HomeMy WebLinkAbout233247 06/04/14 Q
CITY OF CARMEL, INDIANA VENDOR: 368266
ONE CIVIC SQUARE HC CARMEL LLC CHECK AMOUNT: $****85,195.00*
CARMEL, INDIANA 46032 CHECK DAME ER. 06 247CHECK
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
610 5023990 060214 85,195.00 OTHER EXPENSES
t
Prior Deed References
Instrument No.2011049055 in
A: Recorder's Office for
Hamilton County,Indiana
WATER LINE EASEMENT AGREEMENT
This Water Line Easement Agreement (the "Agreement') is made and entered
into this `U day of M , 2014,by and between HC Carmel, an Indiana limited
liability company, formerly khown as Keshav Note, LLC, an Indiana limited liability
company("Grantor") and the City of Carmel, Indiana("Grantee').
RECITALS:
A. Grantor is the owners of certain real property located in Hamilton County,
Indiana ("Grantor's Property") more particularly described in Exhibit 1 attached hereto
and incorporated herein.
B. Grantee, in connection with Grantee's improvement/construction of the
Michigan Road Water Main Installation — 96th Street to Retail Parkway (the "Project")
requires a permanent; exclusive easement over, through, under, upon and across that
portion of Grantor's Property more particularly described and depicted on Exhibit A and
Exhibit B attached hereto and incorporated herein, (the "Easement Property') to provide
for the laying, installing, constructing, maintaining, operating, inspecting, altering,
repairing, replacing and removing water utility lines, and all associated valves, pumps,
fittings, meters, accessories and equipment on, over, and across the Easement Property.
NOW, THEREFORE, for and in consideration of the foregoing recitals which are
incorporated herein by reference and the mutual covenants and agreements hereinafter set
forth and other good and valuable consideration, the receipt and sufficiency of which are
hereby acknowledged,the parties agree as follows:
1. Grant of Easement. Grantor hereby grants and conveys to Grantee an
exclusive, perpetual easement for the purpose of laying, installing, constructing,
maintaining, operating, inspecting, altering, reparing, replacing and removing water
utility lines, and all associated valves, pumps, fittings, meters, accessories and equipment
(the "Improvements") on, over, through, under, upon and across the Easement Property.
Grantee shall have the right to: (a) subject to Section 2, remove from the Easement
Property any fences, structures, asphalt or concrete paving, curbing or other
improvements, trees, bushes, earth berming, landscaping and other structures that exist
prior to, at the time of; or after Grantee's acquisition of such easement; and (b)make such
alterations and improvements to. the Easement Property as Grantee deems may be
necessary or useful in the exercise of Grantee's rights hereunder. The easement also
includes the rights and privileges to temporarily use during the initial installation and
from time to time with written notice prior to using, that includes who and the exact
period of time such minimal additional space on the Grantor's Property, where available
and necessary, for equipment and materials necessary for the installation, repair and
maintenance of the Improvements located in, under, upon, over, and/or across the
Easement Property, to do all acts and things requisite and necessary for the full
enjoyment of the easement hereby granted, and for nearby property owners, their
grantees, successors, agents, or employees, to connect the premises of such nearby
property owners by service pipes to the Improvements installed by Grantee within the
Easement Property, provided such nearby property owners, their grantees, successors,
agents, or employees (i) restore the portion of the Grantor's Property disturbed by their
work to a condition that is as near the condition that existed just prior to the time the
portion was distrubed by them as is practicable; and (ii) do not unreasonably interrupt or
interfere with Grantor's business operations.
2. Obligations of Grantee. To the extent practical and within acceptable
construction practices, Grantee shall utilize directional boring for the initial installation of
the water utility lines that are a part of the Improvements. Open cutting or ditches shall be
utilized to install service lines,taps,hydrants,valves or similar items; as needed as part of
the directional boring process; where two water lines intersect or connect; or if problems
arise with the directional boring process. Grantee shall not be required to use directional
boring for any future repair, maintencnace, replacement, reconstruction, relocation of the
Improvements. Grantee shall maintain, repair, replace and service the Improvments.
Notwithstanding anything in this Agreement to the contrary, Grantee shall restore the
Easement Property and Grantor's Property, to the extent practicable, to the condition as.
existed prior to the commencement of the Project, including driveways thereon. This
obligation to restore the driveways shall apply to all future work, including repair,
replacement or relocation of the Improvements.
