212097 08/28/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $8,453.40
CARMEL, INDIANA 46032 DEVELOPMENT ATTN ACCT RECV
10 N SENATE AVE CHECK NUMBER: 212097
INDIANAPOLIS IN 46204-2277
CHECK DATE: 8/28/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438 708 . 00 FULL TIME REGULAR
1120 4110000 133438 3 , 900 . 00 FULL TIME REGULAR
1301 4110000 133438 -20 .41 FULL TIME REGULAR
2201 4110000 133438 1, 950 . 00 FULL TIME REGULAR
1125 R4110000 30305 133438 1, 915 . 81 UNEMPLOYMENT
133438 -1
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE,INDIANAPOLIS. IN 46204-2277
Toil 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 JUL, 2012
CARMEL IN 46032-2584
NETCHARGES $8,453 .67
POSTING DATE AUG-03 , 2012
IThe 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
SECURITY YEAR END I CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING I 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 Reimbursable
Bill (Form 1067)for these charges and any previous liability still outstanding.
*** NEW CHARGES FOR THE REPORTING MONTH 07/12 ***
M E JACKSON 02/23/13 REG 07/25/12 07/21/12 390.00
---------------
TOTAL NEW CHARGES FOR THE REPORTING MONTH 07/12 8,473.81
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 09/10 ***
315-64-6530 D A HUGHES '�,Zt(k 08/20/11 REG 07/10/12 09/18/10 20.14CR
CONTINUE ON NEXT PAGE ****
An (*) in the ACID column denotes a charge resulting from an acquisition of another business.
� i'�t
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Dept. of Workforce Development
Benefit Administration IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$1,950.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. I ACCT#/TITLE AMOUNT Board Members
2201 I 1 41-100.001 $1,950.00 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, A}ag st 23, 2012
✓'vwv�
(JWVT0eet Co i q1 #
Title sloder
;s
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))
08/03/12 $1,950.00
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
Indiana Department of Workforce Development
Benefit Administration
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$708.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 41-100.00 $708.00
I hereby certify that the attached invoice(s), or
I
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, August 23, 2012
n
Chief of Police
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))
08/03/12 unemployment- Park $708.00
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
Indiana Department of Workforce Development
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204
$3,900.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I 133438 I 41-100.00 I $3,900.00 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
AUG 2 7 2012
Fire Chief
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))
133438 $3,900.00
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
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.
,Payee
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.
20
IN SUM OF $
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
A,
20
Signature
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
8/3/12 133438 Unemployment charges City Acct/Parks Dept JuP12 $ 1,915.81
30305
Total $ 1,915.81
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
120
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$
$ 1,915.81
ON ACCOUNT OF APPROPRIATION FOR
101-General Fund
PO#or INVOICE NO ACCT#/ AMOUNT Board Members
.
Dept# TITLE
30305 133438 4110000 $ 1,915.81 1 hereby certify that the attached invoice(s), or
bilf(s) is (are)true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
23-Aug 2012
Signature
$ 1,915.81 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund