HomeMy WebLinkAbout222272 07/29/2013 CITY OF CARMEL, INDIANA VENDOR: 146500 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF WORKFORCE
1 CARMEL, INDIANA 46032 DEVELOPMENT ATTN:ACCT RECV CHECK AMOUNT: $295.42
10 N SENATE AVE
CHECK NUMBER: 222272
INDIANAPOLIS IN 46204-2277
CHECK DATE: 7/29/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4110000 133438-00 -1, 429 . 00 FULL TIME REGULAR
1120 4110000 133438-00 1, 765 . 00 FULL TIME REGULAR
1125 4110000 133438-00 -5 . 14 FULL TIME REGULAR
1301 4110000 133438-00 -35 . 44 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 S 4
CARMEL IN 4632-2584 REPORTING MONTH JUN, 2013
NET CHARGES $295. 42
POSTING DATE JUL-04, 2013
The receipt of this statement (Form 535) does not reopen the question of the claimant's eligibility for
unel?"pleymcnt insurance since, before any Nayinenis 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 I WEEK AMOUNT
NUMBER I EMPLOYEE'S NAME I 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 06/13 ***
R S LANNAN 04/26/14 REG 06/30/13 06/29/13 353.00
---------------
TOTAL NEW CHARGES FOR THE REPORTING MONTH 06/13 1,765.00
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 09/11 ***
G A PARK 02/18/12 REG 06/18/13 09/03/11 --------75.00CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 09/11 75.00CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 08/11 ***
G A PARK 02/18/12 REG 06/05/13 08/27/11 377.00CR
---------------
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 08/11 : 1,131.00CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 07/11 ***
G A PARK U Q 02/18/12 REG 06/05/13 07/23/11 223.00CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 07/11 : 223.00CR
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 04/11 ***
K L NEFOUSE 7 02/11/12 REG 06/24/13 04/02/11 5.14CR
Ili ---------------
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 04/11 : 5.14CR
*** CONTINUE ON NEXT PAGE ****
An (*) in the ACO column denotes a charge resulting from an acquisition of another business.
Account/Location Number: 133438 -000 Reporting Month: JUNE, 2013 Page 2
Employer Name: CITY OF CARMEL
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM TRANSACTION WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING ACO CHARGED
*** REVERSED CHARGES/CREDITS FOR THE PRIOR MONTH 09/10 ***
D A HUGHES (� 08/20/11 REG 06/13/13 09/18/10 --------35.44CR
TOTAL REVERSED CHARGES/CREDIT FOR THE PRIOR MONTH 09/10 : 35.44CR
TOTAL AMOUNT OF NET CHARGES : 295.42
z
*** END OF BENEFIT CHARGE STATEMENT ****
An (*) in the ACQ 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.
/1 `Payee
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
N SUM OF $
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
CMG '-�5.
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund