208163 04/24/2012 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: $4,420.10
101 N SENATE AVE
CHECK NUMBER: 208163
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 4/24/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1160 4110000 133438 2,216.00 FULL TIME REGULAR
1207 4111000 133438 1,889.00 PART -TIME
1125 R4110000 30305 133438 315.10 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 MAR, 2012
CARMEL IN 46032 2584
NETCHARGES $4,420.10
POSTING DATE APR 06, 2012
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 responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM LRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE I LEVEL DATE I 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 REPORTIN� ONTH 03/12
M EDWARDS V e( 10/31/09 REG 03/26/12 12/27/08 74.74CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 01/09 74.74CR
�l'L�t'l ICU Yl 1- Jw C1v TOTAL AMOUNT OF NET CHARGES 4,420.10
00b1 v� I D.c�
�l
An in the ACO column den 6t6sF&8h%VgFAFiUTi&d�+R:�A §RAa% MtibV6f 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))
04/06/12 133438 Unemployment $1,889.00
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN Department of Workforce Development
Benefit Administration IN SUM OF
10 North Senate Avenue
Indianapolis, IN 46204 -2277
$1,889.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1207 I 133438 I 41- 110.00 I $1,889.00 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, April 19, 2012
?fn�-2'd (14
Director, Br shire Golf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
4/6/12 133438 Unemployment charges City Acct/Parks Dept Mar'12 315.10
30305!
Total 315.10
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
1 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
315.10
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
30305 133438 4110000 315.10 1 hereby certify that the attached invoice(s), or
bili(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
19 -Apr 2012
Signature
315.10 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund