225226 10/22/2013 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: $620.00
10 N SENATE AVE
,o CHECK NUMBER: 225226
INDIANAPOLIS IN 46204-2277
CHECK DATE: 10/22/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1125 R4110000 29276 676277000 620 . 00 UNEMPLOYMENT FEES
676277 -1 l �,c—F, 7 ][�
INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT
BENEFIT ADMINISTRATION, 10 NORTH SENATE AVENUE, INDIANAPOLIS, IN 46204-2277 OCT 1 2013
Toll free 1-800-891-6499 Marion County 232-7436
STATEMENT OF BENEFIT CHARGES (FORM 53-'/
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 SEP, 2013
CARMEL IN 46032-3455
NETCHARGES $620 . 00
POSTING DATE OCT-04 , 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 had the opportunity
and the respor sibiiity to report any information which could disqualify the claimant.
SOCIAL BENEFIT PAID FOR
SECURITY YEAR END I CLAIM RANSACTION 1. WEEK AMOUNT
NUMBER EMPLOYEE'S NAME DATE LEVEL DATE ENDING I 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 09/13 ***
A RICHARD 03/22/14 REG 09/29/13 09/28/13 124.00
---------------
TOTAL NEW CHARGES FOR THE REPORTING MONTH 09/13 : 620.00
---------------
---------------
TOTAL AMOUNT OF NET CHARGES : 620.00
1
*** END OF BENEFIT CHARGE STATEMENT ****
an o � 3
L- ( l000v
An (*) in the ACID 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
10/4/13 676277000 Unemployment charges Parks Acct- Sep'13 29276 $ 620.00
Total $ 620.00
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.
146500 Indiana Dept. of Workforce Development Allowed 20
10 North Senate Ave., SE106
Indianapolis, IN 46204-2277
In Sum of$
$ 620.00
ON ACCOUNT OF APPROPRIATION FOR
101-General Fund
PO#or INVOICE NO. ACCT#/ AMOUNT Board Members
Dept# TITLE
29276 676277000 4110000 $ 620.00 I'hereby certify that the attached invoice(s), or
bill(s) is (are)true and correct and that the
rnaterials or services itemized thereon for
which charge is made were ordered and
received except
17-Oct 2013
Signature
$ 620.00 _ Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund