215939 01/08/2013 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: $1,676.11
t? 10 N SENATE AVE CHECK NUMBER: 215939
INDIANAPOLIS IN 46204-2277
CHECK DATE: 1/8/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 4110000 676277 1, 676 . 11 FULL TIME REGULAR
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
NETCHARGES $1 , 676 . 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 rRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE I ENDING A 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 ****
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An (*} in the ACO column denotes a charge resulting from an acquisition of another business.
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1125 676277 4110000 $ 1,676.11 1 hereby certify that the attached invoice(s),or c, `°— I s y m n D
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