Grantee shall take all reasonable steps to avoid interruption of water service to the
hotel on Grantor's Property; will notify Grantor of any necessary interruption at least five
(5) days prior to such interruption and shall schedule such interruption between the hours
of 12:00 a.m. and 4:00 a.m.
3. Continuous Access. Except for emergencies involving the public health
safety or welfare, in the event that any construction work which is the subject of this
Agreement requires a temporary blockage of access to Grantor's Property, Grantee, or its
specified contractor, shall notify Grantor at least ten (10) days prior to commencement of
the anticipated work. In addition, any such work shall be undertaken in a manner to
minimize the limitation on ingress and egress to the balance of Grantor's Property.
Except for emergencies involving the public health, safety, or welfare, one-half of the
driveway located on the Easement Property and on Grantor's Property shall remain open
at all times.
4. Rights Retained by Grantor. Grantor shall retain unto itself the right to
use the Easement Property for any and all purposes and uses not inconsistent with the
foregoing easement. Subject to Grantee's rights and obligations in Sections 1 and 2 with
respect to the Easement Property, Grantor shall be entitled to maintain all improvements
on the Grantor's Property in existence as of the date of this Agreement. With the
exception of those Improvements in existence on the date of this Agreement, Grantor
2
shall not erect or maintain any permanent structures, obstructions, or other improvements
under and/or upon the surface of or over the Easement Property. Grantor shall not
perform any act which would impair or interfere with Grantee's use and enjoyment of the
Easement Property or the easement herein granted. Unless existing prior to this
Agreement, the immediately preceding sentence prohibits (among the other prohibitions
effected by it)the erecting or maintaining in the Easement Property of any earthen mound
or series or system of earthen mounds.
5. Obligations of Grantor. Grantor shall keep the Easement Property free of
any fence or structure (other than those installed by Grantee). Grantor shall mow and
care for the grass located within the Easement Property and shall maintain all other parts
of the Easement Property in good condition. Grantor shall not block, impede or interfere
with the Improvements or Grantee's access to or use of the Easement Property.
6. Easement and Covenants Appurtenant. The easement granted, created and
made herein, together with the benefits thereof, shall run with the Grantor's Property and
the Easement Property, inure to the benefit of Grantee and its grantees, successors and
assigns and shall bind Grantor and its grantees, successors and assigns. All covenants
and agreements hereunder may be enforced by an action for specific performance, and in
the event that a party breaches any such covenant or agreement, the other party may
exercise any remedy available hereunder, at law or in equity, and recover from the
breaching party all amounts expended in connection with exercising any such remedy
(including without limitation, court costs and attorneys' fees).
7. Environmental Matters. Grantor covenants and represents that to the best
of its actual knowledge, neither the Grantor's Property nor the Easement Property is
presently the subject of, nor is there the threat of any federal, state or states, or local
environmentally related lien, proceeding, claim, liability or action. Grantor agrees that
between Grantor and Grantee, the acceptance of this Agreement by Grantee shall not
increase the liability of Grantee for environmentally related claims arising from or related
to (i) conditions on the Grantor's Property or the Easement Property prior to the
acceptance of this Agreement; (ii) acts of Grantor or any other third party; or (iii)
conditions on the Grantor's Property or the Easement Property not created by Grantee.
8. Jurisdiction. Grantor and Grantee agree that any litigation associated with
or arising from this indenture shall be filed with a court of competent jurisdiction within
the State of Indiana.
9. Other Obligations. Grantor agrees that this Agreement shall not transfer to
Grantee any past, present, or future obligation(s) of Grantor to be responsible for, or to
pay, any tax, assessment, or fee associated with or related to the Grantor's Property or
Easement Property.
10. Waiver. Waiver by either party of any one default hereunder will not be
deemed to be a waiver of any other default under this Agreement. Any remedy or
election under this Agreement will not be deemed exclusive, but instead, whenever
legally permissible, will be cumulative with all other remedies at law or in equity.
3
11. Amendment. Grantor and Grantee agree that this Agreement shall only be
modified or released by the express, written consent of both Grantor and Grantee. Said
consent, when duly recorded, shall run with the Grantor's Property and the Easement
Property.
12. Entire Agreement. This Agreement contains the entire agreement of the
parties with respect to the subject matter hereof, and all prior agreements, communications
and negotiations between the parties, either verbal or written, are hereby merged into this
Agreement. This Agreement may be terminated, modified, or amended only by a writing
signed by the parties, and no agreement or consent of any other persons shall be necessary
for such termination,modification,or amendment.
13. Governing. This Agreement will be governed by and construed in
accordance with the laws of the State of Indiana.
14. Notice. Any and all notices, demands, requests, submissions, approvals,
consents, or other communications or documents required to be given, delivered or
served or which may be given, delivered or served under or by the terms and provisons of
this Agreement or pursuant to law or otherwise, shall be in writing. All notices shall be
either (a) sent by overnight delivery using a nationally recognized overnight courier, in
which case notice shall be deemed delivered one business day after deposit with such
courier, (b) sent by certified or regular U.S. mail, postage prepaid, in which case notice
shall be deemed delivered two business days after deposit in such mails, or (c) sent by
personal delivery, in which case notice shall be deemed delivered upon receipt or refusal
of delivery. All notices shall be addressed to the respective parties as follows:
If to Grantee: City of Carmel
One Civic Square
Carmel, Indiana 46032
Attn: Carmel City Attorney
With a Copy to: City of Carmel
One Civic Square
Carmel, Indiana 46032
Attn: Director of Utilities
If to Grantor: HC Carmel,LLC
101 West Ohio Street
Suite 720
Indianapolis,IN 46204
Attn: Michael Collier
4
With a Copy to: Alerding Castor Hewitt
47 South Pennsylvania
South.700
Indianapolis,IN 46204
Attn: Michael Alerding
Any such notice will be effective three days after the notice has been deposited in the United
States mail,as provided above, or if earlier upon receipt.
15. Severability. If any term, covenant, condition or provision of this
Agreement or the application thereof to any person or circumstance, shall at any time or
to any extent be held invalid or unenforceable, the remainder of this Agreement, or the
application of such term or provision to persons or circumstances other than those as to
which it is held invalid or unenforceable, shall not be affected thereby, and each such
term, covenant, condition and provision of this Agreement shall continue to be valid,
binding and enforceable to the fullest extent permitted by law.
16. Authori The person(s) executing this instrument on behalf of Grantor
hereby represents that he/she has the authority to bind Grantor to the terms and conditions
set forth herein and that all necessary action therefore has been taken. Grantor further
represents and warrants to Grantee that Grantor is the fee simple owner of the Easement
Property; that Grantor has the right to grant this easement; that Grantor guarantees the
quiet possession of the Easement Property to the Grantee; that the Easement Property is
free of any liens or encumbrances, except the lien of current taxes and any other lien or
encumbrance that, as of the date of execution hereof, appears of public record; and that,
subject to the foregoing, Grantor will warrant and defend Grantee's title to the easement
granted hereby against all claims thereon. Grantor shall indemnify, defend and hold
Grantee harmless from and against any and all liability,loss, damage, cost, obligation and
expense arising out of a breach of this Agreement or the untruth or inaccuracy of any of
the representations or warranties contained herein.
17. Attorneys' Fees. In the event of any action or proceeding brought by
either party against the other under this Agreement, the prevailing party shall be entitled
to recover all costs and expenses, including reasonable attorneys' fees.
5
SIGNATURE PAGE TO WATER LINE EASEMENT
IN WITNESS WHEREOF, the parties hereto have executed this Water Line
Easement Agreement as of the day and year first above written.
HC Carmel,LLC
an Indiana limited liability company
formerly known as Keshav Note,LLC
BY: Hotel Capital, LLC
an Indiana limited liability company
Manager
t
BY:
Michael ollier
Managing Member
Date
BY:
Frank Kennedy
Member
4�99
D to
6
GRANTEE:
THE CITY OF CARMEL
By and through its Board of Public Works
and Safety
By:
James Brainard,Presiding Officer
Date:
By:�&
Mar Ann Burke,Member
Date:
By: 7- 7,ed. /7
Lori Watson, Member
Date:
ATTEST.
i L. or ray, IANC, Clerk-Treasurer
Date:
STATE OF INDIANA )
SS:
COUNTY OF HAMILTON )
Personally appeared before me this day James Brainard, Mary Ann Burke, and Lori
Watson, who having been duly sworn/affirmed, state(s)that they are members of the City
of Carmel's Board of Public Works and Safety and have executed the foregoing Water
Line Easement Agreement on behalf of such entity.
WITNESS my hand and notarial seal,this day of 14 E-!� l ,
2014.
My Commission Expires: i�
(/Notary Public
My County of Residence:
.{ 44711/
SANDRA M.JOHNSON
NOTARY PUBLIC—INDIANA
^v� y Comm.Expires Aug.31,2018
8
HEATHER N LONGARONER
Notary Public-SeaV
State of Indiana
STATE OF INDIANA ) My Commission Expires Jun 23,2021
) SS:
COUNTY OF +GAm I I- b n )
Before me, a Notary Public in and for the State of Indiana, personally appeared
Michael Collier,by me known to be the Managing Member of Hotel Capital, LLC, which
is the Manager of HC Carmel, LLC, the Grantor, who acknowledged the execution of the
foregoing Water Line Easement Agreement for and on behalf of said Grantor.
Witness my hand and Notarial seal this day of } , 2014.
My Commission Expires: r WJL �'U'X
jwy' a'a-0;4 Notary Public
My ounty of Residence: T ;" My N1
1 [Printed]
STATE OF I ntk a n c, ) HEATHER N LONGARDNER
Notary Public-Seat
SS: State of Indiana
COUNTY OF ( ) My Commission Expires Jun 23,2021
Before me, a Notary Public in and for the State of IY16tt6Lr10__ , personally
appeared Frank Kennedy, by me known to be the Member of Grantor. who
acknowledged the execution of the foregoing Water Line Easement Agreement for and
on behalf of said Grantor.
Witness my hand and Notarial seal this 4 day of , 2014.
M Commission Expires:
3wit 2-3� dvn Notary Public
My, ounty of Residence: ko YLC.V W
,(,YY Uft« , [Printed]
This instrument was prepared by and after recording return to: Douglas C. Haney, City of
Carmel, One Civic Square, Carmel, IN 46032.
I affirm, under the penalties for perjury, that I have taken reasonable care to redact each
Social Security number in this document,unless required by law. Douglas C. Haney
9
aero
SOL
s°P
lit of.L4tIU 0'w A.as by.'ttie Raplat o�Lvt S,6,and:7 ofNortR Augusta,a .
Subdivtaioa ut FIatnitP.tori:County, Iad1slu as per replat:tb�e�of mcprded October 17,
1997,.:iri.,plat Cabinet 2; Stide'36, u�the office:of the Recorder:of Nani�iton_County,• ,
ltid*ons;.beng:descci'ticed'asfollo' :.. '
B: 'inning et lh Sflntf►east:corder.ofsnid Ldt SA;-thence-South.64'degrees-10:ri iniites'S9=
secotitls.Rest along the:South;lino of said Lot SA a disteace of 280 42 feet to a.potnt: •' '
8istant.l9 58 feet frnui tine Souti4weC come;of t
td poi
:dot.SA;:snt bcngtho Notfieast`
cAnaer:.of the land:tract conxreyea to�e State of Indiana'.by Wananty.Deed recorded es.:
Instiwaent numbs 2l?0,1000319<}l,tbenc North 27 degtow 20 mimrtus ZO`secoads
sloag,the Fast line of said lancl;tract a o€3q0 l i feet to the_Notf►east corner of i
said State oi'.ndiana land tract,'bcfng'ot{tFic Horth liar ofsaid Lot 01 distant.11:61-feet;
=from tlid Northwest corner of saui Lpt:SA, thence North 64 degrees 10 rnmifie$ 59
along.the,_i•1orth;Iir�e af.saW..iot SA a dtstance''of 2�$39 feet,.to the•° ' ..•; . .
Northeast cgrtxc
4881 d_Lot SA;thea9eSouth 25 degrees m
49 m ores 02 seconds East
of3 A
along thio EastUne.of srpitX�ot'SA a: to:tite Point of Begiaglu
-
.. .t
EXHIBIT "A"
EASEMENT.
A PART OF LOTS 5,6,AND 7 IN NORTH AUGUSTA,A SUBDIVISION IN HAMILTON COUNTY,INDIANA,RECORDED IN
DEED RECORD 132,PAGES 446-447 IN THE OFFICE OF THE RECORDER OF SAID COUNTY(BEING ALSO A PART
OF LOT 5A OF THE REPLAT OF LOTS 5, 6 AND 7, NORTH AUGUSTA, RECORDED AS INSTRUMENT NUMBER
9709744338 IN SAID RECORDER'S OFFICE) AND BEING IN THE SOUTHEAST QUARTER OF SECTION 7,TOWNSHIP
17 NORTH, RANGE 3 EAST OF THE SECOND PRINCIPAL MERIDIAN, HAMILTON COUNTY, INDIANA, MORE
PARTICULARLY DESCRIBED AS FOLLOWS.
Commencing at the Southwest comer,of sold.Lot 7; thence North 69 degrees 13 minutes 04 seconds East,
along the Southeasterly line of.said Lot 7, a distance of 34.79 feet to the.PLACE OF BEGINNING; thence
North 25 degrees 08-minutes 29 seconds West, a distance of 300.87 feet to the Northwesterly line of said .
Lot 5; thence North 69 degrees 13 minutes 04 seconds East, along the Northwesterly line of said Lot_5, a
distance of 15.04 feet; thence Sodth 25 degrees 08'minutes 29 seconds East, a distance of 300.87 feet
to the Southeasterly line of said Lot 7; thence South 69 degrees.13 minutes 04 seconds West, along,the
Southeasterly line of said Lot 7,' a distance of 15.04.feet to the.PLACE OF BEGINNING, CONTAINING 0.1036
ACRES(4513 SQ.FT.)MORE OR LESS.
I, Trent E. Newport,.a Registered Land Surveyor in the State of Indiana, do'hereby certify that this,
description was prepared from information obtained from Instrument Number 200100031991, as recorded in
the Hamilton County Recorder's Office. No fieldwork was performed and therefore, this description is
subject to any overlaps, gaps or inconsistencies that a field survey might reveal.
�ESTF£pAO,p
No. 29600021 Trent E Newport Date
Reg. Land Surveyor No. 29600021
STATE of State of Indiana
! IAYA p�
4N�.SUR,
PREPARED BY-
Transportation
YTransportation&
Development Consultants
M7 MRM RM W,11 W07 I"78l=
f
ROAD: MICHIGAN ROADEXHIBIT �g� DRAWN BY: CJL 11-22-11
PROJECT MICHIGAN ROAD FDR MAIN REVISED BY: CAW 02-10-12
96th ST-106th ST. CJL 03-6-12
COUNTY: HAMILTON EASEMENT EXHIBIT , CHECKED BY: TEN
SECTION: 7 SCALE : 1' = 100'
TOWNSHIP: 17 NORTH OWNER: KESHAV NOTE, LLC.
RANGE: 3 EAST RECORD DOCUMENTS: SHERIFF'S DEED, INST.#2011049055
100 0 100 100
SCAM 1•=1o0' ® HATCHED AREA IS THE
APPROXIMATE EASEMENT
LINE TABLE
L1 N6913'09E 34.79' NORTH
L2 N25.08'29"W 300.87
L3 N6913'04"E 15.04'
L4 S25'08'29"E 300.87'
1-5 S6913-04"W 15.04'
/� 1p LOT 5
o1 KESHAV NOTE. LLC
W INST.#2011049055 Z
APP. R/W PER--, \ s �20�1y / NORTH AUGUSTA �'
INST.#200100031991 D.R. 132, PGS. 446-447 \\>!
Cft
KESHAV TE. LLC LOT 6
Va
NO
INST.#2011049055
\ • m
N r� �� / `\
Wo
LOT 7
s` y
KESHAV NOTE: LLC
INST.#2011049055
�1 tis
PLACE OF BEGINNING.
E. Nfjy No fieldwork was performed and therefore, this description is subject to PREPARED BY:
�*�
%STEgF—0,p any overlaps, gaps or inconsistencies that a field survey might reveal.
This plot was prepared from'Information obtained from Instrument Number
200100031991, as recorded in the Hamilton County Recorders Office.
No. 29600021 /r// W, -.W0W
STATE OF /�..�L —1 Nj_24_12 T* _
<4 SND 10 O� Trent E. Newport Date
N0 S �y Reg. Land Surveyor No. 29600021 Transportation&
State of Indiana Development Consultants
3417 MM M MM WF.2 010 Pm 7W-10
r `
ACCEPTANCE OF ADMINISTRATIVE SETTLEMENT
HC Carmel,LLC formerly known as Keshav Note, LLC,landowner of.the property or
interest in property described in the attached Exhibit A and attached Exhibit B, hereby
accepts the administrative settlement of$85,195.00 made by the City of Carmel on this �4
day of V1 2014.
HC Carmel, LLC
an Indiana limited liability company
formerly known as Keshav Note,LLC
BY: Hotel Capital,LLC
an Indiana lim/habty company
Manager
B
Michael Coll&r
Managing Member
Date
BY: -:A�z A /,",
Fra Kennedy
Member
NOTARY'S CERTIFICATE
STATE OF HEATHER N LONGARDNER
)SS: Notary Public-Seal,
State of Indiana
COUNTY OF ! ) My Commission Expires Jun 23,2021
Subscribed and sworn to before me this 14 day of pn F ,2014.
My commission expires: ),31 �Lo)�l
County of residence:
Sig ature
calhey
(Michael Collier) Printed
F
Form W-9 Request for Taxpayer Give Form to the
(Rev.August 2013) Identification Number and Certification requester.Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name(as shown on your income tax return)
N Business name disregarded entity hame,if different from above
d
CO
cLCheck appropriate b r federal tax classification: Exemptions see instructions
C tions :
P ( )
v c ❑Individual/sole proprietor ❑ C Corporation ❑ S Corporation El Partnership
❑Trust/estate
0 o Exempt payee code(if any)
0 Z
o Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)10- Exemption from FATCA reporting
c N code(if any)
d tci ❑ Other(see instructions)►
R Address(number,street,and apt.or suite no.) Requester's name and address(optionaq
v
CL
m City,state,and ZIP code
m
rn
List account number(s)h re(optional)
111`3 Ma Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number
to avoid backup withholding.For individuals,this is your social security numberpag However,for a —m _
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter.FT Ma (J
—1
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined below),and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3.
Sign Signature of , r`
Lb
Here U.S.person► Date►
General In tructlo s withholding tax on foreign partners'share of effectively connected income,and
4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
Section references a to the Int nal Revenue Code unless otherwise noted. exempt from the FATCA reporting,is correct.
Future developments.The S has created a page on IRS.gov for information Note.If you are a U.S.person and a requester gives you a form other than Form
about Form W-9,at www.irs.gov/w9.Information about any future developments W-9 to request your TIN,you must use the requester's form if it is substantially
affecting Form W-9(such as legislation enacted after we release it)will be posted similar to this Form W-9.
on that page. Definition of a U.S.person.For federal tax purposes,you are considered a U.S.
Purpose of Form person if you are:
A person who is required to file an information return with the IRS must obtain your •An individual who is a U.S.citizen or U.S.resident alien,
correct taxpayer identification number(TIN)to report,for example,income paid to •A partnership,corporation,company,or association created or organized in the
you,payments made to you in settlement of payment card and third party network United States or under the laws of the United States,
transactions,real estate transactions,mortgage interest you paid,acquisition or .An estate(other than a foreign estate),or
abandonment of secured property,cancellation of debt,or contributions you made
to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S,person(including a resident alien),to Special rules for partnerships.Partnerships that conduct a trade or business in
provide your correct TIN to the person requesting it(the requester)and,when the United States are generally required to pay a withholding tax under section
applicable,to: 1446 on any foreign partners'share of effectively connected taxable income from
such business.Further,in certain cases where a Form W-9 has not been received,
1.Certify that the TIN you are giving is correct(or you are waiting for a number the rules under section 1446 require a partnership to presume that a partner is a
to be issued), foreign person,and pay the section 1446 withholding tax.Therefore,if you are a
2.Certify that you are not subject to backup withholding,or U.S.person that is a partner in a partnership conducting a trade or business in the
3.Claim exemption from backup withholding if you are a U.S.exempt payee.If United States,provide Form W-9 to the partnership to establish your U.S.status
applicable,you are also certifying that as a U.S.person,your allocable share of and avoid section 1446 withholding on your share of partnership income.
any partnership income from a U.S.trade or business is not subject to the
Cat.No.10231X Form W-9(Rev.5-2013)
r
VOUCHER # 135239 WARRANT# ALLOWED
T0669 IN SUM OF $
HC CARMEL LLC
9797 N MICHIGAN ROAD
CARMEL, IN 46032
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
14 06-1052-06 $85,195.00
Availability
Voucher Total $85,195.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No.201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T0669
HC CARMEL LLC Purchase Order No.
9797 N MICHIGAN ROAD Terms
CARMEL, IN 46032 Due Date 5/27/2014
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
5/27/2014 060214 $85,195.00
I 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
Date ff' er