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Prescribed by State Board of Accounts <br />(Governmental Unit) <br />IDEM <br />General Form No. 99P (Rev. 2009) <br />To Dr. <br />South Bend Tribune <br />County, Indiana 225 West Colfax Ave <br />South Bend, Indiana 46628 <br />Tax ID# 35 -138 1571 <br />PUBLISHER'S CLAIM <br />LINE COUNT Ad #0020143792 <br />Display Master (Must not exceed two actual lines, neither of which shall total more than four solid lines of the type in <br />which the body of the advertisement is set) — number of equivalent .............. . . . . . . <br />Head — Number of lines <br />Body — Number of lines <br />Body — Number of lines <br />........• .... ......... . .... .. <br />Total number of lines in notice 15 <br />COMPUTATION OF CHARGES <br />15 lines, 1 columns wide equals 15.00 equivalent lines at # cents per line $5.54 <br />Additional charges for notices containing rule or tabular work <br />(50 per cent of above amount) <br />............. -- ............. <br />Charge for extra profs of publication <br />($1.00 for each proof in excess of two) <br />TOTAL AMOUNT OF CLAIM $5.54 <br />DATA FOR COMPUTING COST <br />Width of single column in picas 9.4ems Size of 7.5 point. <br />Number of insertions 1 <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 />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# time(s). The dates of publication being as follows: August 11, 2014 <br />Z <br />Title: President & Publisher <br />South Bend Tribune <br />225 W. Colfax Ave, South Bend, IN 46628 <br />$5.54 <br />ON ACCOUNT OF APPROPRIATION FOR <br />Appropri ation No. Tax ID# 35- 138 -1571 <br />ALLOWED <br />IN THE SUM OF $5.54 _ <br />Qku+� <br />Cheryl June Morey, Notary Publ' <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 />certify that the within claim is true and correct; that the services <br />there in itemized and for which charge is made were ordered by me <br />and were necessary to the public business <br />Attest <br />