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3 <br />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 # 0020263064 <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 16 <br />COMPUTATION OF CHARGES . <br />16 lines, 1 columns wide equals 16.00 equivalent lines at # cents per line $6.07 <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 />-----•------------ ............. <br />TOTAL AMOUNT OF CLAIM $6.07 <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 <br />has 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: October 24, 2015 <br />rTitI.:Pes-kdJe/�ntt& Publisher <br />South Bend Tribune <br />225 W. Colfax Ave, South Bend, IN 46628 <br />$6.07 <br />ON ACCOUNT OF APPROPRIATION FOR <br />Appropriation No. Tax ID# 35-138-1571 <br />ALLOWED _ <br />IN THE SUM OF $6.07 <br />Attest <br />� 1 1 <br />eryl June Morey, Notary Public <br />Resident of St, Joseph County <br />MV 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 />