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

SERED {HM LC auaH gsuoans @ SOswOt ANWIIOS A ws genet ital Ls it ty ty or fad i 2 ty a re =] He ry 4 5 t 1 ol ose g " @) 843 US BANE . “ SEC7EOl 2B ST Raut BN eee te "la SESLBEBOEE< S562 Des uouksen aoapontar 64 iS pelt base Ayan ia ilepSDaSy HUATENG WAWAEG NabuG RAT O OU! UONER||EID 8 i raudhhg. pas 4084 (oe Ofer 44 BUN dual die ssouy 58 16 ly saul oy-sH Er § [ws i \ i 1 ~ ‘ as Affac. { COPY - Original invoice Worldwide Head re Geol 31999 1,800.89. (1.800. rate aflac.com invoices Copy SHaianis invoice Numbar: 797658 Account Name: EMERALD COAST CHILDRENS Account Number: Eoke2 Address: Canter Premium Due Osta: ‘2013 At ful Hurst Amount Billed: $1,002.87 NICEVILLE, Fl. 92588 Aevourt Remiting: " Date Pregtrred: SAEZ013 Baing Frequency: MONTHLY Highlighted [ines indicate that the premium amount baing remitted wes adjusted andior a Chatige Raquast was submitted for the employes. 15Sa 01 poawaad | Ace P $3280 poasraas | STD a 347.70 Poagyzas |CANCER | P si1452 sa4.s2 911482 POASTSt | ACS F sasa0 Poasras [cANcER | F COTTON, LAR S031 Poasr2s9 | 87D t COTTON, LISA R 34770 pocsizr2 | UFE 1 COTTON, LISA R s2test rere s2t6.at POOGTEXS {LIFE 1 COTTON, USAR 15 S46 $7.15 POASTZAQ | STD I CROWELL, KATHERINE M 53818 Ponsrase [ACE 8 CROWELL, KATHERINE M 270 ‘PoAs7288 | HOSP 8 ‘CROWELL, KATHERINE M $128.69 $5673 $125.58 Poostzia | ACC s FLORO, JENNIFER O $575 Postar |CANCER | f FLORG, JENNFER O saise PocsiZMa {STD 1 FLORO, JENNFERO $127.58 70.26 $127.58 Poasrzsa | sto Il HOLLIS, DEBORAH J 500.18 sone 380.18 Poas72az | ACG Fe HURST, WUE s3a00 PoAs?ZAS. | STD ' HURST, JULIE # 0645 $06.84 $0644 Pocaiams | HOSP ' JEFFRIES, CHRISTINA A $49.18 Pocet2Po. | LIFE ' JEFFRIES, CHRISTINA A son PocetzF1 | sTD ’ JEFFRIES, CHRISTINA A $110.06 $26.00 $110.08 POASTZ83 | ACC P LEGGETY. RANDALL $3250 Poas7295 [CANCER | P LEGGETT. RANDALL R gets $34.04 $51.34 $24.04 POBGMSA2 |GANCER | 4 LEWELLYN, SHELA DB was $31.85 Poaemtas | STD 1 LEWELLYW, SHEEAD ss120 $93.05 $31.20 558.05 Total Amount Billed: $t00287| AmtDue $4,002.87 Shia, AK P = Prirnary-Spouse and is Pald Ahead F=Famlly Medical Leave ‘YY = Miltary Leave: SOVERAGE TYPE {CT} REMARKS (2M) SHANGE REQUEST (CR) 1 = ndividuat CV = Fending Conversion A=Add parson tn policy H= Name Change O= Other F = Family PA = Polleyis Paid Ahead C=Cance! Coverage I = Delete pareen from policy R = Retired S = Single-Parent Fanily PC = Policyis Pending Comersion | D=Decaased L = Non-Fanilly Medical Leave 7 = Nolongerempicyed here ranster to anottier account Page: 4 oF 1 " age 1 of 2) EMERALD COAST CHILDREN'S ADVOCACY CENTER, INC. RO. BOX 1737 NICEVILLE, FL 32588-1237 : Cosidr coasy . __gbfidrens ; pay One Thousand Two and 87/100 Dollars vom: ; : ORDER 1932 Wynnton Roa Columbus, GA 31999 (Page 2 of 2) QRPER Aflac - er goes }' $3-814-632 : DATE AMOUNT a May 13, 2043 “$ 1,002.87 i VOID AFTER 50 DAYS : CHECKS OVER $1500.00 REQUIRE TWO SIGNATURES. 4 THIS DOCUMENT CONTAINS HEAT SENSITIVE INK TOUCH OR PRESS HERE | HED IMAGE DISAPPEARS: WOOSOARER COLIZ08iL06009 LI be aon DEO] SE feat BE AOJOT Magel{ SUTYC- {yan 99 $ . ee rere _ 2 2h “¥ Be _ Ea OX~§ N BSAS i 1B 9Ro3 Semea& i Buavot ts ae One a . SOEPrOR granaAa S$ e@9 nm ZOU z < oO mid | New York Life Insurance And Arinuity Corporation (NYLIAC} {A Delaware Corporation) PO Bex 922 . . New York, NY 10155-0922 . feooseeaene BILLING STATEMENT AEE uuunaes coe >OOU3L3 244E701 OG02 O4254 192° Registered Representative: ae een OAST CHILDRENS ADVOCACY MOnLE GENERAL OFFICE pooner NS OTWEL SUITE 1010 NICEVILLE, FL 32588-1237 : enaaane Date Prepared: May 20, 2013 - . "> Page 1 of 2 cys cs >a Group Number: 05733 Number of Contracts: & 1 97a0\ 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 ihe Adjustment Details Form. ifyou have any questions, cantaci 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®. Sai Please return this part with your. payment in the enclosed envelope. Group Nurnber, 05733 ., . Group Name: EMERALD COAST CHILDRENS ADVOCACY Remittance Notice YulbeEfecaHfacassfcldeslbaacsaa feral lense esall Total Amount Remiited: New York Life Insurance Contact: and Annuity Corporation 75 Remittance Dr. - Suite 3021 Telephone Number: ( ) - Chicago, iL 60675-3021 Pisase make checks payable to NYLIAC and print your group number on your check. Thankyou. [|] Please cheetcthis boxif the contastinformation has changed. Varlable Products are cifered through properly lioatised tegisiered representatives, 00303 2448701 oonses nho727 didivao! £78 10/10 GROUP NAME: EMERALD COAST CHILDRENS ADVOCACY GROUP NUMBER: 05733 DATE PREPARED: 5/20/2073 . Page 2 of 2 GROUP DETAILS. The policies listed balow support the totals on the first page of the Billing Statament, if any Premiums are not paid as billed, please complete the attached ADJUSTMENT DETAILS FORM and submit it with your payment. Please refer to the reason below for assistance in completing the adjustment form. " Page 2 of 2 ADJUSTMENT DETAILS FORM (it payment ie ather than billed) REASON POLICY SOCIAL SECURITY POLICY AMOUNT AMOUNT Name NUMBER : NUMBER AMOUNT BILLED NUMBER BILLED PAID CODE BRINSON.VIDA NAB 67300 318 YAK XK 1698 $500.00 67300218 £500.00 HOLLIS, DEBORAH 67300 322 XXX XX 7820 $260.00 87.200 322. 4250.00 FLOROWENNIFER OWOZARSKI MRS 87 313 748 XK XX 6472 $100.00 62213 748 9100.00 LEGG@ETT,RANDALL RAMA &7 313 963 XXK XX 1573. $200.00 67.3143. 