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207346 03/26/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1 ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CARMEL, INDIANA 46032 DEVELOPMENT ATTN. ACCT RECV CHECK AMOUNT: $8,608.10 101 N SENATE AVE CHECK NUMBER: 207346 INDIANAPOLIS IN 46206 -0847 CHECK DATE: 3/26/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1160 4110000 133438 2,996.00 FULL TIME REGULAR 1207 4111000 133438 3,869.14 PART -TIME 1125 R4110000 30305 133438 -00 1,742.96 UNEMPLOYMENT 13343$ -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 FEB, 2012 CARMEL IN 46032 -2584 NET CHARGES $8,608.10 POSTING DATE MAR-02, 2012 The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for unernployrnent -insurance since, before any payments were made the.emplo.y.er_ had the opportunity. and the responsibility to 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 ACO 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 Reimbuisabie Bill (Form 1067) for these charges and any previous liability still outstanding. NEW CHARGES FOR THE REPORTING MONTH 02/12 D S ALT 12/01/12 REG 02/01/12 12/17/11 151.00 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: FEBRUARY, 2012 Page 2 Employer Name: CITY OF CARMEL SOCIAL BENEFIT PAID FOR SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING A CHARGED NEW CHARGES FOR THE REPORTING MONTH 02/12 D S ALT 12/01/12 REG 02/26/12 02/25/12 151.00 TOTAL NEW CHARGES FOR THE REPORTING MONTH 02/12 8,682.84 REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 01/09 312 -98 -2537 M EDWARDS 10/31/09 REG 02/20/12 12/27/08 74.74CR TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 01/09 74.74CR TOTAL AMOUNT OF NET CHARGES 8,608.10 END OF BENEFIT CHARGE STATEMENT Purchase Description A P.O. P or F CT r G.L. Budget Line Descr Purchaser aka Approval Date An in the AC© 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 315112 133438 Unemployment charges City Acct/Parks Dept Feb'12 1,742.96 ��30305 Total 1,742.96 I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and I have audited same in accordance with 1C 5- 11- 10 -1.6 20_ Clerk- Treasurer Voucher No. Warrant No. 146500 Indiana Dept. of Workforce Development Allowed 20 10 North Senate Ave., SE 106 Indianapolis, IN 46204 -2277 In Sum of 1,742.96 ON ACCOUNT OF APPROPRIATION FOR 101 General Fund PO# or INVOICE NO. ACCT AMOUNT Board Members Dept TITLE 30305 133438 4110000 1,742.96 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 22 -Mar 2012 Signature 1,742.96 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund VOUCHER NO. WARRANT NO. ALLOWED 20 IN Department of Workforce Development Benefit Administration IN SUM OF 10 North Senate Avenue Indianapolis, IN 46204 2277 $3,869.14 ON ACCOUNT OF APPROPRIATION FOR Brookshire Golf Club PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members 1207 133438 -000 I 41- 110.00 $3,869.14 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 19, 2012 'W��2 Al /4 Director, Broo hire 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)) 03/01/12 133438 -000 Unemployment $3,869.14 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 VOUCHE NO. WARRANT NO. ALLOWED 20 Indiana Department of Workforce Development IN SUM OF Benefit Administration, 10 N. Senate Ave Indianapolis, IN 46204 -2277 $2,996.00 ON ACCOUNT OF APPROPRIATION FOR Mayor's Office PO# Dept. INVOICE NO, ACCT #frITLE AMOUNT Board Members 1160 Statement 41- 100.00 $2,996.00 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 Thursday, March 22, 2012 Mayor 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)) 03/02/12 Statement $2,996.00 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