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Form Prescribed by State Board of Accounts <br />(Government Unit) <br />County, Indiana <br />Acct #: 552635 <br />Ad #: 8827994 <br />DATA FOR COMPUTING COST <br />Width of single column 1.53 to <br />Number of insertions I <br />Size of type 7 point <br />Claim No. Warrant No. <br />IN FAVOR OF <br />South Bend Tribune <br />635 S Lafayette Blvd, Ste 138 <br />South Bend, IN 46601 <br />$ <br />On Account of Appropriation For <br />FED ID <br />83-28t0977 <br />Allowed , 20 <br />In the sum of $ <br />General Form No. 99P (Rev. 2002) <br />To: SBN South Bend Tribune <br />18 lines, 1.0000 columns wide which equals 18 equivalent <br />lines at $2.42 per line @ 1 days <br />Website Publication <br />Charge for proof(s) of publication <br />TOTAL AMOUNT OF CLAIM <br />$43.64 <br />$0.00 <br />$0.00 <br />$43.64 <br />I have examined the within claim <br />and hereby certify as follows: <br />That it is in proper form. <br />That it is duly authenticated as required by law. <br />That is is based upon statutory authority. <br />That it is apparently (correct) <br />(incorrect) <br />I certify that the within claim is true and correct, that the services there -in <br />itemized and for which charge is made were ordered by me and were <br />necessary to the public business. <br />Page 2 of 2 <br />