220024 05/20/2013 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: $856.36
`'+ ? 10 N SENATE AVE
CHECK NUMBER: 220024
INDIANAPOLIS IN 46204-2277
CHECK DATE: 5/20/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 -176 . 00 FULL TIME REGULAR
1115 4110000 939 . 93 FULL TIME REGULAR
1192 4110000 135 . 34 FULL TIME REGULAR
1207 4111000 123 . 00 PART-TIME
1301 4110000 -165 . 91 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 SQ REPORTING MONTH APR, 2013
CARMEL IN 46032-2584
NETCHARGES $856. 36
POSTING DATE MAY-03 , 2013
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 hzd 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 JJ AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING 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 04/13 ***
M D LAYTON 09/07/13 REG 04/29/13 04/13/13 159.93
TOTAL NEW CHARGES' FOR THE REPORTING MONTH 04/13 1,198.27
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 07/11 ***
G A PARK 02/18/12 REG 04/01/13 07/23/11 154.00CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 07/11 176.00CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 09/10 ***
D A HUGHES 0 601�_T 08/20/11 REG 04/16/13 09/18/10 165.91CR
---------------
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 09/10 165.91CR
---------------
---------------
TOTAL AMOUNT OF NET CHARGES 856.36
END OF BENEFIT CHARGE STATEMENT ****
An (*) in the ACO column denotes a charge resulting from an acquisition of another business.
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))
03/03/13 133438-000 Unemployment $123.00
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
IN Department of Workforce Development
Benefit Administration IN SUM OF $
10 North Senate Avenue
Indianapolis, IN 46204-2277
$123.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1207 I 133438-000 I 41-110.00 I $123.00 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, May 20, 2013
Director, BrookshirJAolf Club
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund