 68.56CR
TOTAL AMOUNT OF NET CHARGES 6,640.74
END OF BENEFIT CHARGE STATEMENT
e
c b C)
iM -7.
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.
,n
Payee f
_Dz ���1��� 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 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.
f ALLOWED 20
IN SUM OF
IU
A Ait
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
I'
4
r 0
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT N
ALLOWED 20
Indiana Department of Workforce Development
IN SUM OF
Benefit Administration, 10 N. Senate Ave
Indianapolis, IN 46204 -2277
$1,560-00
ON ACCOUNT OF APPROPRIATION FOR
Mayor's Office
PO# Dept. INVOICE NO. ACCT #frITLE AMOUNT Board Members
1160 Statement 41- 100.00 $1,560.00 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
Friday, February 24, 2012
--cam r
Mayor
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Prescribed by Slate 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))
02/05/12 Statement $1,560.00
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
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
IN Department of Workforce Development ALLOWED 20
Benefit Administration
IN SUM OF
10 North Senate Avenue
Indianapolis, IN 46204 -2277
$1,835.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO# I Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
120% 133438 41- 110.00 $1,835.00 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, February 20, 2012
Director, Brookshlr Golf Club
Title
Cost distribution ledger classification if
claim paid motor 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 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))
02/05/12 133438 Unemployment $1,835.00
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
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
215/12 133438 Unemployment charges City Acct/Parks Dept Jan'12 2,345.42
3Q3051
Total 2,345.42
1 hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and 1 have audited same in accordance
with IC 5- 11- 10 -1.6
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
2,345.42
ON ACCOUNT OF APPROPRIATION FOR
101- General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
30305 133438 4110000 2,345.42 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
17 -Feb 2012
V h p Nv-n o
Signature
2,345.42 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
i
VOUCHER NO. WARRANT NO.
Indiana Dept. of Workforce ALLOWED 20
IN SUM OF
10 North Senate Avenue
Indianapolis, IN 46204
$467.32
ON ACCOUNT OF APPROPRIATION FOR
Carmel Clay Communications
PO# 1 Dept. INVOICE NO. I ACCT #!TITLE AMOUNT Board Members
Encumbered A?- I hereby certify that the attached invoice(s), or
27696 I 43- 509.00 I $467.32
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
Tuesday, February 21, 2012
Director
Title
Cost distribution ledger classification if
claim paid motor 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 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))
02105/12 $467.32
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