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Home My WebLink About259628 06/14/16 CITY OF CARMEL, INDIANA VENDOR: 364085 ONE CIVIC SQUARE MADISON COUNTY COUNCIL OF GOVTSHECK AMOUNT: S".`""325.00` CARMEL, INDIANA 46032 16 E 9TH STREET CHECK NUMBER: 259628 9�,...._., ANDERSON IN 46016 CHECK DATE: 06/14/16 4 ETON� DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4357004 060816 325.00 EXTERNAL INSTRUCT FEE VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) MADISON COUNTY COUNCIL OF GOUTS ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 16 E 9TH STREET IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service ANDERSON, IN 46016 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $325.00 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# Engineering Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 0 43-570.04 $325.00 1 hereby certify that the attached invoice(s),or 6/8/16 0 Annual MS4 Registration Fee $325.00 2200 Q 201 _ 2200 201 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 Wednesday,June 08,2016 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 ,20— Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer 'INDqi .I _ j : AIIA' Ai N:UAL IiiS4 -EETIC Registration Fees Individual_Registration $65 Silver-Sponsor Registration $600 Platinum Sponsor Registration $1200 Please complete the following information: Name: .: Employer/Company Name Amount Due Kurt Anderson Carmel $ 65 :.John Thomas $ 65 Julia Litchford $65 Chris Ogg : $ 65 Aaron Hoover $65 Total Amount Due. $325 Make checks payable to: Madison County Council ofGovernments MCCOG TID00002012189 Mail checks and a copy of this invoice.to: Attn:Jan Ford—2016_lnd.iana Annual.MS4 Meeting Madison County Council of Governments e , 16 E. 9tn St. / Anderson, IN 46016 Questions: Phone: 765.641.9482 \ EAEL jan@heartlandmpo.org �IT`(EN�INEER c NOTE: ALL REGISTRATION/SPONSOR FEES MUST BE RECEIVED BY MAY 13, 2016 OR THE REGISTRATION WILL BE CANCELLED.-IF YOU HAVE A LOCAL POLICY/REQUIREMENT THAT YOU NEED TO ATTEND THE EVENT BEFORE SUBMITTING REGISTRATION PAYMENT,THE INDIVIDUAL WILL NEED TO PAY AND SUBMIT FOR REINBURSEMENT THROUGH THEIR EMPLOYER. THE STATE BOARD OF ACCOUNTS.DOES NOT REQUIRE ATTENDANCE_BEFORE PAYMENT. Form Request for Taxpayer Give Form to the (Rev.August 2013) requester.Do not Oecartmentof the Treasury Identification Number and Certification send to the IFAS. Internal Revenue Serr`ce Name(as shown on your income tax return) Madison County Council of Governments N Business name/disregarded entity name,if different from above m 01 Ca ca Check appropriate box for federal tax classification: Exemptions(see instructions): m A ❑Individuat/sole proprietor ❑ C Corporation ❑S Corporation ❑ Partnership ❑ Trust/estate e o Exempt payee cads(1 any) ❑ Umiled liability company.Enter the tax classification(C=C ccrperal!on,S=S corporation,P=partnership)i Exemption from FATCA reporting 0 ar code(f any) a t Q Other(see Instructions)s Governmental Unit v Address(number,street,and apt,or suite no.) Requester's name and address(optional) U C16 E 9th Street,Room 10O m City,state,and ZIP code m u) Anderson,IN 46011 List account number(s)here(optional) Taxpayer Identification Plumber(TIN) Enter your TIN in the appropriate box,The TIN provided must match the name given on the"Name"line social security number avoid backup withholding.For individuals,this is your social security number However,for a re peg -m resident alien,sole proprietor,or disregarded entity,sea the Part I instructions on page 3,For other entities,It is your employer identification number(EIN).If you do not have a number,see Hove to get a 77N on page 3. Note.if the account is in more than one name,see the chart on page 4 for guidelines on whose Employer Identification number number to enter. 1 7 4 8M75 Certification Under penalties of perjury,I certify that: 1. The number shown on this form is my correct taxpayer Identification number(or-I am waiting for a number to be issued to me),and 2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that 1 am no longer subject to backup withholding,and 3. 1 am a U.S.citizen or other U.S,person(defined below),and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross cut item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the Instructions on page 3. Sign Signature of /�• Mere U.S.person Date General InstrUCt S withholding tax on foreign partners'share of effectively connected income,and 4.Certify that FATCA code(s)entered on this form(if any)Indicating that you are Section references are to the nt al Revenue Code unless otherwise noted. exempt from the FATCA reporting,is correct. Future developments.The I has a..led a page on iFIS.gov for information Note.I1 you are a U.S,person and a requester gives you a form other than Form about Form N!-9,at www.lrs.gov/w9,Information about any future developments W,9 to request your TiN.you must use the requester's form If it is substantially affecting Form W-9(such as legislation enacted after we release It)will be posted similar to this Form W-9. on that pegs. Definition of a U.S..person.For federal tax purposes,you are considered a U.S. Purpose of Form person it you are: A person who is required to file an information return with the IRS must obtain your "An individual who Is a U.S.citizen or U.S.resident alien, correct taxpayer Identification number(TIN)to report,for example,income paid to °A partnership,corporation,company,or association created or organized in the you,payments made to you in settlement of payment card and third party network United States or under the laws of the United States, transactions,real estate transactions,mortgage interest you paid,acquisition or .An estate(other than a foreign estate),or abandonment of secured property,cancellation of debt,or contributions you made to an IRA. •A domestic trust(as defined In Regulations section 301.7701-7). Use Forth W-9 only If you are a U.S,person(including a resident alien),to Special rules for partnerships.Partnerships that conduct a trade or business in provide your correct TIN to the person requesting it(the requester)and•when the United States are generally required to pay a withholding tax under section applicable.to: 1446 on any foreign partners'share of effectively connected taxable Income from 1.Certify that the TIN you are giving Is correct(or you are waiting for a number such business.Further,in certain cases where a Form W-9 has not been received, to be issued), the rules under section 1446 mclulre a partnership to presurris that a partner is a foreign person,and pay the section 1446 withholding tax.Therefore,if you are a 2.Certify that you are not subject to backup withholding,or U S.person that is a partner in a partnership conducting a trade or business in the 3.Claim exemption from backup withholding it you are a U S_exempt payee.If United States,provide Form W-9 to the partnership to establish your U.S.status applicable,you are also certifying that as a U.S.person,your allocable share of and avoid section 1446 withholding on your share of partnership income. any partnership Income from a U.S,trade or business is not subject to the Cat.No,10231X Form VV-9(Rev.8-2013)