985 2200,00 CAROZZONI,AENEE EMRS 87317017 XXX XX 2300 $100.00 BZS17017_ __$100,00 /so.? GROWELL, KATHERINE M 87 317 027 XXX XX 3665 $100.00 8/217 087 pineal Ld HURSTJULIE HMS G 67317 132 XXX XX 8474 $100.00 82317332 ai 00.90 GOTTON,LISA RMRB, qa 67 924.601 XXX XX 4673 $100.00 * New premium as of this bill, Reason Codas for Adjustments: C permanently ramove policy from billing '2) permanently change premium amount Variable Products are offered through properly licensed registered representatives. Billed amount has been reduced ta prevent violation of aurrant tax lawe, We will not bli this policy again until we oan accept further payment, Group Number: 05733 EMERALD COAST CHILDRENS ADVOGACY Group Name: ‘2120GCSE (Fage 1 of 2) wes OnIGINA IPDOCURENT! PRINTED) ON CHEMIGALS RZACTIVS PABER WITH MICROPRINTED BOSDER = fi. gii5 \ 1 ss COASTAL BANK AND TRUST : EMERALD COAST CHILDREN’S ADVOCACY CENTER, INC emerald coast PO BOX 1237 z fdrens NICEVILLE, FL 32588-1237 693-814-682 3 faba Cenier i Se { DATE AMOUNT A : Jun 4, 2013 wert 4400.00 i é pay One Thousand Four Hundred and 00/100 Dollars ri ' 3 VOID AFTER 90D t TOTHE CHECKS OVER $7500 00 REQU ne Ro SIGNATURES i : ORDER New York Life Insurance ; 75 Remittance Dr., Suite 3021 Chicago, IL 60675-3021 VOTZIZEe Nek AUTHORIZED SIGNATURE POOR bbSt OB a 208 BLOHO0F A Be (Page 2 of 2) ret RTE Mew ~ CR TO ACCT OF PAYEE ABSNCE OF ENDRS GTD. . NORTHERN TRUST - >071000152< 130611 93021-4417-2 hae et ‘ we ‘ MONTHLY TIMESHEET Agency Name: Emeraid Coast Children's Advocacy Center, Inc. Employee Name: Debbie Hollis Project Name: Mental Health program Title: Clinical Supervisor Pay Period: May 1 - 31, 2013 Department: Supervisor: Julie Hurst Exempt Non-Exempt [J Hours per} % per source ar Funding Funding Grant Pay Type} 1} 2 | 3 | 4 si61718) 9 | 10) 14] 12) 13 44|15| 16117) 18] 19] 20| 21 22 | 23 | 24) 25| 26 | 27 | 28 29 | 30 | 31 | TOTAL| Source or | Source or Project : Grant Grant Project_|__ Project REG 7.00 | 6.00 | 8,00 6,00 | 8.00 | 7.00 7.00 | 8.00 | 6.00 | 6.00 | 8.00 6.00 | 7.00 | 8.00 | 7.00 | 8.00 8.00 | 8.00| 7.00] 136.00 GR |pTo 8.00 | 8.00 2.00 18.00 162.00 92.05% HOLIDAY 8.00 8.00 REG 4.00 | 2.00 2.00 4.00 4.00 2.00 2.00 | 1.00 1,00 1,00] 14.00 Byrne {PTO 0.00 14.00 7.95% HOLIDAY 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0 0.00 Total Number of 9 Hours by Date 8.00| 8.00| 8.00] 0.00! 