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Home My WebLink About229410 2/25/2014 CITY OF CARMEL, INDIANA VENDOR: 00351239 Page 1 of 1 ONE CIVIC SQUARE BUREAU OF MOTOR VEHICLES CHECK AMOUNT: $15.00 �? CARMEL, INDIANA 46032 CHECK NUMBER: 229410 CHECK DATE: 2/25/2014 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1125 4358300 PARKS 15 . 00 OTHER FEES & LICENSES Carmel (Dlay Parks&Recreation CHECK REQUEST Date: Feb. 18, 2014 FEB 18 2014 j BY: _ Check payable to: Name: Bureau of Motor Vehicles Address: 100 N. Senate Ave. City, State, Zip Indianapolis, IN 46204 Mail check to payee xxx Return check to requestor Check Amount: $ 15.00 Date Required: 2/27/14 Check needed for: Parks vehicle plate transfer fee (Copy of letter from BMV and copy of submittal form are attached) To be paid from: PO#(if applicable) n/a Budget account-GL# 1125-4358300 Budget Line Description Parks -Other Fees and Licenses Invoice(s) MUST be attached. j Requested by(print): Dawn Koepper, Purchasing Administrator Requested by (signature): 0—&),Vv �1 4CL, .__ Approved by (signature of Division Manager): on this date c>2/cP Form revised 7-7-08 Shared/Forms/Business Services/Check Request Form/Check Request(rev 7-7-08) 1 STATE OF INDIANA ^BMV° �., Michael R. Pence, Governor Donald M. Snemis, Commissioner BUREAU OF MOTOR VEHICLES 100 North Senate Avenue Indianapolis, Indiana 46204 Telephone: (888) 692-6841 02/14/2014 CARMEL CLAY PARKS AND REC 1411 E 116TH STREET CARMEL, IN 46032 Dear CARMEL CLAY PARKS AND REC, You recently submitted an information packet to the Bureau of Motor Vehicles(BMV)for processing. After review, we discovered the following document(s)were missing: Vehicle Description: 1 FM5K8B8XEGA62937 Title Number: C OF O 6 31 V IA 9 15 Completed and signed title application: SIGN & DATE Odometer Disclosure Statement: NEED THE PAPERWORK Bill of sale or ST- 108/ST- 108E: SIGN & DATE Total payment due: $15.00- IF NOT LATE Other: WE NEED THE ORIGINAL CERTIFICATE OF ORIGIN. Once you have completed the necessary document(s), please mail the entire packet along with this letter to: Bureau of Motor Vehicles Central Office Title Processing 100 N Senate Ave., Room#41 Indianapolis, IN 46204 Additional information is available on the myBMV.com website. If you need further assistance, please contact the BMV at 888-692-6841. Thank you, Central Office Title Processing 4�BTAr.O,Ce APPLICATION FOR NEW AND/OR TRANSFERRED BUREAU OF MOTOR VEHICLES ::. LICENSE PLATES FOR MUN Municipal Processing � R5 ''-• I AND LAW ENFORCEMENT 100 North Senate Avenue '�•.._.. •State Form 53565(R3 16-13) FEB 14 2014Room N415 )e`.s_,,• INDIANA BUREAU OF MOTOR VEHICLES Indianapolis, IN 46204 INSTRUCTIONS 1. Complete in blue or black ink or print form. R� E e� 2. Complete all information in sections 1, 2, 3, and as app Icab nd mail to the address listed above. 3. The application must be accompanied by a copy of each vehicle title, title application,or lease agreement. 4. Choose one of the following:a permanent license plate type that is reflective of your entity;a standard passenger license plate,or indicate other license plate type desired. 5.A safety inspection must be completed by the Indiana State Police for all school bus plate requests. vat.? °=;`Y: SECTION`'1:'i4P,PLICANfiINF O MATIQN" Official name of entity that owns or leases /the vehicle(s) State Board of Accounts number Federal Identification Number -� )F `Ql C1i 4- PuLc eaI-D/7 ujJam'��0tel'�`'f Entity's Executive Officer's name and title Contact Telephone number Email Address ��`'K �FJ��C Ili✓ '� ` "EC� )� (,5 I"1 ) 673 — yb/ �eS e�(CGCLL�w�E.ICIA �Ka.00Ir Entity street address(number and street) City State ZIP Code County Township L�arrne I IN �U32 .;SE LE INFORMATION CTION•2.�VEHIC J; (LisL'tlie followingiinforination.7o'r each;vehicle,"attactiradditional'sheets if,necessa ,. JY):1. 1 VEHICLE IDENTIFICATION NUMBER : (Please enter ins aces below. X Purchase or lease date(mm/dd/yyyy) I F1 ME, K S6 6 X E G A � z 9 3 17 a 1/o // �-/ Color Type Make Model Year Gross Vehicle Weight Ph"f= ]13�xp)Ln 1' Fv SIA K S 6 F' z,o I q (if applicable) G. .�o I bs Description of official busi o„iuCjy(,�(in�µtetdff�y�I use the vehicle Financial Responsibility(Source of self-insurance;or Insurance Company Name and (LEA's should include here if tactical or non-t c ical vehicle.) Policy number) /71 8 10 3 0 3� P&q l'3 rh- 1 ct,,4 Jnsu-«nC C-0r 3 The application is for(check one) License Plate Type: check one _City Police _Sheriff Municipal _School Bus _State Owned University _Driver Education New License Plate ^ /�n ,1 Or you may choose one of the following: Transfer an Existing License Plate: Co a c�I `7 Passenger Other: (plate number) _ (enter plate type) 2 VEHICLE IDENTIFICATION NUMBER : (Please enter in spaces below. Purchase or lease date(mm/dd/yyyy) Color Type Make Model Year Gross Vehicle Weight (if applicable) Description of official business for which the entity will use the vehicle Financial Responsibility(Source of self-insurance;or Insurance Company Name and (LEA's should include here if tactical or non-tactical vehicle.) Policy number) The application is for(check one) License Plate Type: check one _City Police _Sheriff _Municipal New License Plate _School Bus _State Owned University _Driver Education Or you may choose one of the following: _Transfer an Existing License Plate: Passenger _Other: (plate number) (enter plate type) Zv -TION. �. 'CL#ASSIFICAS ION;!-,'�;St.`O�: The entity shall indicate which one (1)of the following classifications the entity belongs, thus entitling the entity to a permanent municipal license plate. The entity must also submit the following requested written documentation or meet the requirements that establish that the entity meets the classification for which it qualifies for a municipal or law enforcement license plate. Please check one(1): 1. The State of Indiana ---_a) a state agency _b) a state university,or _0 other state entity 2. A municipal corporation(as defined in IC 36-1-2-10)"Municipal corporation"means any of the following: -a) a county,city,town,or township _b) school corporation(Must be listed as a school corporation with the Indiana Board of Education), _c) library district(Must be listed as a library with the Indiana State Library), _d) local housing authority(Must provide a certified copy of the ordinance(s)that establishes the authority), _ e) fire protection district(Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security), _f) public transportation corporation(Must provide a certified copy of the ordinance(s)that establishes the corporation), _g) local building authority(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority), _h) local hospital authority or corporation(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority), _i) local airport authority(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority), special service district(Must provide a certified copy of the resolution or ordinance(s)that establishes the district, 4k) other separate local governmental entity that may sue and be sued(Must provide a certified copy of the statute,ordinance or resolution that establishes the entity) 3. A volunteer fire department(as defined in IC 36-8-12-2)(Must be listed with the Indiana State Fire Marshall or Department of Homeland Security and provide a copy of the contract or resolution to provide firefighting services for a county,city,town,or township.) 4. A volunteer emergency ambulance service that meets the requirements of IC 16-31 and has only members that serve for no compensation or a nominal annual compensation of not more than$3,600.00(Must be registered as a Volunteer Emergency Ambulance Service with the Indiana Emergency Medical Services and provide an official letter from the Indiana Emergency Medical Services Commission.) 5. A rehabilitation center funded under IC 12-12(Must be fisted as a rehabilitation center with the Indiana Rehabilitation Bureau and provide a letter from the Indiana Rehabilitation Bureau of the FSSA.) 6. A community action agency(IC 12-14-23)(Must be designated by the Governor or under Federal law as a community action agency.) 7. An area agency of aging and the aged(IC 12-10-1-6)and a county council on aging that is funded through an area agenciMust provide a copy of the contract with the Bureau of Aging and In-Home Services.) 8. A community mental health center(IC 12-29-2)(Must provide a copy of the Division of Mental Health and Addiction's certificate to operate in Indiana as a community mental health center.) For Law Enforcement License Plate(only available to these entities pursuant to IC 9-18-3-6): (Must provide official identification showing the representative is employed with the entity. 9. The Indiana State Police Department 10. A county police department _1 1. A city or town police department ;,:SECTION 4.'AFFIRmATION,ANDSIGNATURE-.."' The authorized representative submitting this application swears or affirms under the penalty of perjury that the answers and information contained in this application are true and correct, that the entity for which this application is made owns or leases the above listed vehicle(s)and uses it for official business pursuant to IC 9-18-3-1.A municipal license plate issued to a vehicle shall be permanently attached to the vehicle listed in this application in accopdtine with/C 9-18-3-4. Date(M th day,year) Sign re 'ri,ed entity represe Typed or printed name of entity representative �Z L/ lurei� l I fQarl< I Typed or print titlO of entity represAtAX Office telephone number of entity representative C I Dr- (3) -7 '40) r7 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Bureau of Motor Vehicles Terms 100 N. Senate Ave. Indianapolis, IN 46204 Invoice Invoice Description Date Number (or note attached invoice(s)or bill(s)) PO# Amount 2/18/14 Ck Request Parks vehicle plate transfer fee $ 15.00 I Total $ 15.00 1 hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 20_ Clerk-Treasurer Voucher No. Warrant No. Bureau of Motor Vehicles Allowed 20 100 N. Senate Ave. Indianapolis, IN 46204 In Sum of$ $ 15.00 ON ACCOUNT OF APPROPRIATION FOR 101 -General Fund Board Members PO#or INVOICE NO. ACCT#/TITLE AMOUNT Dept# 1125 Ck Request 4358300 $ 15.00 1 hereby certify that the attached invoice(s), or bill(s) is (are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 20-Feb 2014 Signature $ 15.00 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund