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Home My WebLink About249993 09/30/15 CITY OF CARMEL, INDIANA VENDOR: 360614 ® ONE CIVIC SQUARE BUREAU OF MOTOR VEHICLES CHECK AMOUNT: $******"*45.00* r CARMEL, INDIANA 46032 MUNICIPAL PROCESSING CHECK NUMBER: 249993 9M[rON�� 100 N SENATE AVE ROOM N415 CHECK DATE: 09/30/15 INDIANAPOLIS IN 46204 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4239099 45.00 OTHER MISCELLANOUS ,�"E"4r�re Ac APPLICATION FOR MUNICIPAL CORPORATION BUREAU OF MOTOR VEHICLES AND LAW ENFORCEMENT LICENSE PLATES Municipal Processing State Form 53565(R414-15) 100 North Senate Avenue Indiana Bureau of Motor Vehicles Room N415 Indianapolis,IN 46204 INSTRUCTIONS. 1. Complete in blue or black ink or print form. 2. Complete all information in sections 1,2,3,and 4,as applicable,and mail to the address listed above. 3. The application must be accompanied by a copy of each vehicle title,title application,or lease agreement if applying for registration only. 4. For a new license plate request,choose either the license plate type that is reflective of your entity,a standard passenger license plate,or other license plate type desired. 5. Indicate in Section 3 which of the municipal classifications applies to the entity named on this application. The entity must submit the'requested documentation or proof that the entity meets the indicated classification. 6. A safety inspection'must be completed by the Indiana State Police for all school bus plate applications. ,tr - y r t� agF3.RS� SECTION;1 PPLIANT NFORMAT,ION� g etR.ACI �_.f. .... :1� ..✓5 `$ .. _'2.r a .:»,Y... g'£.-ah. '•t '{y Name of Owner ' Federal Identification Number City of Carmel 356000972 Street Address of Entity(number and street) 1 Civic Square City State ZIP Code County Township Carmel IN 46032 Hamilton Clay Mailing Address(if different from street address) ! City State ZIP Code IN Name and Title of Entitys Executive Officer Telephone Number James Brainard, Mayor 317-571-2441 „,� �,�,��_a, ��°.��'L•isf�the,�followm"�'inforniationfor,�each'�vecfe Aftachadtlhonal,heetsifneeessa;"'��` s�'��;�`�yx,_;�� . `• Purchase or Lease Date mm/dd/ (1)`Vehicleadentification Number(VIN) (P/ease enEerin_spaces,below) �; • ( YYYY) 1 F' M C U 9 G X 6 G U A 5 5 3 0' 3 08/31/2015 Year Make Model Type Color Gross Vehicle Weight(if applicable) 2016 Ford Escape SE 4WD 4DR White 3547 lbs. 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) Official City Business Charter Oak Fire Insurance Co. H8103036P64ACOF15 The application is for: (check one) License Plate T e checkone New License Plate City Police —Sheriff ✓ Municipal —School Bus State Owned University —Driver Education ✓ Transfer an Existing License Plate: 68559 Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger —Other: enter platetype) Page I of 3 (2) Vehicle Identification Number(VIN):(Please enter in spaces below.) Purchase or Lease Date(mm/dd/yyyy) 1 IF I M C1 U1 9 G X 81GI 81GUJAJ 5 5-13 10 4 08/31/2015 Year Make Model Type Color Gross Vehicle Weight(if applicable) 2016 Ford Escape SE 4WD 4DR White 1 3547 Ibs. 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) Official City Business Charter Oak Fire Insurance Co. H8103036P64ACOF15 The application is for: (check one) License Plate Type (check one) _ , New License Plate _City Police Sheriff ✓ Municipal _School Bus State Owned University _Driver Education ✓ Transfer an Existing License Plate: 27780 _Law Enforcement Administrative (plate number) Or you may choose one of the following: _Passenger _Other. enter plate e _(3)'.Ve'hidle den'titiidat'ion.Number(VIN) (Please enter a„spaces'be/ow) Purchase or Lease Date(mm/dd/yyyy) 1 F M C1 U1 91 G X XI GI U A 5 5 3 0 5 08/31/2015 Year Make Model Type Color le Weight(!f applicable) 2016- Ford Escape SE 4WD 4DR White7�"3547 Ibs.- 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) Official City Business Charter Oak Fire Insurance Co. H8103036P64ACOF15 The application is for: (check one)-, " e: License Plate Type .(check one) 'rrt ✓ 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) (4)Vehicle Identificaton:Number(VIN) (Please enter in S.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) I en"se Plate`T a check one YP (� J 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 4` SECTION 3 ENTITY CLASSIFICATION - x _ �.E.:�Y..�"?.•-c{"-c� ._ �,.y,�'.E.,..0 L'rr>....x ,.>4.?.....r....w_.-;..! Please check one(1): 1.The State of Indiana a)a state agency b)a state university c)other state entity 2.Amunicipal 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 Department 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 ordinance(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 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 ora 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 official letter from the Indiana Emergency Medical Services Commission.) 5. A rehabilitation center funded under IC 12-12(Must be listed as rehabilitation center with the Indiana Rehabilitation Bureau and provide a letter from the Indiana Rehabilitation Bureau of the FSSAJ 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-Horne 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 Plates(only available to these entities pursuant to IC 9-18-3-6):(Must provide official identification showing the representative is employed with the entity.) a)The Indiana State Police Department b)A county police department c)A city or town police department " SECTION 4 AFFIRMATION The authorized representative submitting this application swears or affirms under the penalty of perjury that the information provided in this application is true n and correct,that the entity for which this application is made owns or leases the above listed vehicle(s)and uses it for official business pursuant to IC 9-18-3- 1. Signature of ed Representative Printed Name of Representative Date(mm/dd/yyyy) Jeremy Kashman 09/08/2015 Title of Representative Telephone Number of Representative City Engineer (317) 571-2441 Pave 3 of 3 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 State of Indiana-Bureau of Motor Vehicles Purchase Order No. Central Office Processing- 100 North Senate Avenue, Ro, Terms Indianapolis, IN 46204 Date Due Invoice Invoice Description Date Number (or note attached invoice(s)or bill(s) Amount 9/29/2015 0 Municipal Vehicle Titling and Registration $ 45.00 Total $ 45.00 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.. State of Indiana-Bureau of Motor Vehicles ALLOWED 20 Central Office Processing-100 North Senate Ave IN SUM OF$ Indianapolis, IN 46204 $ 45.00 ON ACCOUNT OF APPROPRIATION FOR Board Members Po#or INVOICE NO. ACCT#/TITLE AMOUNT DEPT# I hereby certify that the attached invoice(s), or 0 0 2200-4239099 $ 45.00 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 9/29/2015 Signature City Engineer Cost Distribution ledger classification if Title claim paid motor vehicle highway fund