214527 11/19/2012 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
} ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
€ CHECK AMOUNT: $15,954.43
s; = CARMEL, INDIANA 46032 DEVELOPMENT ATTN.ACCT RECV
10 N SENATE AVE CHECK NUMBER: 214527
INDIANAPOLIS IN 46204-2277
CHECK DATE: 11119/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 1, 988 . 00 FULL TIME REGULAR
1115 4110000 12, 036 . 57 FULL TIME REGULAR
1120 4110000 1, 950 . 00 FULL TIME REGULAR
1301 4110000 -20 . 14 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 SO
CARMEL IN 46032-2584 REPORTING MONTH OCT, 2012
NET CHARGES $15,954.43
4
POSTING DATE NOV-02, -,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 cppertUnity
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM �TRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ .- CHARGED , [.
THIS AS 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 10/12 ***
P D GORDON 08/31/13 REG 10/18/12 10/13/12 390.00
*** 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: OCTOBER, 2012 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM R WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ CHARGED
*** NEW CHARGES FOR THE REPORTING MONTH 10/12 ***
L H MOORE _ 07/06/13 REG 10/28/12 10/27/12 `� . 304.11_
TOTAL NEW CHARGES FOR THE REPORTING MONTH 10/12 : 16,326.57
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 05/11 ***
G A PARK 02/18/12 REG 10/07/12 05/07/11 24.000R
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 05/11 352.00CR
*** REVERSED HARGES/CREDITS FOR THE PRIOR MONTH 09/10
A HUGHES 08/20/11 REG 10/10/12 09/18/10 20.14CR
---------------
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 09/10 : 20.14CR
TOTAL AMOUNT OF NET CHARGES : 15,954.43
*** END OF BENEFIT CHARGE STATEMENT ****
An {*) in the AC® column denotes a charge resulting from an acquisition of another business.
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Department of Workforce Development
Benefit Administration
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$1,988.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1110 41-100.00 $1,988.00
I hereby certify that the attached invoice(s), or
I 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
Friday, November 16, 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))
11/02/12 unemployment charges- Herron $1,988.00
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.
-FlaPayee
w4u�-(Z7N4 e� )" 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.
ALLOWED 20
IN SUM OF $
K)
$
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
20
Signatur
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Department of Workforce Development
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204
$1,950.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. I ACCT#!TITLE AMOUNT Board Members
1120 I I 41-100.00 I $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
NOV 1
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
'rescribed by State Board of Accounts City Form No.201 (Rev.1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
\n invoice or bill to be properly itemized must show: kind of service,where performed, dates service rendered, by
vhom, 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))
$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