215530 12/18/2012 a CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
` ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE CHECK AMOUNT: $12,381.11
�a CARMEL, INDIANA 46032 DEVELOPMENTATTN:ACCT RECV
10 N SENATE AVE CHECK NUMBER: 215530
INDIANAPOLIS IN 46204-2277
CHECK DATE: 12/18/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438-000 894 . 00 FULL TIME REGULAR
1115 4110000 133438-000 9, 978 . 25 FULL TIME REGULAR
1120 4110000 133438-000 779 . 00 FULL TIME REGULAR
1207 4110000 133438-000 750 . 00 FULL TIME REGULAR
1301 4110000 133438-000 —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 S4
CARMEL IN 46032-2584 REPORTING MONTH NOV, 2012
NET CHARGES $12, 381. 11
POSTING DATE DEC-07 , 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 �TRANSACTION 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 11/12 ***
D M HEINZMAN JR 08/24/13 REG 11/05/12 11/03/12 390.00
*** 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: NOVEMBER, 2012 Page 2
Employer Narne: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
*** NEW CHARGES FOR THE REPORTING MONTH 11/12 ***
G A PARK 02/18/12 REG 11/27/12 05/28/11 .106.00CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 05/11 1,252.00CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 09/10 ***
315-64-6530 D A HUGHES n 08/20/11 REG 11/28/12 09/18/10 ------"20�14CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 09/10 20.14C
---------------
TOTAL AMOUNT OF NET CHARGES 12,381.11
*** END OF BENEFIT CHARGE STATEMENT ****
An j*) in the ACQ column denotes a charge resulting from an acquisition of another business.
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN Department of Workforce Development
Benefit Administration IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$750.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. I ACCT#!TITLE I AMOUNT Board Members
1207 I 133438-000 I 41-110.00 I $750.00 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, December 17, 2012
Director, Brookshi e Golf 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))
12/07/12 I 133438-000 I Unemployment Charges I $750.00
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
$894.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Police Department
PO#/Dept. INVOICE NO. ACCT#!TITLE AMOUNT Board Members
1110 41-100.00 $894.00
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
Monday, December 17, 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))
12/07/12 unemployement charges- Herron/Park $894.00
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.
Indiana Department of Workforce Development ALLOWED 20
IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204
$779.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1120 I I ,� o o I $779.00 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 DEC 17 2012
Ci .PSG'�°9 � i��-�•r �i
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
Irescribed 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))
$779.00
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
676277 —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
CARMEL CLAY BOARD OF PARKS ACCOUNT/
AND RECREATION LOCATION NUMBER 676277 —000
1411 E 116TH ST REPORTING MONTH NOV, 2012
CARMEL IN 46032-3455
NET CHARGES $1, 676 .11
POSTING DATE DEC-07 , 20127]
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unemployment insurance since.. before-an-v-na_vrner±ts were !rode the c^ �.lcr=r-:=ad a�6:: cNpv:t: r�lty
and the responsibility to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAREND CLAIM RANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACQ 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 11/12 ***
K R APPLEMAN 03/02/13 REG 11/18/12 11/17/12 162.00
---------------
TOTAL NEW CHARGES FOR THE REPORTING MONTH 11/12 : 1,676.11
---------------
---------------
TOTAL AMOUNT OF NET CHARGES : 1,676.11
*** END OF BENEFIT CHARGE STATEMENT ****
CEIVED
DEC �ai
i
An (*) in the ACQ column denotes a charge resulting from an acquisition of another business.
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
1.2/7/12 J, 676277. Unemployment charges Parks Acct- Nov'12 $ 1.676.11
Total $ 1,676.11
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$
i
$ 1,676.11
ON ACCOUNT OF APPROPRIATION FOR
101-General Fund
PO#or INVOICE NO. ACCT#/ AMOUNT Board Members
Dept# TITLE
1125 676277 4110000 $ 1,676.11 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
14-Dec 2012
1
Signature
$ 1,676.11 Accounts Payable Coordinator
Cost distribution ledger classification if , Title
claim paid motor vehicle highway fund