246846 06/30/15 �,q" CITY OF CARMEL, INDIANA VENDOR: 00350929
® 1 ONE CIVIC SQUARE INDIANA DEPT OF REVENUE ATTN:JANWECK AMOUNT: S*******131.25*
f'. CARMEL, INDIANA 46032 7811 MILLHOUSE ROAD SUITE P CHECK NUMBER: 246846
+,�,,roN�� INDIANAPOLIS IN 46241 CHECK DATE: 06/30/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2201 4358300 131.25 OTHER FEES & LICENSES
I
Form Indiana Department of Revenue
-i SF-801 Alternative Fuel Decal Application
State Form 46292
(R5/3-14)
Name(as shown on vehicle registration) Federal Identification or Social Security Number(must be
provided)
City of Carmel Street Department FED ID4 356000972
Addressity State ZIP Code
3400 W. 131ST STREET [CCARMEL IN 46074
Annual Motor Carrier or IFTA Permit Number(if applicable)
Registered Vehicle Year Make Model Current Date of Type Registered Vehicle Tax Rate
Identification Odometer Purchase, of Gross Category from Rate
Number Reading Conversion, Fuel Weight Number Schedule
or Used
Registration
1 1FTBF2B60FEC46708 2015 FORD F-250 73.1 6/23/2015 'ROPAN110,000LBS 3 $131.25
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Total Decals Ordered 1
Tax Due $131.25
For Department Use Only For Department Use Only
Category Number From To Check Amount Check Number
Keep copies of this application form in each vehicle until you
receive your decals!
Under the penalty of perjury, I have examined this return(including accompanying schedules and statements)and,to the best of my
knowledge and belief,it is true,complete,and correct
Taxpayer or Authorized Agent: Date: m-)ols Telephone Number: 312- 7.?3 -,Uav
Type or Print Name: Sa J/ 0 !d [L
' Title: Sh'(-e f CaP111-7 /;S/d�1P✓
Please Check Box If Last Filing Date Business Closed
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))
06/30/15 $131.25
1 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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Indiana Department of Revenue
Jamie
IN SUM OF $
7811 Milhouse Rd., Suite P
Indianapolis, IN 46241
$131.25
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. ACCT#/TITLE I AMOUNT Board Members
2201 I I 43-583.001 $131.25 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
fi Tu?sdayy J ne 30, 2015
Street Commiss r
Street OW1101110iner
Cost distribution ledger classification if
claim paid motor vehicle highway fund