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Prescribed by State Board of Accounts <br />Governmental Unit <br />General Form No. 99P (Rev. 2009A) <br />To.................................................................................... Dr. <br />IDEM <br />............................................County, Indiana <br />South Bend Tribune <br />225 West Colfax Ave <br />South Bend, Indiana 46628 <br />Tax ID# 35-13-1571 <br />PUBLISHER'S CLAIM <br />LINE COUNT Ad #: 161476 <br />Display Master (Must not exceed two actual lines, neither of which shall total more than four solid lines of type <br />in which the body of the advertisement is set) -- number of equivalent ................................... <br />Head --Number of lines <br />................................... <br />Body -- Number of lines <br />Body -- Number of lines „_, <br />Total number of lines in notice 19 <br />COMPUTATION OF CHARGES <br />19 lines, 1 columns wide equals 19 equivalent lines at 1.68 cents per line <br />Additional charges for notices containing rule or tabular work <br />(50 per cent of above amount) .... <br />Charge for extra proofs of publication <br />($1.00 for each proof in excess of two) ..$0.00 <br />................................. <br />TOTAL AMOUNT OF CLAIM $95.76 <br />DATA FOR COMPUTING COST <br />Width of single column in picas 9.4ems Size of 8 point <br />Number of Insertions 3 <br />Pursuant to the provisions and penalties of IC 5-11-10-1, 1 hereby certify that the foregoing account is just <br />and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has <br />been paid. <br />I also certify that the printed matter attached hereto is a true copy, of the same column width and type size, <br />which was duly published in said paper 3 time(s). The dates of publication being as follows: South Bend Tribune: <br />12/05/16, 12/06/16, 12/07/16. <br />w tt ii <br />(Publisher <br />South Bend Tribune <br />225 W. Colfax Ave. South Bend, IN 46628 <br />ON ACCT OF APPROPRIATION FOR <br />$95.76 <br />Appropriation No. Tax ID# 35-138-1571 <br />ALLOWED _. <br />IN THE SUM OF $95.76 <br />Cheryl Ju6e Morey, Notary Public <br />Resident of St. Joseph County <br />My Commission expires December 21, 2016 <br />That it is duly authenticated as required by law. <br />That it is based upon statutory authority. <br />That it is apparently <br />correct <br />incorrect <br />I certify that the within claim is true and correct; that <br />the services there in itemized and for which charge is <br />made were ordered by me and were necessary to the <br />public business <br />Attest <br />