243243 03/18/15 / \ CITY OF CARMEL, INDIANA VENDOR: 229400
ONE CIVIC SQUARE INDIANA DEPT OF HOMELAND SECURI-AHECK AMOUNT: $......*360.00'
CARMEL, INDIANA 46032 DIV OF ELEVATOR SAFETY-FISCAL OFFIC CHECK NUMBER: 243243
M,iTON.� 302 W WASHINGTON ST,RM E221 CHECK DATE: 03/18/15
INDIANAPOLIS IN 46204
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4350100 45581 120.00 BUILDING REPAIRS & MA
1205 4351501 45582 120.00 EQUIPMENT MAINT CONTR
1205 4351501 45583 120.00 EQUIPMENT MAINT CONTR
E �
r
ELEVATOR OPERATING CERTIFICATE INVOICE
ARMEL PUBLIC WORKS & SAFETY ONE CIVIC SQ CARMEL IN 46032
l.If Code = * An annual test report is due before a permit is issued.
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 '501
45581 $120.00 $ 0.00 3 CIVIC SQ, CARMEL IN 46032 0
I
45582 $120.00 $ 0.00 1 CIVIC SQ, CARMEL IN 46032
45583 $120.00 $ o.00 1 CIVIC SQ, CARMEL I /�S
'3u M! T®
Bui1C. ,-;: "aintenance MAR 16 2015
Account
Department 1. ---
r.
Treasure
Reference Number Invoice Date Please submit ENTIRE document with payment
7675-03022015 -1 03/02/2015 Unit(s) 3 Total Due upon receipt
of 3 $ 360.00 of $ 360.00
Owner Id 7675
Ref.Num. :7675-03022015 - 1 $360 of $ 360.00 Invoice Date 03/02/2015
If Paying by check, include a check made payable to the Department of Homeland security. You can pay all your
---payments--online at-IDHS.web site-.https://myoracle.in.gov/dfbs/idhsFeesFinea/start.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 dues online.OR complete the following information and return by mail :Indiana Department of
Homeland Security, Fiscal Department, 302 W.Washington St., Rm : E221,Indianapolis, IN 46204 or fax to
(317)233-0401. Questions? call(317)232-6427 or E-mail:elevator-invoice@dhs.in.gov 2.25% convenience fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address:-,-Street
City State Zip Code
CC type:Visa/Am.Express/Discover/Master Card ONLY (circle one)
Acct. Number Exp.Date (mm/yy)
CVV2 Number Contact Phone Number Signature
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
Ref.Num. :7675-03022015 - 1 $360 of $ 360.00 Invoice Date 03/02/2015
F
� j ,
VOUCHER NO. WARRANT NO.
j ALLOWED 20
IN Department of Homeland Security 1
Fiscal Department
IN SUM OF$
302 W. Washington St., Rm E221 ;
Indianapolis, IN 46204
$360.00
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
I hereby certify that the attached invoice(s), or
1205 45583 43-515.01 $120.001
bill(s) is (are)true and correct and that the
1205 45582 43-515.01 $120.00
materials or services itemized thereon for
0 I 45581 I 501 $120.00
which charge is made were ordered and
received except
M nday, March 16, 2015
Director, Administration
Title
i
1
Cost distribution ledger classification if I
claim paid motor vehicle highway fund
I
I
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 service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s)or bill(s))
03/02/15 45583 1 Civic Square-Admin $120.00
03/02/15 45582 1 Civic Square-Admin $120.00
03/02/15 I 45581 I 3 Civic Square-Police I $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
20
Clerk-Treasurer