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246052 06/09/15 CITY OF CARMEL, INDIANA VENDOR: 00351239 ONE CIVIC SQUARE BUREAU OF MOTOR VEHICLES CHECK AMOUNT: $*******109.50* ' 4• ?� CARMEL, INDIANA 46032 WATERCRAFT RENEWAL CENTER CHECK NUMBER: 246052 9M�TON 1009 W MAIN ST CHECK DATE: 06/09/15 CARMEL IN 46032 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 651 5023990 TK5238505 109.50 OTHER EXPENSES r. 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 Application Requirements I&L Application for Certificate of Title—State Form 44049 'Q Original Certificate of Title or Certificate of Origin ❑ Phvsical Inspection of a Vehicle or Watercraft—State Form 39530. Required for vehicles purchased outside of Indiana. IR Odometer Disclosure Statement—State dorm 43230(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. 'R ST108E_Certificate of Gross Retail or Use Tax Exemption—State Form 48841 $15.00 title application fee. Payable by MasterCard or Visa,check, electronic check,or money 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. Registration AS1011cation Requirements Application for New and/or Transferred License Plates for-Municipal Corporations and Law Enforcement—State Form 53565 l� Copy of Certificate of Title or Application for Certificate of Title—State Form 44049_(If already titled to applicant) ❑ Copy of the lease agreement or Statement of Existing Lease Agreement—State Form 12787 if the vehicle is being leased from a leasing company. ❑ 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 are not submitted or information is incomplete the entire application 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: MGI h ��Lk Atli_� Phone Number: 3 )7 `-6'21 ,26 3 Yo Email: %wfA11S Cl�fm�� , in - 2 L/ An Equal Opportunity Employer APPLICATION FOR MUNICIPAL CORPORATION BuEAv ooTORVEHIct; AND LAW ENFORCEMENT LICENSE PLATES MuriitpaPrbceSs�ny x Y f8/6 cr State Form 53565(R414-15) x, p 50Qrj�VOrk SeC12tEAbenl(8` z Indiana Bureau of Motor Vehicles `2tiom N4�5 'Ind�anap'�ol�s,IN X6204' �;� INSTRUCTIONS: 1. Complete in blue or black ink or print form. 2. Complete all information in sections 1,2,3,and 4,as applicable,and mail to the address listed above. 3. The application must be accompanied by a copy of each vehicle_title,title application,or lease agreement if applying for registration only. 4. For a new license plate request choose either the license plate type that is reflective of your entity,a standard passenger license plate,or other license plate type desired. 5. Indicate in Section 3 which of the municipal classifications applies to the entity named on this application. The entity must submit the requested documentation or proof that the entity meets the indicated classification. 6. A safety inspection must be completed by the Indiana State Police for all school bus plate applications. Name of Owner Federal Identification Number City of Carmel Utilities 35-6000972 Street Address of Entity(number and street) One Civic Square City State ZIP Code County Township Carmel IN 46032 Hamilton Carmel-Clay Mailing Address(if different from street address) City State ZIP Code IN Name and Title of Entity's Executive Officer Telephone Number James Brainard (Mayor) 317-571-2400 ,.:' _ ,1W'? :;, "� ^•"c �';a7 ,°,�' ®Nf kyl I.�r:.s ' d f, W- 141 rNO � . i� 4� ,t1 In i �h © aNr1 9drmatorioreaC t�eh ae t �3 act Jtgna hed i,"{ec sa , ,a , ' - y + x�,t g r s v'�.r" �+..' tai s� r+ .YF' .a sE 1ideidenti i tion umber �/IN /ease�nf ref Ys aces bel ) ; Purchase or Lease Date(mm/dd/yyyy) . ? ,(.t_ MIIW L x a 1 F T B F 2 1 B 6 7I F E C 4 1 8 6 2 05/05/2015 Year Make Model Type Color Gross Vehicle Weight(if applicable) 2015 Ford F250 TK RED Description of Vehicle Official Business.Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) Hylant-Indianapolis H8103036P64ACOF15 The application Is for: (check one) New License Plate _City Police _Sheriff Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter latetype) Page 1 of 3 (2J,Veh[cle ItlentiicafionNumber(UIN (P(ease erterrnhspaces bglow� Purchase or Lease Date(mm/dd/yyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle.OM Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application Is for: (check one) � New License Plate _City Police _Sheriff _Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: Passenger _Other: enter plate type) #3 Vehicle de�nt�f(c tion u nber VlN Please a ter)s aees be/off) `"' k z x' Purchase or Lease Date mm/dd Year Make Model . Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application is for: (check one) �4`1censeeTy '(ci�c�jc'�i et e �u New License Plate _City Police _Sheriff _Municipal School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: Passenger _Other: enter plate e (4�tiehje[ey4dentificatiorfNuamlier(lfxll ;(I/easeenteriff saceslie/Qw# t �j Purchase or Lease Date(mm/dd/yyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application is for: (check one) E � �Licens Pia e T"Pt, 4 U I New License Plate _City Police _Sheriff _Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter latetype) Page 2 of 3 The entity shall Indicate which one(1)of the following classifications the entity belongs,thus entitling the entity to a permanent munlclpal 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 or law 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 of the 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), ej.fiire protection district (Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security), t1 public transportation corporation (Must provide a certified copy of the ordinance(s)that establishes the corporation), g)local building authority (Must provide a certified 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 ordtnance(s)that establishes the authority), 1)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 nominal 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 offlcial 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 asa 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(IC 12-29-2) (Must provide a copy of the Division of Mental Health and Addictions certificate to 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 this 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 vehlcle(s)and uses It for official business pursuant to IC 9-18-3-1. A municipal license plate issued to a vepicle shall be permanently attached to the vehicle listed in this application in accordance with IC 9-18-3-4. Date(month,day,year) SI tura of autho Ize enn;�a Appa- -ZI 20C) Typed or printed title of entity representative Ty ed or printed name of entity repro a ative Office telephone number of entity representative 78599 APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA • BUREAU OF MOTOR VEHICLES State Form 44049(R413-02) Approved by State Board of Accounts 2002 TO BE COMPLETED BYAPOLICE OFFICER,BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE IME THE UNDERSIGNED SWEAR OR AFFIRM"THAT THE INFORMA- FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM- TION NTERED ON THIS FORM IS CORRECT.IME UNDERSTAND INED THE FOLLOWING VEHICLEAND FIND THE IDENTIFICATION NUMBER TO REAS FOLLOWS. THAT MING A FALSE STATEMENT ON THIS FORM MAY CONSTI- VEHICLE IDENTIFICATION NUMBER TUT E IME OF PERJURY. FUTHERMORE, 1/WE AGREE TO I I I I I I I I I I I I I I I I IN IF ND HOLD HARMLESS THE INDIANA BMV FROM ANY 1 F ;T : B :F : 2 : B :6 :7 F Ettl:C :4t31: 1 :8 6 :2, LIABI qK GFRO T S TRS CTI N. I I I I I 1 I I 3 YR. MAKE MODEL TYPE DATE 15 FORD 15 PU 105/05/2015 x INSPECTOR'S PRINTED NAME&TITLE CITY DATE: 05/05/2015 ZIONS VILLE The law requires that you apply for Certificate of Title 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. dorsed Titles,liens must be released.supporting documents surrendered with this application cannot be returned to the appli- 0401267 cant.9n accordancewlth Federal Code383. 1. TITLE NUMBER BRANCH NO.INVOICE NO. I BMV USE ONLY 2. 'SOC.SECJFEDERAL I.D.NO. APPLICANT'S NAME BMV USE ONLY CITY OF CARMEL UTILITIES 3. STREETADDRESS CITY STATE ZIP CODE 1 CIVIC SQ CARMEL IIN 46032-2584 4. VEHICLE I.D.NUMBER VEH.YEAR EH.MAKE IVEH.MODEL NO.VEH TYPE ODOMETER 1FTBF2B67FEC41862 12015 FORD 15 TK 185 5. FORMER TITLE NUMBER PURCHASE DATE I LIEN SPEED PICK UP I MAIL DEALER NO. JBMVUSEONLY 05/05/2015 NO 1808M FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS STREETADDRESS 6. CASH CITY STATE ZIP CODE BMV USE ONLY 7. SECOND LIEN'S NAME STREETADDRESS 8. CITY STATE ZIP CODE LICENSE NUMBER LICENSE I FORMS BMV USE ONLY 9• YEAR USED GROSS RETAIL&USE TAX AFFIDAVIT-IfWE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW. SELLING PRICELs' ESS TRADE-IN' AMOUNT SUBJECTTO TAX AMOUNT OF TAX DEALER BRANCH EXEMPT IF EXEMPT 10. $ $ $ $ PLACE PARA. '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 ��d f nim. ODOMETER DISCLOSURE STATEMENT 78599 ay State Form 43230(R315-13) �y F INDIANA BUREAU OF MOTOR VEHICLES INSTRUCTIONS: 1. In accordance with federal and state law,the seller of a motor vehicle must disclose the current mileage to a purchaser in writing upon transfer of ownership. The disclosure must be signed by the seller,including the printed name. If more than one person is a seller,only one seller is required to sign the written disclosure. 2. The purchaser must sign the disclosure statement,including printed name and address,and return a copy to the seller. a Complete this form in its entirety,in blue or black ink. Federal and State law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines, imprisonment, or both. I PEARSON FORD, INC. residing at: Printed name(s)of Seller(s) 10650 N. MICHIGAN RD.ZIONSVILLE IN 46077 certify to the best of my knowledge that the Address of Seller(s)(number and street,city,state,and ZIP code) odometer reading is the actual mileage of the vehicle described below unless one of the following statements is checked: Miles(no tenths) ❑ 1. 1 hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage in excess of its mechanical limits. 185 ❑ 2. 1 hereby certify that the odometer reading is NOT the actual mileage and should not be relied upon. WARNING-ODOMETER DISCREPANCY. Vehicle Make Vehicle Model Vehicle Year Vehicle Body Type FORD 15 2015 PU Transfer Date(month,day,Year) 1 1 F T B F 2 B 6 7 F E C 4 1 1 8 6 2 05/05/2015 1 will not hold the Bureau of Motor Vehicles or the Bureau of Motor Vehicles Commission responsible for any discrepancy shown on the odometer reading. I,the undersigned,swear or affirm that the information entered on this form is correct. I understand that making a false statement may constitute the crime of perjury. Signature(s)of Seller(s) Date(month,day,year) 05/05/2015 PURCHASER'S INFORMATION I am are of and acknowledge the above odometer certification made by the seller(s). Sign (s)of. rchaser(s) Date(month,day,year) Wa— 05/05/2015 Prin ame(s)o Purchasers) CITY OF CARMEL UTILITIES Address of Purchaser(s)(number and street) 1 CIVIC SO, City State ZIP Code CARMEL IN 46032-2584 � e S,��y Form Indiana Department of Revenue = _ z ST State Form 488-1088 41 Certificate of Gross Retail or Use Tax 7- (R413-08) EXEMPTION for the Purchase of a 616 Motor Vehicle or Watercraft 78599 NAME OF DEALER Dealer's RRMC#(Registered Retail Merchant Certificate Number) 1 0 0 0 1 8 7 8 1 9 0 10 0 1 PEARSON FORD, INC. TID#(10 digits) LOC#(3 digits) Dealer's FID#(Federal Identification Number,s digits) Dealer's License Number(seven digits) 35-1053374 0401267 Address of Dealer City State Zip Code 10650 N. MICHIGAN RD. ZIONSVILLE IN 46077 NAME OF PURCHASER(S) (PRINT OR TYPE) SSN,TID, OR FID#(Mandatory) CITY OF CARMEL UTILITIES Address of Purchaser City State Zip Code 1 CIVIC SQ ICARMEL IN 46032-2584 !",10,enttfcatt4n�lnfornafionof Purchase,,R _ >x Ir . VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) Year Make Model/Length 1FTBF2B67FEC41862 2015 FORD ��5d �v Calculatton�O�Purctase Price �g >Y � c Xan X tiTracle m Information VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) 1. Total Purchase Price......................... 1. 28626.20 2. Trade-Allowance (Like-kind exchanges only)................ 2. N/A Year Make Model/Length 3. Net Purchase Price (Line 1 minus Line 2)......................... 3. 28626.20 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 salesluse 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 thatthe above vehicle orwatercraft 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 usingexempti #15 was actually collected by the dealer and the dealer has not provided the buyer with a check to be paid to the BMV.1 understan at akin alse stateme is form may constitute the crime of perjury. Date _05/05/2015 Signature of Purchaser p _ 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 A�rI<gation Requirements ❑ Appiicatlon for Certificate of Title—State Form 44049 ❑ Original Certificate of Title or Certificate of Origin ❑ Physical Inspection of Ig or Waters raft-State Form 39530. Required for vehicles purchased outside of Indiana. ❑ Odometer Disclosure Statemerit—State Form 43230 (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. ❑ ST108E-Certificate of Gross Retail or Use Tax Exemption—State Form 48841 ❑ $15.00 title application fee. Payable by MasterCard or Visa,check, electronic check,or money 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. ,Regisira Ion Application Requirements Application for New and/or Transferred License Plates for Munni _i_anal Corporations and Lam fgreamgnt—State Form 63565 Copy of Certificate Of Title or Application for Certificate of Title—state Form 44049(if already titled to applicant) Copy of the lease agreement or Statement of_ExistingLease Aareement—State Form 12787 if the vehicle is being leased from a leasing company. ❑ 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 are not submitted or information is incomplete the entire application 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: fAn►1 a= of dl PV ]�C Phone Number: 317-5^21 —213 )X I Yz) Email: 0 CV IS �CQ f`m�1 - i ja,9=0 I/ An Equal Opportunity Employer APPLICATION FOR MUNICIPAL CORPORATION BUREAUOF'MOTOR VEHICLES3 AND LAW ENFORCEMENT LICENSE PLATES Municlpai Proegsstng "a.. `. State Form 63565(R4/415) 1A0 Nor((1 SeW"AventfQ, `Old Indiana Bureau of Motor Vehicles Room N415 >� ' Indtanap;Dhs IN 4;6204 INSTRUCTIONS: 1. Complete In blue or black ink or print form. 2. Complete all information In sections 1,2,3,and 4,as applicable,and mail to the address listed above. 3. The application must be accompanied by a copy of each vehicle title,title application,or lease agreement if applying for registration only. 4. For a new license plate request,choose either the license plate type that is reflective of your entity,a standard passenger license plate,or other license plate type desired. 