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244792 04/29/15 J;t�'E,pMF� CITY OF CARMEL, INDIANA VENDOR: 358894 j; ® f ONE CIVIC SQUARE SAFELITE AUTOGLASS CHECK AMOUNT: $'"""'256.85' =a; CARMEL, INDIANA 46032 PO BOX 633197 CHECK NUMBER: 244792 9''��r6ii��°' CINCINNATI OH 45263-3197 CHECK DATE: 04/29/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 01830236454 256.85 OTHER EXPENSES SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1-800-835-2257 dba: Safelite Auto Glass, Elite Auto Glass, Auto Glass Specialists, and IF YOU HAVE ANY QUESTIONS REGARDING Diamond Triumph Glass PAYMENT OF THIS INVOICE: 1-800-835-2092 INVOICE 01830-236454 INVOICE: 04/14/15 BD ORDERED: 04/07/15 INSTALLED: 04/14/15 PLEASE REMIT PAYMENT TO: W.O. # : 653279 REFERRAL#: 000000 SAFELITE FULFILLMENT, INC INSURED: P.O. BOX 633197 CARMEL, CITY OF CINCINNATI, OH 45263-3197 WATER DISTRIBUTION PLEASE WRITE INVOICE NUMBER ON CHECK CARMEL IN 46074-0000 PH1:765-413-9412 PH2:765-413-9412 CARMEL, CITY OF Acct #: 371835 WATER DISTRIBUTION 3450 W 131ST CARMEL IN 46074 POLICY# : PO#/REF : 120 CLAIM # : LOSS LOC: AUTH/VER: TRENT LOSS DATE/CAUSE: 04/14/15 -------------------------------------------------------------------------------------- ------ ------______ 2004 FORD ECONOLINE 3 DOOR VAN ARR_ MOBILE MILEAGE: 123,456 VIN: 1FTNE24W64HA57277 LICENSE/ST: UNK IN STOCK #: 120 ------------------------------------------------------------------------------------ QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION 1 DWO1504 GBY 204.29 188.95 50.00 .00 _00 238.95 SOLAR 1 DISPOSAL FEE 4.95 .00 7.95 .00 .00 7.95 DISPOSAL FEE 1 FUEL SURCHARGE 3.99 _00 9.95 _00 .00 9.95 FUEL SURCHARGE PART TOTAL 188.95 LABOR TOTAL 67.90 SUB-TOTAL 256.85 SALES TAX 0.00 P A Y T H I S A M O U N T 256_85 TERMS: NET 30 ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/A SAFELITE AUTOGLASS # 01830 INDIANAPOLIS IN 46268-0000 SAFELITE TAX ID #: 36-4523816 041415-371835-371835 00609-371835-236454 CARMEL, CITY OF WATER DISTRIBUTION 3450 W 131ST 0000000020150414742 CARMEL IN 46074 i 1 VOUCHER # 151553 WARRANT# ALLOWED IN SUM OF $ 358894 SAFELITE FULFILLMENT INC PO BOX 633197 CINCINNATI, OH 45263-3197 i Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR I l Board members 1 PO# INV# ACCT# AMOUNT Audit Trail Code 01830-23645¢ 01-6500-04 $256.85 ! 1 I f I i . I4 i i Voucher Total $256.85 i; Cost distribution ledger classification if I 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 358894 SAFELITE FULFILLMENT INC Purchase Order No. PO BOX 633197 Terms CINCINNATI, OH 45263-3197 Due Date 4/20/2015 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 4/20/2015 01830-23645 $256.85 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 Officer