245168 05/13/15 ,`/y1_G4A t�f
l 1 CITY OF CARMEL, INDIANA VENDOR: 360614
ONE CIVIC SQUARE INDIANA BUREAU OF MOTOR VEHICLE§HECK AMOUNT: S'"'"'"'36.50'
:9� �_�: CARMEL, INDIANA 46032 100 N SENATE AVE ROOM N415 CHECK NUMBER: 245168
ydTON�°' INDIANAPOLIS IN 46204 CHECK DATE: 05/13/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 36.50 OTHER EXPENSES
� t�3
STATE OF INDIANA
Michael R.Pence,Governor Kent W.Abernathy, Commissioner
MUNICIPAL CORPORATION AND LAW ENFORCEMENT TITLE AND REGISTRATION
Title Application Checklist
Title and registration applications for Municipal Corporations and Law Enforcement are processed by the BMV
Municipal Processing Department to improve the security and efficiency of these transactions. Prior to submitting each
application, please verify that all required information is included. Contact(888)692-6841 with any questions.
Title A0lin cation Requirements
E' ARRilcatioo for Certificate of Title-State Form 44049
Nr Original Certificate of Title or Certificate of Origin
phvsl,cal Inspection of a Ve icle or Watercraft-State Form 39530. Required for vehicles
purchased outside of Indiana.
.T Odometer Disclosure Statement-State E,orm43230 (if odometer statement is not completed on
the certificate of title or certificate of origin).Trailers and motor vehicles over 16,000 Ib. are exempt.
0-,ST108E-Certificate of Gross Retail or Use Tax Exemption-State Form 48841
tet? Z'$15.00 title application fee. Payable by MasterCard or Visa,check,electronic check,or money
�l4 Y order. A$21.50 delinquent fee will be assessed on packets received thirty one(31)days after the
purchase date listed on the Certificate of Title or Certificate of Origin.
Registratlon Anplication Requirements
Anolication for New and/or Transferred License Plates for Municloal Corporations and Law
Enforcement-State Form 53665
040 Copy of Certificate of Title or Application for Certificate of Title-State Form 44049(if already
titled to applicant)
NAI Copy of the lease agreement or Statement of Existing Lease Agreement-State Form 12787 if the
vehicle is being leased from a leasing company.
l)ipl Safety Inspection completed by ISP for all municipally owned school buses
If the BMV determines that sufficient credible evidence exists to substantiate the applicant's claim of
ownership,a title and registration will be issued. If all required documents atg not submitted or information
is Incomolete the entire anolication will be returned.
For your convenience,the required forms are included with this checklist. The forms are also available at
mvBMV.com. Mail the completed: packet to:
Central Office Municipal Processing
100 North Senate Avenue,Room N415
Indianapolis,IN 46204
Please include this checklist and contact information with your application.
Print Name:�ll A 11'� dq r U'1 S Phone Number: 317- 6'71• 263 y
Email: P a-ry S L' q ryvi e) • j r 9L o
An Equal Opportunity Employer
> a Please submit all
APPLICATION FOR NEW AND/OR TRANSFERRED MUNICIPAL A_wlicatlons to:
.9 AND LAW ENFORCEMENT LICENSE PLATES Indiana Bureau of Motor
x State Form 53565(4-08) Vehicles
" r
D Indiana Bureau of Motor Vehicles Registration Division-Special
INSTRUCTIONS; 1.Complete application with all Information In sections 1, 2,3,and 4 as applicable, Plates
100 N.Senate Ave.,N404
2.Attach additional sheets if necessary for information for each vehicle for which a municipal or law Indianapolis,IN 46204
enforcement license plate Is requested. Telephone:(317)233-3146
3.The application must be accompanied by a copy of each vehicle(s)title,title application,or Fax number;(317)233-0053
lease agreement. Internet:htt ://www.m bmv.in. ov
Official Name of entity that owns or leases the vehicle(s) Entity Telephone number Entity's Executive Officer's name and title
C(Tj OF OPP-Y & LM QT ES ).57 I-7. o -be- A-r2. -M,4 •o 12
Entity street address(number and street)) City County Zip Code
N& GV�C
HA-MI cFou Indiana
State Board of Accounts number Federal I.D.number
A
ME
M S.
VIN Vehicle color Vehicle type Vehicle Description
(of New Vehicle or Vehicle that (e.g.Passenger,truck,motorcycle,school bus, (Make,model, Year)
Municipal License Plate will be re— city bus,trailer,semi-trailer,recreational vehicle)
F transferred to) �
v >MC-UIGx e,)976U L /J
Basis of Flnanclal Responsibility Description of official business for which the entity will use the vehicle Vehicle purchase or lease date
(Source of self-insurance;or SGw p-('` l 6CA�e VeWc)� e +rfPS +v s �U 4 (month,day,year)
insurance Company Name and r
Polic um er)
�-Pe - „ ,iare�Pol,s '/ - /3 ;2 o1S'
)f'816 3 a 3 to Pb NA F)
The application is for(check one): If a Transfer,VIN of Vehicle from which the License Plate Is
Transferred
` �A new Municipal or Law Enforcement License Plate A c N1—
t -73 r 9510 o8a(D 3.2
v To transfer an existing License PlateQ D/ apps C-I,lev% �n
"
VIN Vehicle color Vehicle type Vehicle Description
(of New Vehicle or Vehicle that (e.g.Passenger,truck,motorcycle,school'bus, (Make,model,Year)
Municipal License Plate will be city bus,trailer,semitrailer,recreational vehicle)
transferred to)
Basis of Financial Responsibility Description of official business for which the entity will use the vehicle Vehicle purchase or lease date
(Source of self-insurance;or (month,day,year)
Insurance Company Name and
Policy number)
The application Is for(check one): If a Transfer,VIN of Vehicle from which License Plate Is Transferred
A new Municipal or Law Enforcement License Plate
To transfer an existing License Plate
VIN Vehicle color Vehicle type Vehicle Description
(of New Vehicle or Vehicle that (e.g.Passenger,truck,motorcycle,school bus, (Make,model,Year)
Municipal License Plate will be city bus,trailer,semi-trailer,recreational vehicle)
transferred to)
Basis of Financial Responsibility Description of official business for which the entity will use the vehicle Vehicle purchase or lease date
(Source of self-Insurance;or (month,day,year)
Insurance Company Name and
Policy number)
j
cation is for(check one): If a Transfer,VIN of Vehicle from which License Plate is Transferred
ew Municipal or Law Enforcement License Plate
transfer an existing License Plato
L#.
The entity shall Indicate which one(1)of the following classifications the entity belongs,thus entifling 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 orlaw enforcement license plate.Please check one(1):
1.The State of Indiana
a)a state agency,
b)a state university,or
c)other state entity
2.A municipal corporation(as defined In IC 36-1-2.10)"Municipal corporation"means any oflhe 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 cen9fled 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),
f)local airport authority (Must provide a certified copy of the resolution or ordinance(s)that establishes the authority),
J)special service district (Must provide a certified copy of the resolution or ordinance(s)that establishes the district),
k)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 no annual compensation of not more than$3,500.00.
(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 listed 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 agency
(Must provide a copy of the contract with the Bureau of Aging and In-Home Services.)
B. A community mental health center(i0 12-29-2)
(Must provide a copy of the Division of Mental Health and Addiction's cartificate'fo operate In Indiana as a community mental health center.)
For Law Enforcement License Plate(only available to these entities pursuant to IC 9.19-3-6):
(Must provide official identification showing the representative is employed with the entity.)
9. The Indiana State Police Department
10. The Indiana Department of Natural Resources
11. A county police department
12. A city or town police department
The authorized representative submitting thin 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 officlal business
pursuant to IC 9-18-3-1. A municipal license plate Issued to a vericle shall be permanently attached to the vehicle listed in this application In accordance with
iC 9-18-3-4.
Date(month,day,year) Situra of authoize en repr sentative
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Typed or printed title of entity representative Typed or printed name of entity repro a ative Office telephone number of entity representa0ve
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90788
CITY OF CARMEL FT6075
CUSTOMER'S NAME STOCK NO.
ODOMETER DISCLOSURE STATEMENT
Federal law (and State law, if applicable) requires that you state the mileage upon
transfer of ownership. Failure to complete or providing a false statement may result in
fines and/or imprisonment.
1 DON HINDS FORD, INC. (transferor's name,PRINT)
state that the odometer now reads 13 (no tenths) miles and to the
best of my knowledge that it reflects the actual mileage of the vehicle described below,
unless one of the following statements is checked.
1 I hereby certify that to the best of my knowledge the odometer reading reflects
❑ ( ) y �
the amount of mileage in excess of its mechanical limits.
❑ (2) I hereby certify that the odometer reading is NOT the actual mileage. "
WARNING-ODOMETER DISCREPANCY.
MAKE MODEL BODY TYPE
FORD -FO
UT
VEHICLE IDENTIFICATION NUMBER YEAR
1 F GX5F 1 6 2015
X j' RANDOLPH WALKER
TRA SF FOR' I RE
DON HINDS FORD, INC.
PRINTED NAME
12610 FORD DRIVE
TRANSFEROR'S ADDRESS (STREET) '
FISHERS IN, 46038
CITY STATE ZIP CODE
04/13/2015
DATE OF STATEMENT
X
*10
TRANS SIGNATURE
CI Y OF CARMEL
PRINTED NAME
CITY OF CARMEL
TRANSFEREE'S NAME
1 CIVIC SQ
TRANSFEREE'S ADDRESS (STREET)
CARMEL IN 46032-2584
CITY STATE ZIP CODE
90788
APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA • BUREAU OF MOTOR VEHICLES
State Form 44049(R4/3-02) Approved by State Board of Accounts 2002
TO BE COMPLETED BYAPOLICE OFFICER.BMV OFFICIAL ORBMV CERTIFIED DEALER SIGNEE 1lWETHE UNDERSIGNED SWEAR ORAFFIRM THAT THE INFORMA-
FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM- TION ENTERED ON THIS FORM IS CORRECT. INVE UNDERSTAND
INED THE FOLLOWING VEHICLEAND FIND THE IDENTIFICATION NUMBER TO BE As FOLLOWS. THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI-
TUTE THE CRIME OF PERJURY. FUTHERMORE, IIWE AGREE TO
VEHICLE IDENTIFICATION NUMBER
, INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY
1 F I M: C I U 9 G X 5 F U„ C 1,j 3 7 ;6 Q„ LIABILITY ARISING M THIS TRANSACTION.
YR. MAKE MODEL JTYPE DATE X 6((�:1K1S 1 YL
15 FORD ESCAPE UT 04/13/2015 x_
INSPECTOR'S PRINTED NAME 8 TITLE CITY DATE: 04/13/2015
' The law requires that you apply for Certificate of Titre within thirty-one days from the date of purchase of a
INSPECTOR'S SIGNATURE BADGE,BRANCH OR motor vehicle.There is a delinquent fee for failure to do so.Attach Certificate of Title assigned by seller.On an.
DEALER PLATE NO. dm
oed Tlfies,liens must be released.Supporting documents surrendered vdth this application cannot be retumed to the appli-
cant.*In accordancewith Federal Code383.
TITLE NUMBER BRANCH NO.INVOICE NO. JBMVUSEONLY
1.
'SOC.SECJFEDERAL I.D.NO. APPLICANT'S NAME BMV USE ONLY
2. -
CITY OF CARMEL
STREETADDRESS CITY STATE ZIP CODE
3.
1 CIVIC SO CARMEL IN 46032-2584
VEHICLE I.D.NUMBER VEH.YEAR IVEH.MAKE I VEH.MODEL NO.VEH TYPE ODOMETER.
4.
1 FMCU9GX5FUC13760 12015. FORD . ESCAPE TK 13
FORMER TITLE NUMBER PURCHASE DATE LIEN SPEED PICKUP MAIL DEALER NO. BMV USE ONLY
s 04/13/2015 INO INO 040420
FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS STREETADDRESS
6.
CITY STATE ZIP CODE BMV USE ONLY
7.
SECOND LIEN'S NAME STREETADDRESS
B.
CITY STATE ZIP CODE LICENSE NUMBER LICENSE FORMS BMV USE ONLY
9 YEAR USED
GROSS RETAIL&USE TAXAFFIDAVIT-INVE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW.
SELLING PRICELESS TRADE-IN- AMOUNT SUBJECT TO TAX AMOUNT OF TAX IDEALER]BRANCH EXEMPT PLACE PARA.