5..,Indicate in Section 3 which of the municipal classifications applies to the entity named on this application.The entity must submit the requested documentation or proof that the entity meets the indicated classification. 6. A safety inspection must be completed by the Indiana State Police for all school bus plate applications. x_ ` � SECTfONIsAPPLICANTIIVFORMA�'TION�� #Y Name of owner Federal Identification Number t City of Carmel Utilities 35-6000972 Street Address of Entity(number and street) One Civic Square City State ZIP Code County Township Carmel IN 46032 Hamilton Carmel-Clay Mailing Address(if different from street address) City State ZIP Code IN Name and Title of Entity's Executive Officer Telephone Number James Brainard (Mayor) 317-571-2400 v- SEG�IO�Nt2VEHICLE X's, Lrsf�he�foiloyv/nlnforma#lonforeach vel3,cle Attachkadc#ionaltfsheefs inec;?ssa Mo .' } (�);uehicle Identiflcationk�Number,(UyI�J)�jPlease enterr/t spaces{below) ti w Purchase or Lease Date(mm/dd/yyyy) Q 8 0 Q V B K 2 0 8 9 03/16/2015 Year Make Model Type Color le Weight(if applicable) 1978 Ford F8000 TK RED Gross Vehic Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must Include here if tactical or non-tactical vehicle.) name and policy number) Water Tratisport within City limits Hylant-Indianapolis H8103036P64ACOF15 The application is for: (check one) + ,,, <s g a PxltType `(checkone)c � e New License Plate _City Police _Sheriff Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter plate type) Page 1 of 3 (2j 1/ehlele ItlentificationNumber(1/IN){(P/pease enter(rspxacesbje/ow) £ st Purchase or Lease Date(mm/dd/yyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application is for: (check one) gyp " kk " L�cense'Plate T "e' check ne `� �� New License Plate _City Police _,Sheriff _Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: Passenger _Other: enter late type) £(3)";Vef�lcle Itlentlfication Number(VIN)�(P/ease enterin's a°ces below ;R"� p Purchase.or Lease Date(mm/ddtyyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application is for: (check one) � �r° xrLlcerase Plate T e check�o»e�� wIffiFtOAR, nm h� New License Plate _City Police _Sheriff _Municipal _School Bus State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: Passenger _Other: enter latetype) O4 Vehicle Identif(cation`Number(VIN) (Please enter in space's be/o�v)rq ,y } r Purchase or Lease Date(mm/dd/yyyy) . _ l r u.a. a_, ,.t. Year Make Model Type Calor Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application is for: (check one) 1� 3 - 1 ; 3if License Plate Type (check one) z New License Plate _City Police _Sheriff _Municipal _School Bus State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter platetype) Page 2 of 3 151 The entity shall indicate Which one(f)of the following classifications the entity belongs,thus entitling the entity to a permanent municipal Ilcense 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 qualities for a municipal or law enforcement!!cense 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 of.the 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), 0 public transportation corporation (Must provide a certified copy of the ordinance(s)that establishes the corporation), g)local building authority (Must provide a certlfled copy of the resolution or ordinance(0)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), 1)local airport authority (Must provide a certified copy of the resolution or ordinances)that establishes the authority), ))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 3. A volunteer fire department(as defined In IC 36-8.12.2) establishes the entity) (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 nominal 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 oft/at 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.) 8. A community mental health center(IC 12.29.2) (Must provide a copy of the Division of Mental Health and Addiction's certificate to operate In Indiana as a community mental health center.) For Law Enforcement License Plate(only available to these entitles 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 J 10. The Indiana Department of Natural Resources 11. A county police department 12. A city or town police department The authorized representative submitting this 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 vehlcle(s)and uses it for official business pursuant to iC 9-18-3-1. A municipal license plate issued to a vepicle shall be permanently attached to the vehicle listed in this application in accordance with iC 9-18-3-4. Date(month,day,year) S=tureof orize enrept sentative hev,ic_.- Z1 I -�-Od9 Typed or printed title of entity representative Typed or printed name of entity repre a ative offlce telephone number of entity representative /I e) (Z11) M�(��+A..I.�.F�. .r,3� ', �[�•'•'•`.''._•S"n'"�a 1.Jei �^y—ry i` . '"„1• ..x: t"�^a,.r-.., •�:"„""`r��-�,+yW" � 'i��� ��+�� �.�.�i.ro '-�,,. ..: ri. d...r...r.._.,...A�,„� 1 i 3”9.r• s� � ueaY. y� .;�•.. �:,',d- g+• -� . ...._.._......_..._ _.. .. .. ...-!ay,,�,'J�:•W;3,,>i�z-L���"".`>;'`'-�'':.----ra.—:'7."�'.�. .� '.eta si.�r�9 ��• ."�'•�,a,Gf,�',1L�.r`3,�.:•: >.`•ter�ri,�i',� ts;.:..y�'�Q1G��� r�~�•� STATE OF INDIANA 4, ••O IV•• 'a` •�% 6...• CERTIFICATE OF TITLE FOR A VEHICLE 1 MAKE MODEL NAME YEAR VIN FORD F8000 1978 Q80QVBK2089 TITLE TYPE FORMER TITLE/STATE PURCHASE DATE BODY TYPE !a .i NORMAL .B OF S/IN 01/15/15 TK i � USAGE TAX PAID ISSUE DATE OWNER(S) NAME $0.00 02/26/15 ;s STATE OF INDIANA FEDERAL SURPL ODOMETER/BRAND -s 601 W MCCARTY ST EXEMPT/EXEMPT ' INDIANAPOLIS IN 462251242 MAILING ADDRESS BRAND(S) l: +; I I STATE OF INDIANA FEDERAL SURPLUS PR ! 601 W MCCARTY ST 'i INDIANAPOLIS IN 462251200 SECOND LIENHOLDER s' I•:� S'j I ?. ADDITIONAL OWNER(S) LIEN RELEASED BY: ! - >: i ?9. X I T is i' PRINTED NAME: POSITION: i „• DATE: F FIRST LIENHOLDER THIRD LIENHOLDER a :j l LIEN RELEASED BY: LIEN RELEASED BY: ! X X i 4 !y_ PRINTED NAME: POSITION: PRINTED NAME: POSITION: `j DATE• - i DATE: ! •i ! ,j The Commissioner of the Bureau of Motor Vehicles,pursuant to the laws of the State of Indiana,certifies that the vehide/watercraft has been duly titled and the ! v owner of the described vehicle/watercraft is subject to the liens set forth. J INDIANA BUREAU OF MOTOR VEHICLES Kent W. Abernathy, Commissioner lµ: F 7 1 7 4 2 5 5 TITLE NUMBER !"` tl) 15503019000002 '> 1 :Sl* G!`�'E.C�C' ItltC?� ti:tGGYIC -f .. rr i' Thpf4Aowgs3aEemnEcrrustFsePrOpet[ysi9r>e�rTsYt> h[essarandLessee:and'RrehidQ;the8areaurjfMofbVehcclesi4r2#!e% g[sb�a6arof alhleaseclr'riofos vehicles. ` We Jrndiano Federal:'Sarglus> Rddres 5p11 460 aretbe owners bf Year f t8' [Vl2if� l=ord__ ., Ide-�'ri�doce�, 1�8Q�1%8FC2489: and �reemeat vritti;ttte fpltpiitirittg tes'�.�•-' . l esske ... F�Sldrgss Carlrrat,tJbiifies Ci'� of :�. _ '.. 7fiQ`7bti'd l�venus SVv,:t�rnte�[N:4643�,. . . .Namflton.. ,•. ,' THE P[A'IV;FEEAN4 tAUMYbCG[SE TAXA 7Q ARID<Y TM� heck net SEE CA S E.at�d Vhlt rgniat tt►s�.ptrzAeri Jf, latelaxcisadwneis[if rs-:tJill' httfianFnd+r�(`erl:arralF�c#e�la�dF�vil�ta .•Js s ...- . .-._: THI�AC=�fDAV1't`HASSF..[:NRES[[E1NED AND1S'8�1N�StG[df NDS;pENAL''lYt3Fp>�tJURY,... Sig,.. (3wrtEt'7t:@Ssof . ,.. Q2te':jjltonlrridel.'-i!�Q ... By(Name,) _ D3103tZtitS .` Positip�}, ttatlitart $ arrnart ar► eder4u 'lis _...,.. _ . brirgrv: .. Si�tr'alureof Cel - _ Date.( ;4P ym- w� 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 Application Requirements Application for Certificate of Title—State Form 44049 tL Original Certificate of Title or Certificate of Origin Physical Inspection of a Vehicle or Waterrraft—State Form 39530. Required for vehicles purchased outside of Indiana. 1�1 Odometer Disclosure Statement—State Form 43230(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. IR ST108E-Certificate of Gross Retail or use Tax Exemption—State Form 48841 $15.00 title application fee. Payable by MasterCard or Visa,check, electronic check,or money 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. Registration Applicat�uirements 191 Application for New and/or Transferred License Plates for Munlcl[al Corporations and Law Enforcement—State Form 53565 �3 Copy of Certificate of Title or Application for Certificate of Title—State Form 44049(If already titled to applicant) ❑ Copy of the lease agreement or Statement of Existing Lease Agreement-State Form 12787 if the vehicle is being leased from a leasing company. ❑ 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 are not submitted or information is incomplete the entire application 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:, ua Vl c �w-y i S _ Phone Number: 31 Ma Email: A 1'a-r ij i's c-o,4'me-) y Y1 C An Equal Opportunity Employer I ��sT4re�, APPLICATION FOR MUNICIPAL CORPORATION 13UR�AU OFMOTl012wVEHICLES AND LAW ENFORCEMENT LICENSE PLATES MGnicipa4Proces'smg State Form 53565(R414-15) 00 Ntlttlj Segate/�Vet1U8 :-- Indiana Bureau of Motor Vehicles Ftoorrr�t495 Indiarfaptllist IN�46204 INSTRUCTIONS: I. Complete in blue or black ink or print form. 2. Complete all information in sections 1,2,3,and 4,as applicable,and mail to the address listed above. 3. The application must be accompanied by a copy of each vehicle title,title application,,or lease agreement if applying for registration only. 4. For a new license plate request,choose either the license plate type that is reflective of your entity,a standard passenger" license plate,or other license plate type desired. 5. Indicate in Section 3 which of the municipal classifications applies to the entity named on this application. The entity must submit the requested documentation or proof that the entity meets the indicated classification. 6. A safety inspection must be completed by the Indiana State Police for all school bus plate applications. v, a x Naa' M- .a.". ." s 4 i �,.rir Name of Owner Federal Identification Number City of Carmel Utilities 35-6000972 Street Address of Entity(number and street) One Civic Square City State ZIP.Code County Township Carmel IN 46032 Hamilton Carmel-Clay Mailing Address(if different from street address) City State ZIP Code IN Name and Title of Entity's Executive Officer Telephone Number James Brainard (Mayor) 317-571-2400 7�11,4' `r` '"- h,'�'rr „^ :sgv x }," 7 -,. 