212876 09/25/2012 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: $5,708.66
10 N SENATE AVE CHECK NUMBER: 212876
INDIANAPOLIS IN 46204-2277
CHECK DATE: 9125/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438 -724 . 00 FULL TIME REGULAR
1115 4350900 133438 1, 824 . 66 OTHER CONT SERVICES
1120 4110000 133438 1, 560 . 00 FULL TIME REGULAR
2201 4110000 133438 1, 170 . 00 FULL TIME REGULAR
1125 R4110000 30305 133438 1, 878 . 00 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 SO REPORTING MONTH AUG, 2012
CARMEL IN 46032-2584
NETCHARGES $5 , 708.66
POSTING DATE SEP-09, 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 I CLAIM RANSACTION WEEK AMOUNT
NUMBER I EMPLOYEE'S NAME I DATE LEVEL DATE I 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 REPORTIN'Gn 4ONTH 08/12 ***
L H MOORE 07/06/13 REG 08/26/12 08/25/12 304.11'
TOTAL NEW CHARGES FOR THE REPORTING MONTH 08/12 6,730.66
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 07/12 ***
303-84-5760 G A PARK 03/30/13 REG 08/01/12 06/30/12 38.00CR
303-84-5760 G A PARK �O�W 03/30/13 REG 08/01/12 07/07/12 --------38�OOCR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 07/12 76.00CR
*** 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: AUGUST, 2012 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM TRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 06/12 ***
G A PARK �O 03/30/13 REG 08/01/12 06/23/12 38.00CR
---------------
TOTAL REVERSED CHARGES/CREDIT FOR' THE PRIOR MONTH 06/12 279.95CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 05/12 ***
G A PARK 03/30/13 REG 08%01/12 05/26/12 138.05CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 05/12 138.05CR
i
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 05/11 ***
G A PARK 02/18/12 REG 08/27/12 04/09/11 -------138-
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 05/11 528.000R
---------------
TOTAL AMOUNT OF NET CHARGES ,708.66
The following charges)are POTENTIAL credits to your account. A determination was made and you re found not
liable for these charges. But because you have chosen to make payment in lieu of contributions for Unemployment
Insurance,your account cannot be credited for these charges unless or until the claimant(s) refund the overpayment.
Your account will be credited as the claimant refunds the overpayment in full or in monthly installments.
G A PARK 02/18/12 REG 02/18/12 263.00
*** END OF BENEFIT CHARGE STATEMENT ****
An (*) in the ACO column denotes a charge resulting from an acquisition of another business.
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Department of Workforce Development
IN SUM OF $
10 North Senate Avenue ------ -------- —_ r__
Indianapolis, IN 46204
$1,560.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE I AMOUNT Board Members
1120 I I 41-100.00 I $1,560.00 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
SEP 2 4 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)
ACCOUN1-v PAYABLE VOUCHER
CITY OF CARMEL
An klivQice or bill to be properly itemized musi show: kind of service,where periorn-ied, dates service rendered, by
whom, rates pc!-day, ntu,1ber of hours, ralc 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))
$1,560.00
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
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 Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO# Amount
9/9/12 133438 Unemployment charges City Acct/Parks Dept Au '12 $ 1,878.00
30305
Total $ 1,878.00
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.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204-2277
In Sum of$
$ 1,878.00
ON ACCOUNT OF APPROPRIATION FOR
101-General Fund
PO#or INVOICE NO. ACCT#/ AMOUNT Board Members
Dept# TITLE
30305 133438 4110000 $ 1,878.00 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
20-Sep 2012
VA Y-up- Y2f
Signature
$ 1,878.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
F,.
i:
VOUCHER NO. WARRANT NO.
Indiana Dept. of Workforce Development ALLOWED 20
Benefit Administration
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$1,170.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
2201 I I 41-100.00 $1,170.00 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
$ .� Friday�/Septeiriber 21, 2012
A j!r
/, ' - a
Street eCommissiot%e er
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))
09/09/12 $1,170.00
hereby certify that the attached invoice(s), or bill(s), is (are)true and correct and I have audited same in accordance
vith IC 5-11-10-1.6
, 20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Dept. of Workforce
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204
$1,824.66
ON ACCOUNT OF APPROPRIATION FOR
Carmel Clay Communications
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1115 I I 43-509.00 I $1,824.66 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
Tuesday, September 18, 2012
Director
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))
09/09/12 $1,824.66
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
($724.00)
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 41-100.00 ($724.00)
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
6
received except
Wednesday, September 19, 2012
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))
09/09/12 credit/G. Park ($724.00)
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