Okaloosa County BOCC — August 6, 2013 — Emerald Coast CAC Final Payment — reading text

Deposits/Other Credits | Date Transaction Type Description Amount | 04-01 Preauthorized Credit American Express Settlement 6,475.05 Vv 130401 4093656080 fi 04-01 Remote Express Dep &171.000/ 04-02 Deposit 632.00¥/ 04-03 _ Remote Express Dep 24,315.55 ¥ 04-04 Preauthorized Credit Square Inc 13040302 (e716 130404 M155249849 04-04 Preauthorized Credit Square Inc 13040302 (az0)/ 130404 M155255258 ‘ 04-04 Preauthorized Credit Merche-Solutions Merch Dep 1,890.00,/ 130404 000000010177032 ¢ : 04-05 Preauthorized Credit Square Inc 130405M2 70.005 ni Un 130405 M155568770 uD 04-08 = Preauthorized Credit Bked Processing Bkcd Depst C 0.0 j V - 130408 273800043450 J ultt 04-08 = Preauthorized Credit Bked Processing Bkcd Depst gj 0.01 130408 273800043450 04-08 Preauthorized Credit Merche-Solutions Merch Dep 250.00 v 130408 000000010177032 fi 04-08 Preauthorized Credit American Express Settlement 291.45 f 130408 4093656080 04-08 Preauthorized Credit Square Inc 13040602 130408 M155718542 Deposits/Other Credits April 30, 2013 000-009-494-6 Page 3 of 3 EMERALD COAST CHILDRENS ADVO | Date Transaction Type Description Amount | 04-09 Preauthorized Credit Square Inc 13040962 130409 M156093704 C2028634 M6 mM " 04-10 Preauthorized Credit Square Inc 130410N2 130410 M156247598 Csr) un “f 04-16 Deposit 4,186.01V, . 04-17 Remote Express Dep 67,572.177, 04-18 — Preauthorized Credit Paypal Transfer 300.00 4/ 130418 5CY226YAFRQLQ 04-18 Preauthorized Credit Merche-Solutions Merch Dep 380.00. Wa 130418 000000010177032 04-22 = Preauthorized Credit Merche-Solutions Merch Dep 400.00,/ 130422 000000010177032 04-22 ~~ Preauthorized Credit. American Express Settlement 1,060.70. WA 130422 4093656080 y 04-23 Remote Express Dep 8,260.19V_ 04-29 ~—- Preauthorized Credit American Express Settlement 242.87, / 430429 4093656080 04-30 Remote Express Dep Balance Summary { 10,740.92 Vf [ Date Amount Date Amount Date Amount | 03-31 247,046.25 04-10 295,991.81 04-22 356,650.42 04-01 261,692.30 04-11 294,915.00 04-23 364,592.61 04-02 259,247.53 04-12 289,220.54 04-24 352,353.24 04-03 276,792.71 04-15 286,662.12 04-25 348,524.42 04-04 276,857,13 04-16 289,372.74 04-26 348,324.42 04-05 276,802.08 04-17 356,944.91 04-29 340,431.86 04-08 279,648.75 04-18 357,074.41 04-30 317,227.32 04-09 299,935.09 04-19 356,738.72 NEW YORK LIFE BOX 500 MINNEAPOLIS ME 55499-0500 PHONE: 800-695-1272 Y CONSOLIDATED BILLING FREAIUM STATEMENT FOR REMITIER ID 621923294 A _ >OB0L95 2243673 DOR 952184 207 PREPARED ON; MARCH 29, 2013 EMERALD COAST CHILDRENS ADVOCACY CENTER INC PASNENT MUST BE MADE WITHIN PO BOX 1237 10 DAYS OF THE DUE DATE OF: NICEVILLE FL 32588-1237 APRIL 10, 2013 PAGE 10F 2 ZN ORDER TO CONTINUE THE SERVICING AGREEMENT FOR THE C THE ARRANG FOR CONTRACTS UNDER EMENT . NUMBER(S) LISTED BELOW, THE PAYMENT MUST BE MADE WITHIN 10 DAYS OF tae DUE DATE SHOWN ABOVE. PLEASE REMIT YOUR PavMyr BY THE SPECIFIED DATE 0 PREVENT THE DISCONTINUATION OF YOUR GROUP BILLING ARRANGEME! ARRANGEMENT NUMBER OF BILLED NUMBER ARRANGEMENT NAME CONTRACTS AMOUNT N40879 000 EMERALD COAST CHILDRENS 7 690.45 TOTAL AMOUNT DUE 690.45 158 api SAS PLEASE RETURN THIS PART WITH YOUR PAYMENT(S) IN THs ENCLOSED ENVELOPE . PLEASE DO NOT STAPLE ENCLOSE ARY CORO L Tees STUB. _ REMEMBER TO WRITE YOUR REMITTER ID HUNEER OFS CHECKS AND ENCLOSE ANY COMPLETED ADJUSTMENT DETAILS, REMITTER ID 021923294 4 A EMERALD COAST CHILDRENS EMERALD COAST CHILDRENS PREPARED MARCH 29, 2013 PAYMENT(S) DUE 10 DAYS FROM THE DUE DATE OF: APRIL 10, 2013 (NOTE ANY CHANGES 10 ABOVE ADDRESS HERE) TOTAL AMOUNT DUE 690.45 VobesBsdsPasolstbevcbsdesBsaletalafsBeoDoorlabbesfessddaredl BO Boe a ene (ENCLOSE ADJUSTHENY DETAILS) ? PO BOX 74a582 CINCINNATI OH 45274-2582 AMOUNT REMITTED > 02021023294804101310% OD006904502.023294a5 }o779 GoUtmone 87-1 (aoa 00195 2383601 mN0390 Dd! VRUY br2e- SUL CUKU FOZUI LEEQUO IGBCUEZ SOLS NEW YORK LIFE BOX 500 MINNEAPOLIS NN 55440-0500 ADJUSTMENT DETAILS (Please detach and return with your payment if any adjustments have been made ATED B GS DETAILS LIST ZF ANY PREMIUMS ARE NOT PAID AS SHOWN, PLEASE INDICATE THE ADJUSTED AMOUNT AND REASON: Ph Hie SPACE PROVIDED, DETACH AND RETURN THE FORM AND BILLING STUB WITH YOUR THE FOLLOWING PAGES CONTAIN A LIST OF THE CONTRACTS THAT SUPPORT TRE TOTALS LISTED IN THE CONSOLIDATED BILLING PREMIUM STATEMENT. ENTRIES PRECEDED BY AN O&) INDICATE AMOUNTS DUE BUT NOT PREVIOUSLY BILLED UNDER THE ARRANGEMENT(S). ENTRIES PRECEDED BY A (+) INDICATE THE FIRST PAYMENT DUE FOR A CONTRACT. Here st Gu Pu fi eS Se tm (03) PAYMENT NOT REQUIRED (AD) NEW CONTRACT OR RESTART EXISTING CONTRACT (42) NEN BUSINESS - NoT TAKEN please refer to your Trust Agraenent for instructions on disposition of centracts from the trust, REAITTER ID: o2102z8298 6A DUE DATE: APRIL 10, 2013 CONTACT: TELEPHONE: BorT CONTRACT | ARRANGEHENT CRITERIA NUMBER NUMBER NUMBER em ———— eee | BRINSON V BRINSQN VIDA L 39709930 N40879 000 = aav28 125.00 126.00 i H 39709980 - CAROZZ0NI GAROZZONT RYAN 39724824 640879 900 = 03715 150.50 150.50 ! B97ZKBR4 CAROZZONZ RENEE"BL 99726769 N4Qa79 000 0315 119,50 119,50 | 39725769 TF Employee Deduction Sunnarized 270.00 270,00) DUNN THOM = DUNN THOMAS 89711575 N4va79 000 ©=— 03/28 425.00 425.00 | 99771575 ROLLS DB KOLLIS DEBORAH 39708224 Na0a79 000 © 03725 66.00 66,00 39708224 HURST JUL = HURST JULIE H 39756131 N4Oa79 000 = 03/138 34.70 34,70 . 39756131 LERELLYN RLEWELLYN SHEILA DI 389918937 N40879 ODO 03712 69.75 69.75 39915937 i L Jt ! SS —$$— = == SS TOTALS 699.45 690.45 | =< —— Tt * IMPORTANT: PLEASE INDICATE AY CODE THE REASON FOR ANY ADJUSTED ITEN - H TOTAL AHOUNT DUE | Tora, apsustannte (01) REMOVE CONTRACT FROM BILLING 1 (PLUS OR HINUS) Note: If a Participant is ! removed From 4 Pension Plan, (82) PREMTUN CHANGE ! AKOUNT REITTED ! ' i i i J pecs (Page 1 of 2) t f COASTAL BANK AND TRUST t t mi ne EMERALD COAST CHILDREN’S ADWOCACY CENTER, INC. ‘emerais coat PO. BOX 1237 i idrens NICEVILLE, FL 32588-1237 63-814-632 2 Cenler i ~ DATE AMOUNT a Apr 16, 2013 ““$ 690.45 i pay Six Hundred Ninely and 45/100 Dollars j one | 21g oven SUB A TERE Who sronarunes i ,| onoeR New York Life Insurance | | 75 Remittance Dr., Suite 3021 : | Chicago, IL 60675-3021 } rs | “#0080 Sui WOES 2051408009 Lah Br #000006 904 5 (age 2 of 2) x SY pn. : at ? 2 38332 (Cn! . 2] | 4 2 g23a77: : 3 [ § = ee ! - — a ae eS . 2S - d- s gyi! 2282 | c ico ns nee nT ee ROE a . E x a 3 ze ° , . a ° . 22 ; i og a meat 35 S191 a ab = 32 go 50° Ss : Bet . - 33 SS oe eS zo 1 Tit bee? Sa cee ISFS1AR LPS Pi - 38; : ai: 2 US BAN NA MY LIFE Bi eeeesg eat ee ST Pad mi _ - iat . AG) Bea meee 252° izo: 2 Es ea 2g, ae Zo ae sz! es $= fe <a a2. e ; 2 i i I i i _Aftac. 1 COPY - Original Invoice ; hes ee Georgia 21995 wie ee ARLAC 8G (1 60e, invoice Cony sr20%8 inveles Number: RS Account Name: EMERALD COAST CHILDRENS Account Nimber: EK Adtiress: Advocacy Center Premium Due Date: Sft#2013, Attn Jufle Hurst Amount Billed: g100287 8 BO Bax 1237 ‘Amount Ramilting: $1,002.87 Date Prepared: AM82013- Billing Frequency; MONTHLY 7 Highlighted ines incloate that ho premium aroun being reed was aus nora Orange Reaves es Suntec smployes. _ Polley” a we copioee S| Se rorat Poas7Zaé | ACC Pp ‘CAROZZON, RENEE E $250 Posar2as | 51D ' (CAROZZONI RENEE E $47.20 poasv2ag |CANCER =| P CAROZZOM|, RENEE E $34.22 $114.22 $94.82 $194.82 POAST2e1 | ACC F COTTON, LISA R. $39.80 $39.80 Poagrza4 [CANCER | COTTON, LISA R $50.31 $50.31 Poagyze? | STD ‘ COTTON, USAR 387.70 $47.70 POCeIaP2 | UFE i COTTON, LISA R wert $214.51 O70 ‘S216t PODO7SKS | LIFE q COTTON, LEAR 87.15 $7.15 $7.45 w716 POAaTZAD | SID i CROWELL, KATHERINE M $38.16 538.16 PQAST292 | ACG 8 CROWELL, KATHERINE M R270 $3270 POATTZ05 | HOSP s CROWELL, KATHERINE M A783 $125.58 $54.73 $125.58 Pecsiama | ACC s FLORO, JENNIFER O $85.75 338.75 PoCeI2M7 | CANCER 1 FLORO, JENNIFER 0 $24.58 $2158 Pocsiae [sip t FLORO, JENNIFER $t0.20 $127.68 ‘$720 $127.58 POA3T298 | STD. i HOLLIS, DEBORAH J $60.48 $00.18 $80.18 $60.28 PoOAgTZA2 | ACT F HURST, JULIE H $30.80 $39.50 POASTZAS | STD ' HURST, JULIE H 558.04 $08.44 $08.64 $95.44 Poceiats | HOSP iy SEFFRES, CHRISTINA A 48.16 38.48 Pacei2ro | LE 1 JEFFRIES, CHRISTINAA , 340.90 $40.90 Pocetzet | STD 1 JEFFRIES, CHRISTINA A, 528.00 $110.08 $28.00 $110.05 poagrzss | ACC P LEGOETT, RANDALL $9230 sa2.50 POASTZ85 | CANCER F LEGGET?, RANDALL R sore 04.04 S8174 a POBEMIAZ | CANCER: 1 LEWELLYN, SHERA D $31.85 $39.85 PORSMIAS | STO ' LEWELLYN, SHEILA D $31.20 SB.05 $31.20 563.05 Total Amourtt Billed: 1.00287) Amt Due $1,082.87 BZ 15 ¥20\ a as COVERAGE TYPE (CT) REMARKS (RM} CHANGE REQUEST (CR) CV = Pending Conversion A= Add person to policy H= Name Change PA = Policy Is Paid Ahgad Se Cancel Ceres! Coverage 1 = Detete person from policy PC = Policy is Pending Conversion L = Non-Family Medical Leave T = No fonger employed here and is Paid Ahead Be Unto hesurad-Rerrore M= Missed Deduction We Transter te another account F=Femily Medical Lasve ¥ = Military Leave Page 1 of t (Page 1 of 2) EMERALD COAST CHILDREN'S ADVOCACY CENTER, INC. one: coast RO. BOX 1237 i NICEVILLE, Fl, 32588-1237 . 