3 TION,2 a ESI GLE INFORMATIO,1 srn.''`2¢ :;} ,.sp`5.'€e �i.t,. .a.. . +-. '' x'r W—�ist�th,e�fo#010g nfor ion for each ve is/e Aita_ch alio!ilonat sheets lI necessa, ,d ,v,Po ;• � aµ' (1�) 1 (cte ltltentificatton Number(�liN)�,(Pleese'enterrspacesxbelot!rj� � ��i � Purchase or Lease Date(mm/dd/yyyy) 1 F D X E 4 F S 4 F _Dj A 1 0 6 1 7 . 8 4 ' 04/28/2015 Year Make Model Type Color Gross Vehicle Weight(if applicable) 2015 Ford E45OSD CUT VAN WHITE Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must Include here if tactical or non-tactical vehicle.) name and policy number) Hylant-Indianapolis H8103036P64ACOF15 The application Is for: (check one) y a,r d xM � tix� ✓ New License Plate _City Police _Sheriff ✓ Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one.of the following: _Passenger _Other: enter latetype) Page 1 of 3 } 2>' a icle#den iflcaion Number VIN Please enter=�n s aces below ��` Purchase or Lease Date(mm/dd/yyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application Is for: (check one) } { .* f` License P�lateY a `cheek oRe)€ ` 5 New License Plate _City Police _Sheriff _Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: (3) V£ehicie ldentificatibn Number(U�MP�ease°enter'in spaces be'lovya) e { ; t"z 7} Purchase or Lease Datelate(mm/dd/yyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) rThe application is for: (check one) I $ �' uLicense Plate T OMNI k Yp ( )� ..�., � New License Plate _City Pollee _Sheriff _Municipal _School Bus _State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter Dletetype) �(4) Uehiclekl entificatlod Numbet(,VIN) '(P/ease enfe�Nt space"s be/ow) r �`EZ" Purchase or Lease Date(mmlftyyyy) Year Make Model Type Color Gross Vehicle Weight(if applicable) Description of Vehicle Official Business Usage(Law Enforcement Agency Financial Responsibility(Source of self-insurance or insurance company must include here if tactical or non-tactical vehicle.) name and policy number) The application Is for: (check one) , r{ * ,k. L�censecPlate TypW (check one) R New License Plate _City Police Sheriff _Municipal _School Bus State Owned University _Driver Education _Transfer an Existing License Plate: _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other: enter late e Page 2 of 3 Is "M 110 The entity shall Indicate which one(1)of the following classlflcatlons the entity belongs,thus entitling 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 classiflcation for which it qualifies for a municipal or law 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 of the 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 certified 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 ordlnance(s)that establishes the authority), i)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 ordinances)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 orresolution 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 nominal 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 offlclal letterfrom the Indiana Emergency Medical Services Commission.) 5. A rehabilitation center funded under IC 12.12 (Must be 11sted 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.) 8. A community mental health center(IC 12-29-2) (Must provide a copy of the Division of Mental Health and Addiction's certificate to operate In Indiana as a community mental health center.) For Law Enforcement License Plate(only available to these entities pursuant to 1C 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 pollee department The authorized representative submitting this application swears or affirms under the penalty of pedury 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 vehicla(s)and uses it for official business pursuant to IC 9-18-3-1. A municipal license plate issued to a vehicle shall be permanently attached to the vehicle listed in this application In accordance with IC 9-18-3-4. Date(month,day,year) SI ture of autho ize en rapt sentative PQ,I -- Typed or printed title of entity representative Typed or printed name of entity repre a ative Office telephone number of entity representative � Print Foam_;r i APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA • BUREAU OF MOTOR VEHICLES State Form 44049(R4 13-02) Approved by State Board of Accounts 2002 TO BE COMPLETED 13YAPOLICE OFFICER,BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE IIWE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA- FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM- TION ENTERED ON THIS FORM IS CORRECT.I/WE UNDERSTAND INED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS. THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI- VEHICLE IDENTIFICATION NUMBER TUTE THE CRIME OF PERJURY. FUTHERMORE, I/WE AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY l lr i�( P �' it IABILITYARISING M THIS TRANSACTION. YR. MAKE MODErLTYPE DATE x &3®7 15 �pQ� c�tS CS �.