210221 07/02/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
0 ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $4,156.05
CARMEL, INDIANA 460.32 DEVELOPMENT ATTN: ACCT RECV
`o 101 N SENATE AVE CHECK NUMBER: 210221
INDIANAPOLIS IN 46206 -0847
CHECK DATE: 7/2/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438 138.05 FULL TIME REGULAR
1203 4110000 133438 1,948.00 FULL TIME REGULAR
2201 4110000 133438 2,070.00 FULL TIME REGULAR
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 MAY, 2012
CARMEL IN 46032 2584
NET CHARGES $7,737.26
POSTING DATE JUN 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 TRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING A CHARGED
I 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 05/12
N R GREEN 01/19/13 REG 05/21/12 05/19/12 163.98
TOTAL NEW CHARGES FOR THE REPORTING MONTH 05/12 7,871.67
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 02/11
307 -06 -3124 J N SPENCE 10/23/10 EB 05/31/12 02/05/11 6/ 115.21CR
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: MAY, 2012 Page 2
Employer Name: CITY OF CARREL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 02/11
J N SPENCE 10/23/10 EB 05/31/12 02/12/11 6.86CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 02/11 122.07CR
REVERSED CHARGES /CREDITS FOR THE PRIOR MONTH 01 /11
J N SPENCE 10/23/10 EB 05/31/12 01/29/11 12.34CR
TOTAL REVERSED CHARGES /CREDIT FOR THE PRIOR MONTH 01 /11 12.34CR
TOTAL AMOUNT OF NET CHARGES 7,737.26
END OF BENEFIT CHARGE STATEMENT
4
Ta
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. 7995)
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.
f (�0 P
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 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.
4 1LOWED 20
IN SUM OF
D J
k& (�j
s T-Y, Oar
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# INVOICE NO. ACCT #!TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
l ��U bill(s) is (are) true and correct and that the
/�3`7 107 materials or services itemized thereon for
which charge is made were ordered and
received except
20
r �Gr
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund