241038 01/13/15 CITY OF CARMEL, INDIANA VENDOR: 229400
® ; ONE CIVIC SQUARE INDIANA DEPT OF HOMELAND SECURIWECK AMOUNT: $......*120.00*
f• ?� CARMEL, INDIANA 46032 DIV OF ELEVATOR SAFETY-FISCAL OFFIC CHECK NUMBER: 241038
9y�TON 302 W WASHINGTON ST,RM E221 CHECK DATE: 01/13/15
INDIANAPOLIS IN 46204
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1093 4239099 734241 120.00 734241-12292014-1
ELEVATOR OPERATING CERTIFICATE INVOICE
RMEL/CLAY BOARD OF PARRS & RECREATION 1411 E 116TH ST Pat Schlemmer CARMEL IN 46032
l.If Code = * An annual test report is due before a permit is issued.
i 2.If Code = # A 5 year Test report is due before a permit is issued.
3.0ver due fees must be paid before a permit is issued.
If elevator(s) are not in service please request an "ELEVATOR OUT OF SERVICE
AFFIRMATION" form.
State No.Code Due Over Due Location Address
111703 * $120.00 $ o.00 1235 CENTRAL PARR DR EAST, CARMEL IN 40632
xx �5b�
DEC H 2014
1093 --�-2- D°l'� BY:
Reference Number Invoice Date Please submit ENTIRE document with payment
73-4241 12,29.20-]4 1 12/29'/2'014' IInit(s) 1 Total Due upon receipt
of 1 $ 120.00 of $ ,-1-20..0,0
i
i
j Owner Id 734241
Ref.Num. :734241-12292014 -1 $120 of $ 120.00
Invoice Date 12/29/2014
I If Paying by check, include a check made payable to the Department—&f:Homeland'security.;You can pay all your
payments online at-IDHS web site https://myoracia.in.gov/dfb6/i:d sFeeiiFines/dtast:do-with-visa/Master
Card/Discover cards. Use Owner Id on this letter or State Number on the invoice to pull"up information when
paying the online.OR complete. thefollowing information and return_by mail Indiana Department of,
I Homeland Security, Fiscal Department, .3.02 W,Washington St: Rm E221,Iridianapolis =IN.46204.pr fax to
(317)233-0401.-'Qtiestioiis? call(317)232=6427 or E-mail:elevator-invoice@dha.in.gov"2:25% convenience 'fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address: Street
City State Zip Code
`I
{ CC type:Visa/Am.Express/Discover/Master Card ONLY (circle one)
{{i Acct. Number Exp.Date (mm/yy)
J
I CVV2 Number Contact Phone Number Signature
i
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
Ref.Num. :734241-12292014 -1 $120 of $ 120.00 Invoice Date 12/29/2014
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
229400 Indiana Department Purchase Order No.
of Homeland Security Terms
Fiscal Department
302 W Washington St., Rm E221
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s)or bill(s)) PO# Amount
12/29/14 734241122920141 Elevator permits xxl566 $ 120.00
Total $ 120.00
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
, 2Q_
Clerk-Treasurer
I
Voucher No. Warrant No.
Indiana Department
229400 of Homeland Security Allowed 20
Fiscal Department
302 W Washington St., Rm E221
Indianapolis, IN 46204 In Sum of$
$ 120.00
I
I
ON ACCOUNT OF APPROPRIATION FOR
ti
109 -Monon Center 1
PO#or Board Members
INVOICE NO. ACCT#/TITLE AMOUNT
Dept#
1093 734241122920141 4239099 $ 120.00 ` 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
f _
I
i
January 8, 2015
i
Signature
$ 120.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
r
claim paid motor vehicle highway fund