�al °5�17�2urj� X INSPECTORS PRINTED NAME&TITLE CITY DATE: T-/,.L dfi I I The law requires That you apply for Certificate of 7111e within thirty-one days from the date of purchase of e 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 on- DEALER P 7E NO. domed Tides,liens must be released.Supporting documents surrendered with this application cannot be returned to the appli- r GIS cant.'In accordance with Federal Code 383. , TITLE NUMBER BRANCH NO INVOICE Nb. BMV USE ONLY 1. 'SOC.SECJFEDERAL I.D.NO. APPLICANTS NAME BMV USE ONLY 2' City of Carmel STREETADDRESS CITY STATE ZIP CODE 3' One Civic Square Carmel 11N 46032 VEHICLE I.D.NUMBER VEH.YEAR �VEH.MAKE VEH.MODEL NO.VEH TYPE ODOMETER 4' 1 FDXE4FS4FDA06784 015 FORD ted VAN 1000003 FORMER TITLE NUMBER 1 PURCHASE DATE LIEN SPEED PICK UP MAIL IFET197V USE ONLY 6' ©04/28/15 © NO FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS STREET ADDRESS 6. CITY STATE ZIP CODE BMV USE ONLY 7. SECOND LIEN'S NAME STREETADDRESS a. CITY STATE ZIP CODE LICENSE NUMBER LICENSE FORMS I BMV USE ONLY 9. YEAR USED GROSS RETAIL&USE TAXAFFIDAVIT-IME HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW. SELLING PRICE LESS TRADE-IN• AMOUNT SUBJECT TO TAX I AMOUNT OF TAX DEALER BRANCH EXEMPT JIFEXEMPT 10. $ $ $ $ PLACE PARAM 'Your Social Security number/Federal I.D.number is being requested by this agency under IC 4-181. 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 f7 PHYSICAL INSPECTION OFA VEHICLE OR WATERCRAFT r- �° �o State Form 39530(R5/1211) f q>> dptYrdved by_State Board of Acco�nts' 011 f INRIANA Bl7REAU OF MOTOR VEHICLES INSTRUCTIONS: 1. Approved inspector must complete information in blue or black ink or print form. 2. The vehicle identification number(VIN)or hull identification number(HIN)must be inspected to verify the existence and condition of the number.An ownership document is not required to be submitted for inspection. 3. Inspections may be performed by an employee of a dealer designated by the Indiana Secretary of State,a military policeman assigned to a military post in Indiana,a police officer,or a designated employee of a BMV full or partial service license branch. 4. Police officers completing this form may not charge a fee of more than$5.00 for vehicles.No fee may be collected for watercraft inspections.Authorized Indiana dealers and BMV full or partial service license branches may not assess a fee. 5. Dealers may not perform watercraft inspections. a ' � �` �• �°� ��' � �_ n I��'(�FORMATIO � ''��t �*meg, � '. y� •. ,r�'.4r^"� :.;xs H...�.3"�•u��. Y!.ry_.�3 � °?k ?'� ,t 4�.N:+�.��kG .�: Name(last,first,middle Initial or company name 9) City of Carmel Utilities Address(number and street) 1 Civic Square city State ZIP Code Carmel IN 146032 �.��� `��� � � �a�/EH1hClE OR�WAT,ER$CRAFaT�INFO'`itMATION ��"`�'�"` ' '"" °'' `•*" �.,.d@'?' "�'t�)����� r�`^�d 4s��L`r3r'�•,�'�`�,•i�#p� ,�`'Y'$R'k'te V.. ,�,}� >...:� � � ,�r��sr„f ' .� ,.:t,. �9 ..�,: _'rca �.- F ..:.,. ?� d". i m-. ,. ” ``, �-e �".:�, rr +� t s rvY:et, s` �,. s S' �... 5' zur �.' �.•s3 C +ice fiCd(IOR,Numbe��-i:'X;�'Ott.��� rH':,t:y'r�^zs :r,"s.._�' u�'�'�-°, .,h axe" ,n:YLr,�rs�<'a'r��• ,�.k ':" � µ ''.>..�^" �}_�;5� ry£�.��iw-"..7'�".S.'S ".r�fe,r w,.� +_}���.: -_..,.�:a�_„�_,.t-._ ,;: ><w�� �. :� �Fk�,�� � x�, ���� �,��� � ~?� a❑ NOS nen .o .,-.Y4.. .����s.t.. o�:�.�-�, ,� .n .r.,•4�.M.,�_,tE4 .•�,� � ���..u;:,, �.NE(se/e�ct;fnoa�denhfcahos: u�be�found�a 1 F D X s E 4 F S 4 F D A 0 6 7 8 4 A: '�W y" - 7g' ftiFnber'+ a ,! s s a V�(atercra )2egistratio . Statwa;;t� R niJumbef:rf?a licable�"� r? 2015 FORD E450SD CUTAWA VAN rYl ' �For,a`ssembled vehicles or,watercraft�ncludetserl�altnumberssfor,txta�orr�comp ne t�parts�tf „resent �5, 6#z.;�t•rwazi kS: >`�YH.,._?r+ td�.". 2-. ..:.s.-v ..,.....s>t -,xY,.:vs,� ,.�,.,�x+e>diza�.@,i.�, �:rw. "tr. <�.,.:�...:,• s�,�i'a a_-r,,,�-�,.r:��s 63,u�£'+�d,:�}i a.�tF'.$:-�:L���r E.,.x�Jk:'d ri�.�'i�� rrr�' Engine/Motor 3 Transmission Body Chassis Front Assembly Rear Clip Frame Other(specify): ,.'+ .,;:ate 't ! +x�. ;?.,,. t'U�.,.' ,..r..,;�t�•:�tx L r: a'`4, �•".: � � ^� :�, s � ��� 4 sxs r s. �IpAC,Ss/,NCIC Checka a utredJ ifto �s cam le#e. �a� t � # � ��e` � � ` r , �� ����� w� '�s���'+ •>���I �n »��',� �4 s (F 9 , f� r.�;,, P � .�by poi c�of�esr)d ,;�• � � �� �„ t,fi ,�„ `�, :�� .�,M�� ,�_ .��'��E,ra.�w� is �sDate('fleck B�°4+��C�.ii �Yh �S.,.M�k�a�'•;W,��"'� '�,Mi��Ii�Y Px�f�� t,Rr vt,�„ e�i�-s::fix. ii z,"'�,�Y,yy< �'� �� 3nal���»k k¢. r � I a lau '¢ ea'6. f�+� S y !„� ,+ rfomted(mm/dd/yyyy) Comments '�`� �" '&, `'<.. {A� :.:fix ,�, i�� �' j,?