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Prescribed by State Board of Accounts General Form No. 99P (Rev. 2009A) -e - :- _' Governmental Unit To ..................................................... ............................... Dr. IDEM South Bend Tribune 225 West Colfax Ave .................... ........................County, Indiana South Bend, Indiana 46628 Tax ID# 35 -13 -1571 PUBLISHER'S CLAIM LINE COUNT Ad #: 9925 Display Master (Must not exceed two actual lines, neither of which shall total more than four solid lines of type in which the body of the advertisement is set) -- number of equivalent .... ............................... Head --Number of lines .... ............................... Body -- Number of lines .... ............................... Body -- Number of lines .... ............................... Total number of lines in notice COMPUTATION OF CHARGES 9 lines, 1 columns wide equals 9 equivalent lines at 0.365 cents per line Additional charges for notices containing rule or tabular work (50 per cent of above amount) .... ............................... Charge for extra proofs of publication ($1.00 for each proof in excess of two) .... ............................... TOTAL AMOUNT OF CLAIM $3.29 DATA FOR COMPUTING COST Width of single column in picas 9.4ems Size of 8 point Number of Insertions 1 Pursuant to the provisions and penalties of IC 5- 11 -10 -1, 1 hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has been paid. I also certify that the printed matter attached hereto is a true copy, of the same column width and type size, which was duly published in said paper 1 time(s). The dates of publication being as follows: South Bend Tribune: ' ! - 04/11/16. South Bend Tribune 225 W. Colfax Ave. South Bend, IN 46628 ON ACCT OF APPROPRIATION FOR $3.29 Appropriation No. Tax ID# 35- 138 -1571 ALLOWED IN THE SUM OF $3.29 Che�Je ey, Nota�Publ ' Resident of St. Joseph County My Commission expires December 21, 2016 That it is duly authenticated as required by law. That it is based upon statutory authority. correct That it is apparently incorrect I certify that the within claim is true and correct; that the services there in itemized and for which charge is made were ordered by me and were necessary to the public business Attest