63-814-632 5 pelle Sars . i RRS : an DATE. AMOUNT a : Apr16,2013 = **$ 1,002.87 z pay One Thousand Two and 87/100 Dollas = = © es . - 4 . : : 2 . . . VOID AFTER 99 DAYS g TO THE . - - IECKS OVER $1500.00 REQUIRE TWO SIGNATURES s ORDER Aflac : oF 1932 Wynnton Road a Columbus, GA 31999 WOOBOSS" 063208400009 4oh Er (Page 2 of 2) ot ' } 3 2? zi 3 28 28 iy asag : +S om & H a Cam | Semmes Russom sz abZrue 2 = SRErO a r BOARD € 5 o@G = iN 200 z | gO ca 7 Zz | 5 i 2 i 14 19d New York Life Insurance And Annuity Corporation (NYLIAG} {A Delaware Corporation) , PO Box 922 JEW. New York, NY 10159-0922 ‘ 1-800-598-2019 _ BILLING STATEMENT - eapeaatunpamamans _ —_ — >ODDRS? 24O5LUS OOOL 292454 10Z Registered Representative: EMERALD COAST CHILDRENS ADVOCACY JAMES T KERGANAG LUTOF CENTER ING MOBILE GENERAL OFFICE ADVOCACY CENTER INC ; 1440 MONTLIMAR DRIVE PO BOX 1237 407TH FL SUITE 1010 NICEVILLE, FL 32588-1237 MOBILE, AL 36609-1723 : (251) 400-4608 Date Prepared: Apr 18, 2013 Page 1 of 2 Group Number: — 05733 Number of Contracts: 8 NSTQO\ A detailed list of the policies in this group and their premiums is provided on the following page(s). If premiums are not paid as billed, please indicate the remitted amount and reason for the difference on the Adjustment Details Form. If you have any questions, contact your registered representative at the number above, or contact one of our customer representatives at 1-800-598-2019. Thank you for making us The Company You Keep®. <9, Please return this part with your payment in the enclosed envelope. Group Number: 05733 Group Name: EMERALD COAST CHILDRENS ADVOCACY Remittance Notice FiMlaHbeellcoaveletsboeeecocabol vende Total Amount Remited: New York Life Insurance Contact: and Annuity Corporation : : 75 Remittance Dr. - Suite 3021 Telephone Number: ( } - Chicago, IL 60675-3021 Please make checks payable fo NYLIAC and print your group number on your check. Thankyou. oO Please check this boxif the contact information has changed. Variable Products are offered thraugh properly licensed registered representatives. ‘0157 2490640 ODO1EE OOCITS COnIAATDI E78 1010 GROUP NAME: EMERALD COAST CHILORENS ADVOCACY ~—Y Page 2 of 2 GROUP NUMBER: 95733 : Page 2 of 2 DATE PREPARED: 4/19/2013 ; GROUP DETAILS. ADJUSTMENT DETAILS The polictes listed below suppor the totals on the first page of the Billing Statement. if any-Premiums are not pald as billed, FORM please complete the attached ADIUSTMENT DETAILS FORM and submit it with-your payment. Please refer to the reason * @f payment Is other than billed) below for assistance in completing the adjustment farm. : . —— a —= Te . POLICY SOCIALSECURITTY = - POLICY AMOUNT AMOUNT REASON Name . NUMBER NUMBER AMOUNT BILLED .{ NUMBER @ILLED = PAID CODE BRINGON,VIDA MRS - 67 300318 YOOLXK 1588 $600.00