^,'� '�``• � ��,G�-'Ra#`� �;fi" 2 �i� rtt it � i. l'swe�a''or affir'rt tha the'tnformat nkl have ente aecl on this fo"rm We r ect l'Un"derstantl makin a alse statement co 116'e, he crime oIV erg Signature of Inspector Printed Name ,b Title Date( m/dd/yyyy) a Badge/Branch/Dealer Number Police Department/Branch/Dealership City ZIP Code 1?3j Telephone Number Email Address ( 3 `�) 6-7 i MICHIGAN DEPARTMENT OF STATE ODOMETER MILEAGE STATEMENT www.Michigan.gov/sos (See Reverse Side for Leased Vehicles) Federal law and section 233a of the Michigan Vehicle Code require that you state the mileage in connection with the transfer of ownership. Failure to complete or providing false statement may result in civil liability, fines and/or imprisonment. Year Make Model 2015 FORD L) Body Style Vehicle Identification Number TRUCK 1FDXE4FS4FDA06784 I (we) certify that the odometer reading is: [0] E R [0] FO] [3] (No Tenths) And certify that to the best of my knowledge the odometer mileage is: actual mileage Check One * not actual mileage - WARNING - ODOMETER DISCREPANCY Ijexceeds mechanical limits of odometer (5-digit odometer has rolled over) * Note: Mileage cannot be corrected at a later date. Name of Seller(s)(Please Print) Jack Doheny Companies, Inc Address PO Box 609 City State Zip Code Northville MI 48167 Sign of Seller(s) Date X Name of Purchaser(s)(Please Print) City of Carmel Address One Civic Square City State Zip Code Carmel IN 46032 "I am aware of the-above odometer certification made by the seller(s)." Signature(s)of Purchaser s) Date PUre.l��s�r►�- f��ev�f g 17-S71 BDVR-108(09/07) Authority granted under Public Act 300 of 1949 as amended. Form Indiana Department of Revenue �'`�•n--.�, ST-108E Certificate of Gross Retail or Use Tax State Form 48841 (R4/3-08) EXEMPTION for the Purchase of a pare Motor Vehicle or Watercraft NAME OF DEALER Dealer's RRMC#(Registered Retail Merchant Certificate Number) Jack Doheny Supplies, Inc. I 0125668465 I 1 001 TID#(10 digits) LOC#(3 digits) Dealer's FID#(Federal Identification Number,s digits) Dealer's License Number(seven digits) 38-2026979 1101074 Address of Dealer City State Zip Code 4937A Fieldstone Drive Whitestown IN 46075 NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TID,OR FID#(Mandatory) City of Carmel Address of Purchaser City State Zip Code One Civic Square- Carmel IN 146142 Vehicles Identification Information of Purchase VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) Year Make Model/Length 1 FDXE4FS4FDA05784 T201 5 FORDy��b Calculation Of Purchase Price Trade.in Information 1. Total Purchase Price......................... 1. 204,200.00 VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) 2. Trade-Allowance Like-kind exchanges only) 2. 0.00 Year Make Model/Length 3. Net Purchase Price 204,200.00 (Line 1 minus Line 2)......................... 3. 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 exemption#15 was actually collected by the dealer and the dealer has not provided the buyer with a check to be paid to the BMV.I understand that making a false statement on this form may constitute the crime of perjury. Pi,rAQs'n Date Signature of Purchaser - C ✓1�"� l fTA � ONE AND THE SAME PERSON AFFIDAVIT - State Form 13637(R313-14) �a INDIANA BUREAU OF MOTOR VEHICLES an *This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1;disclosure is mandatory and this record cannot be processed without it. INSTRUCTIONS: 1. A person,as defined by Indiana Code§9-13-2-124(6),may present this affidavit to clarify any differences or discrepancies between an owner(s)name as indicated on a title and/or registration application. This includes individuals and business entities. 2. Complete in blue or black ink or print form. ONE AND THE SAME PERSON AFFIRMATION Name(last,first,middle initial or company name) Name(last,first,middle initial or company name) Jack Doheny Companies, Inc Jack Doheny Supplies, Inc Social Security Number*or Federal Identification Number(last four digits) Social Security Number*or Federal Identification Number(last four digits) 38-2026979 38-2026979 Address(number and street) Address(number and street) PO Box 609 4937A Fieldstone Drive City State ZIP Code City State ZIP Code Northville MI 48167 Whitestown IN 46075 I swear or affirm that, upon my oath,the information I have entered on this form is correct and the persons named above are one and the same person. I understand that making a false statement may constitute the crime of perjury. Signature of Affiant Printed Name Date Signed(mm/dd/yyyy) VOUCHER # 155620 WARRANT # ALLOWED 79627 IN SUM OF $ BUREAU OF MOTOR VEHICLES Watercraft Renewal Center 1009 W. Main St. Carmel, IN 46032 Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code TK 52 38 505 01-7500-02 $109.50 Voucher Total $109.50 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 79627 BUREAU OF MOTOR VEHICLES Purchase Order No. Watercraft Renewal Center Terms 1009 W. Main St. Due Date 6/5/2015 Carmel, IN 46032 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 6/5/2015 TK 52 38 50' $109.50 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