10' $ 23243.00 $ 2000.00 1$21243.,00 $ NIA
`Your Social Security number/Federal I.D.number is being requested by this agency under IC 4-1.8.1. Disclosure is manadatory and this document cannot be processed without It
APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION
APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA * BUREAU OF MOTOR VEHICLES
BUREAU -TO BE MAILED WITH TITLE REPORT
0 STA Tg
Form Indiana Department of Revenue
ST-108E
State Form 48841 Certificate of Gross Retail or Use Tax
as•,,8ia r' (R4/3-08) EXEMPTION for the Purchase of a
Motor Vehicle or Watercraft 90788
NAME OF DEALER Dealer's RRMC#(Registered Retail Merchant Certificate Number)
10 0 0 1 7 6 8 6 0 31 0 0 1
DON HINDS FORD, INC. TID#(10 digits) LOC#(3 digits)
Dealer's FID#(Federal Identification Number,9 digits) Dealer's License Number(seven digits)
35-0361768 0404208
Address of Dealer City State Zip Code
12610 FORD DRIVE FISHERS IN 46038 .
NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TID,OR FID#(Mandatory)
City of Carmel 38-3670462
Address of Purchaser City State Zip Code
1 Civic S CarmelTM
�� s ` ' VshtcleI�entt>facatton lnformatrory of Purchase`
a � x
VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) Year Make Model/Length
1FMCU9GX5FUC13760 2015 FORD ESCAPE
Y
' � Cr81f:U IOtl QfgPurc aSe race , � 9 1CdXl a If1f0�tY1St101 �0 t
.. rtl..,,, .rs
.... .;, ., i.,.. ... a... a.,.�.r. i ,�,.,t-<..,,
u-
1. Total Purchase Price......................... 1. 23243.00
VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number)
2. Trade-Allowance 2CNDL73F956082032
(Like-kind exchanges only)................ 2. 2000.00 Year Make Model/Length
3. Net Purchase Price
(Line 1 minus Line 2)......................... 3. 21243.00 2005 CHEVROLET EQUINOX
CALCULATION OF PURCHASE PRICE LINES 1,2&3 MUST BE COMPLETED FOR ALL EXEMPTED PURCHASES
NEW RESIDENT STATEMENT Must Be Completed if Exemption#8 is claimed,see reverse side.
I certify that I became a resident of INDIANA on(month&year)
My previous State of Residence was I hereby certify that the above statement is true and correct.
Date Signature of Owner
SALES/USE TAX WORKSHEET To be completed if Sales and/or Use Tax was paid to a state other than Indiana,Exemption#15.See reverse side.
Date of Purchase
1.Purchase price of property subject to sales/use tax..................................................... .....1. $
2.Indiana sales/use tax due:Multiply Line 1 by sales/use tax percentage(7%)..................................2.
3.Credit for sales tax previously paid to another state..........................................................................3.
(Do not include flat fees, local,and/or excise taxes.)In what state was the tax paid?
4.Total amount due:Subtract Line 3 from Line 2. 4. $
(Line#3 can not exceed Line#2)
DIRECT RELATIVE IDENTIFICATION EXEMPTION(Must Be Completed if Exemption#11 is claimed,see reverse side).
Name(s)on original title Relationship of above parties
Name(s)being added/deleted
PUBLIC TRANSPORTATION EXEMPTION(Must be completed if exemption#6 is claimed and you are not a school bus operator.)
USDOT#(U.S. Department of Transportation Number)
I certify that the above vehicle or watercraft is exempt from sales/use tax under exemption# (see reverse side). I also certify
that any sales tax credit shown as paid to an out of state dealer using exemptio a ually c lected by the dealer and the dealer has
not provided the buyer with a check to be paid to the BMV.I understand at alse state nt on this form may constitute the crime
of perjury.
Date 04/13/2015 Signature of Purchaser (Al
VOUCHER # 155464 WARRANT # ALLOWED
79627 IN SUM OF $
BUREAU OF MOTOR VEHICLES
Watercraft Renewal Center
1009 W. Main St.
Carmel, IN 46032
i. Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members \
PO# INV# ACCT# AMOUNT Audit Trail Code
-3 c,<
FORD ESCAF 01-7500-02 44S-26-
it
I,
V� I
i
I!
Voucher Total $46.25
Cost distribution ledger classification if
claim paid under vehicle highway fund 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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
79627
BUREAU OF MOTOR VEHICLES Purchase Order No.
Watercraft Renewal Center Terms
1009 W. Main St. Due Date 5/6/2015
Carmel, IN 46032
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
5/6/2015 FORD ESCA $46.25
I hereby certify that the attached invoice(s), or bih(s) is.(are)true and
correct and I have audited same in accordance with IC 511-10-1.6
Date Officer