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' Prescribed by State Board of Accounts General Form No. 99P (Rev. 2009) <br />(Governmental Unit) To <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 #0020219964 <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 $0.00 <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 $0.00 <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 />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 # time(s). The dates of publication being as follows: May 12, 2015 <br />*Title:President & Publisher Cheryl June Morey, Notary Public <br />Resident of St, Joseph County <br />My Commission expires December 21, 2016 <br />South Bend Tribune <br />225 W. Colfax Ave, South Bend, IN 46628 That it is duly authenticated as required by law. <br />That it is based upon statutory authority. <br />$0.00 <br />ON ACCOUNT OF APPROPRIATION FOR correct <br />That itis apparently <br />Appropriation No. Tax ID# 35-138-1571 incorrect <br />ALLOWED 1 certify that the within claim is true and correct; that the services <br />IN THE SUM OF $0.00 there in itemized and -for which charge is made were ordered by me <br />and were necessary to the public business <br />Attest <br />