247628 07/20/15i
CITY OF CARMEL, INDIANA VENDOR: 355486
IV(9,
ONE CIVIC SQUARE INDIANA ALCOHOL & TOBACCO COMPHECK AMOUNT: S`""""`50.00`
CARMEL, INDIANA 46032 302 W WASHINGTON ST ROOM E114 CHECK NUMBER: 247628
INDIANAPOLIS IN 46204 CHECK DATE: 07/20/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1207 4355300 50.00 PERMIT
STA
� 9e 302 West Washington Street
o v IGCS Room El 14
STATE OF INDIANA Indianapolis,IN 46204
ALCOHOL AND TOBACCO COMMISSION Telephone 317/232-2430
Fax 317/234-1520
late www.IN.gov/atc
July 7, 2015
CITY OF CARMEL
12120 BROOKSHIRE PKWY
Carmel IN 46033
Notice of Missing information from the Alcohol and Tobacco Commission
-- - -- —
Permit-Number RR2903542 -
Your application is missing the following item(s) indicated below. Please submit the requested
information along with any forms attached to this notice. The following missing items must be filed
in sufficient time to process the application otherwise a request for extension will be required to be
filed. Failure to submit the following can result in delay or denial of your permit.
• Your permit renewals were not submitted 90 days prior to the expiration date. Please
complete the request for extension with the fee of 50.00 per 905 IAC 1-26-2 If the Request
for Extension is not submitted within 30 days after the expiration date you will need to
contact your local Excise office and schedule an inspection before an extension will be
granted.
If you have any questions, please contact us at (3)17) 232-2430.
Thank you in advance for your cooperation.
Please return a copy of this letter with correspondence.
Indiana Alcohol and Tobacco Commission
302 W. Washington Street Room E 112
Indianapolis; Indiana 46204
Phone: (3 17) 232-2430
Fax: (317) 234-1520
AN EQUAL OPPORTUNITY EMPLOYER
Form Revised 06/23/2010
o�STA If01
REQUEST FOR EXTENSION
Nc State Form 4125(R2/10-00 _Renewal Filed
Approved by State Board of Accounts,2000 _Fee paid
r t Sales tax paid
lNFORMATION,,:i::=`�::,;.
Permit name Permit number Expiration date
; i (3� 12 sa 7- ��
DDeu-]076)�
bss as — elephone number
W Cl u 3/7-���
Premise address(number and street,city,state,ZIP de)
1,,-2426 ,eoa �� G�
_ x.:,4,,5 -s leak"'::'.' "s, s;:sh,%.:...�j.,,:.:...,.'.:• E:: :%•J, :_.; - - -.l F: `, ..s_YE�:%• ..�,;;. .,%;,,Ey",.-
STEP2 APPL:ICANTINFORMATlONs;$`
Name of applicant
Address(number and street,city,state,ZIP code
Telephone#1 Telephone#2 Fax Number
Check one
❑ Sole-proprietor ❑ Corporate officer ❑ Partner Manager
:;.,..- 5
TEP;-3.REASON,F,;,OR:EXTENSION(Check`orie'and,,,pi-ovide reason)
need for an extension(or its renewal)is occasioned by the act or omission of the permittee or his agent thereof(eg.Attorney,accountant,
[2e
eparer,etc.). A$50.00 extension fee is required.
PAY BY CASHIER'S CHECK,CERTIFIED CHECK,BUSINESS CHECK,OR MONEY ORDER TO THE"INDIANA ALCOHOLIC BEVERAGE
COMMISSION" (PERSONAL CHECKS CANNOT BE ACCEPTED)
Reason:
S -
` The need for an extension or the renewal of an existing extension is occasioned by the act or omission of the Alcoholic Beverage Commission,a
❑local board:or an unrelated third party who is not an employee of the permittee nor under the control of the permittee.
Reason:
STEP 4: :SIGNATUREt%
.,
I affirm under penalties of perjury thol all statements in this request are true and that all sales taxes have been paid.
Signature_of•applicant Date(month,day,year)
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))
07/07/15 Extension Permit Extenision $50.00
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 Alcohol & Tobacco Commission
IN SUM OF $
302 West Washington Street, Room E 114
Indianapolis, IN 46204
$50.00
ON ACCOUNT OF APPROPRIATION FOR
Brookshire Golf Club
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
1207 I Extension I 43-553.00 I $50.00 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
Friday, July 17, 2015
Director, Brookshire Golf lub
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund