209004 05/21/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $1,626.38
>•�'o CARMEL, INDIANA 46032 DEVELOPMENT ATTN: ACCT RECV
101 N SENATE AVE CHECK NUMBER: 209004
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 5/21/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438 263.00 FULL TIME REGULAR
1203 4111000 133438 720.00 PART -TIME
1207 4111000 133438 228.00 PART -TIME
1301 4110000 133438 -20.14 FULL TIME REGULAR
1125 R4110000 30305 133438 435.52 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
y Page 1
CITY OF CARMEL ACCOUNT/
ATTN CLERK TREASURER LOCATION NUMBER 133438 000
ONE CIVIC SQ
CARMEL IN 4b032 -2584 REPORTING MONTH A1?R, 20'12
NETCHARGES
POSTING DATE MAY 06„ 20,1;2 f
The receipt of this statement (Form 535) does not reopen the question of the claimant's elgtbdity for
unemployment insurance since, before any payments were made the employer hadthe`-opportunify K
and the responsibility to report any information which could disqualify the claimant.
SO CIAL BENEFIT PAI
SECURITY YEAR E ND CLAIM RANSACTION WEEK ;AMOUNT
r NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACU. CHARGED h
THIS IS NOT A BILL OR A REQUEST FOR MONEY DUE TO THIS DEPARTMENT. It is a statement:of beneftt 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.
D B JACKSON 12/15%12 REG 04/29/12 04/.28%12,5,
TOTAL NEW CHARGES REPORTING MONTH 04/12 1,721.26
"REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 09/10
j ^t.
TOTAL REVERSED CHARGES /CREDIT 'OR THE PRIOR MONTH 09/10 20'14
M EDWARDS 10/31/09 REG 04/20/12 01/03/09 70.40CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 01/09 74.74CR
0 a ((Lqf�s= �72, TOTAL AMOUNT OF NET CHARGES 1, 626.38
i'loi 47 m,the,ACQ column denbtLs EH g���ir> i A4RWMtibV6f another business.
y
OXTA o. I L�
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN Department of Workforce Development
Benefit Administration IN SUM OF
10 North Senate Avenue
Indianapolis, IN 46204 -2277
$228.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1207 I 133438 -000 I 41-110.001 $228.00 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, May 21, 2012
]Li 1A t4 i
Director, Brookshir &If 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))
05/06/12 133438 -000 Unemployment $228.00
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., SE 106 Date Due
Indianapolis, IN 46204 -2277
Invoice voice Description
Date ;N;umber (or note attached invoice(s) or bill(s)) PO Amount
516112 33438 Unemployment charges City Acct/Parks Dept Mar'12 435.52
30305'
Total 435.52
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.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204 -2277
In Sum of
435.52
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT AMOUNT Board Members
Dept TITLE
30305 133438 4110000 435.52 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
21 -May 2012
0 &.Lwp 7W
Signature
435.52 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund