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Prescribed by State Board of Accounts General Form No. 99P (Rev. 2009) <br />(Governmental Unit) To Dr. <br />IDEM 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 # 0020143796 <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 />................... <br />Body — Number of lines <br />Body — Number of lines <br />Total number of lines in notice <br />COMPUTATION OF CHARGES <br />16 lines, 1 columns wide equals 16.00 equivalent lines at # cents per line <br />Additional charges for notices containing rule or tabular work <br />(50 per cent of above amount) <br />Charge for extra profs of publication <br />($1.00 for each proof in excess of two) <br />TOTAL AMOUNT OF CLAIM <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 />............. <br />16 <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: September 08, 2014 <br />Y <br />Title: President Publisher <br />South Bend Tribune <br />225 W. Colfax Ave, South Bend, IN 46628 <br />$5.90 <br />ON ACCOUNT OF APPROPRIATION FOR <br />Appropriation No. Tax ID# 35-138-1571 <br />ALLOWED _ <br />IN THE SUM OF $5.90 <br />Attest <br />$5.90 <br />O -A% Tu.� <br />Cheryl June Morey, Notary P 'c <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 />$5.90 <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 />