0.00] 8.00 8.00} 8.00] 8.00) 8.00) 0.00) 0.00 8.00] 8.00] 8.00] 8.00] 8.00] 0.00 0.00} 8.00} 8.00) 8.00} 8.00} 8.00 0.00] 0.00] 0.00) 8.00) 8.00 8.00|8.00| 176.00} 176.00 100.00% By signing below, | hearby attest N the time recorded on thi “ is true and accurate to the best of my knowledge. N Employee's Signatu! ~\ Date: S}23)1> : Supervisor's Signa’ \ 4 <i Date: - ay ’ ~kshkat MONTHLY TIMESHEET Agency Name: Emerald Coast Children’s Advocacy Center, Inc. Employee Name: Vida Brinson Project Name: Mental Health program Title: Mental Health Therapist Pay Period: May 1 - 31, 2013 Department: Supervisor: Julie Hurst Exempt Non-Exempt [1] fl Hours per| % per enn . Funding | Funding Grant Pay Type| 1 | 2 4 6|7\|8 9] 10) 11 42| 13 | 14| 15] 16} 17 48 | 19 | 20| 21) 22 | 23 24 | 25 | 26 | 27 | 28 29 | 30 | 31 | TOTAL) Source or Source or Project Grant Grant Project Project REG 4.00 | 5.50 | 7.00 7.00 | 3.00 | 6.00 | 8.00 | 6.00 8.00 | 8.00 | 6.00 | 6.00 | 7.00 7.00 | 7.00 | 6.00 | 8.00 | 6.00 115.50 GR [PTO 4.00 | 1.50 4.00 | 1.00 2.00 2.00 8.00 | 8.00| 8.00} 35.50 159.00 90.34% HOLIDAY 8.00 8.00 REG 3.00 } 1.00 | 1.00 1.00 | 1.00 | 1.00 2.00 | 1.00 1.00 | 1,00 | 2.00 2.00 17.00 Byrne [PTO 0.00 17.00 9.66% HOLIDAY 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0.00% 0.00 0.00 0.00 0.00 0 0.00 Total Number of 9, Hours by Date 8,00] 8.00] 8.00] 0.00] 0.00] 8.00) 8.00 8.00] 8.00| 8.00] 0.00} 0.00) 8.00 8.00] 8.00} 8.00| 8.00} 0.00} 0.00 8.00] 8.00| 8.00] 8.00) 8.00} 0.00 0.00] 0.00| 8.00] 8.00/ 8.00 8.00| 176.00) 176.00 100.00% By signing below, lhearby attest that, ne time rect bee Employee's Signature: 1 led on this timesheet is true and accurate to the best of my knowledge. Abb, LNtc- vate: Sere 5} 3)) ‘Supervisor's Signature: S ial Ve ctes). Date: Siz 3 a wy, ‘ Nena MONTHLY TIMESHEET Agency Name: Emerald Coast, Children’s Advocacy Center, Inc. Employee Name: Rick Leggett Project Name: Mental Health program Title: Mental Health Therapist Pay Period: May 1-31, 2013 Department: Supervisor: Julie Hurst Exempt Non-Exempt ([] Hours per| % per eunen / Funding | Funding Grant Pay Type| 1 2/31'415)|6 718 | 9 | 10) 11 42) 13 | 14) 15 46 | 17} 18 | 19 90 | 21 | 22 | 23 24| 25 | 26) 27 28 | 29 | 30 | 31 TOTAL| Source or | Source or Project Grant Grant Project_| Project REG 4,00 } 8.00 | 8.00 6.00 | 8.00 | 8.00 | 5.00 | 8.00 8.00 | 8.00 | 8.00 | 8.00 | 7.50 8.00 | 8,00 | 8.00] 8.00 8.00 | 8.00 | 6.50) 151.00 GR |PTO 4.00 0.50 8.00] - - 12.50 173.00 98.30% HOLIDAY 8.00 1.50] 9.50 REG 3.00 3.00 Byrme [PTO 0.00 3.00 1.70% HOLIDAY 0.00 | 0.00 0.00 0.00 0.00% 0.00 0.00 6.00 0.00 0.00% 0.00 0.00 0.00 0.00 0 0.00 Total Number of . 6 Hours by Date 8.00] 8.00 8.00} 0.00) 0.00 8.00| 8.00] 8.00] 8.00] 8.00 0.001 0.00| 8.00] 8.00} 8.00 8,00| 8.00] 0.00] 0.00| 8.00 8.00} 8.00] 8.00} 8.00} 0.00 0.00] 0.00] 8.00) 8.00 8.00] 8.00| 176.00 176.00 | 100.00% By signing below, 1 fearby attest thet the ti orded on this timesheet is true and accurate to the best of my knowledge. ’ | Employee's Signature; Date: 6 (2 ry _ Supervisor's Signatures qu Date: S| q | ‘ 4