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Home My WebLink About302111 08/22/16 r Cqq- ^°4<�- '�F. CITY OF CARMEL, INDIANA VENDOR: 370964 j; d ONE CIVIC SQUARE DUBOIS CHEMICALS CHECK AMOUNT: $**'**'*597.85' r, :° CARMEL, INDIANA 46032 2659 SOLUTION CENTER CHECK NUMBER: 302111 9.y._..,...p.` CHICAGO IL 60577-2006 CHECK DATE: 08/22/16 t riON� DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2201 4232100 IN-1472063 597.85 GARAGE & MOTOR SUPPIE VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995) DUBOIS CHEMICALS ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 2659 SOLUTION CENTER IN SUM OF$ CITY OF CARMEL An invoice or bill to be properly itemized must show:kind of service,where performed,dates service CHICAGO, IL 60677-2006 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $597.85 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# Street Department 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 IN-1472063 42-321.00 $597.85 1 hereby certify that the attached invoice(s),or 7129/16 IN-1472063 $597.85 2201 201 2201 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 Tuesday,August 09, 2016 Dave Huffman Director 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 distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer INVOICE DuiB: 01S 3630 EAST KEMPER RD,SHARONVILLE,OH 45241 TEL(800)543-4906/FAX(800)543-1720 DUNS 82-823-5445/FED TAXPAYER I.D.80-0244824 Sold To Account#: LEI-815041 Ship To Account#:LEI-815041 CARMEL STREET DEPT CARMEL STREET DEPT ATTN:ACCOUNTS PAYABLE CARMEL STREET DEPT 3400 W 131 st St 3400 W 131 st St Westfield, IN 46074 8267 Westfield, IN 46074 8267 Invoice# : IN-1472063 Date: 712912016 Sales Rep: LUENSMAN,JOHN Tax Exempt#: Sales Order#: SO-2469610 Terms: Net 3.0 Days-- P.0. #: _ - ---JAMES BENTLEY- - Page 1 SHIP DATE NET WEIGHT DESCRIPTION SELLING UNITS UNIT PRICE CONTAINER PRICE QUANTITY NET AMOUNT 7/13/2016 403.00 BIOSOLV.055 55 GL 10.8700 $597.85 1 $597.85 Bio—Sole 55G Drum SUB TOTAL $597.85 TOTAL INVOICE NET WGT 403.00 CIT TAX $0.00 TOTAL INVOICE GROSS WGT 428.00 LOCAL TAX $0.00 TOTAL IN OICE ORDER GROSS WGT 428.00 STATE TAX $41.85 Invoice# : IN-1472063 PLEASE REMIT THIS AMOUNT $639.70 Remit To DuBois Chemicals 2659 Solution Center Chicago, IL 60677-2006 We accept Visa,MasterCard,and American Express. Please contact Accounts Receivable at 800-543-4906 to pay by credit card. Invoice Terms and Conditions are available at www.duboischemicals.com Form ST-105 Indiana Department of Revenue State Form 49065 R4/8-05 General Sales Tax Exemption Certificate Indiana registered retail merchants and businesses located outside Indiana may use this certificate.The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not for purchases from Indiana vendors.This exemption certificate can not be issued for the purchase of Utilities. Vel+ieles, atercra t,or Aircrgff Purchaser must be registered with the Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unless all information in each section is fully completed by the purchaser.Purchasers not able to provide all required j information must pay the tax and may file a claim for refund(Form GA-110L)directly with the Department of Revenue. »'r Name of Purchaser CITY OF CARMEL Business Address ONE CIVIC SQUARE city CARMEL State INZip 46032 Purchaser must provide minimum of one ID number below.* Provide your Indiana Registered Retail Merchant's Certificate 4a9 0031201550 — 020 TID and LOC Number as shown on your Certificate............................... ' 3 its 10 TID# di ( digits) LOC#(3 digits) i If not registered with the Indiana DOR,provide your State Tax IDNumber from another State................................................................ gy 3 *See instructions on the reverse side if you do not have either number. State ID# State of Issue = Is this a ®blanket purchase exemption request or a [3single purchase exemption request? (check one) ;td- '`Q. Description of items to be purchased. Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain) i KfflU❑ Sales to a retailer,wholesaler,or manufacturer for resale only. I Sale of manufacturing machinery,tools,and equipment to be used directly in direct production. M =am C3 Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin#10. IV (May not be used for personal hotel rooms and meals.) 4:33 i ❑ Sales of tangible personal property predominately used(greater then 50 percent)in providing public transportation-provide USDOT#. A person or corporation who is hauling under someone else's motor carrier authority,or has a contract as a school bus operator,must j }o provide their SS#or FID#in lieu of a State ID#in Section#1. USDOT# CI Sales to persons,occupationally engaged as farmers,to be used directly in production of agricultural products for sale. gRy Note:A farmer not possessing a State Business License#may enter a FID#or a SS#in lieu of a State lD#in Section#1, i ® Sales to a contractor for exempt projects(such as public schools,government,or nonprofits). Ma j ® Sales to Indiana Governmental Units(agencies,cities,towns,municipalities,public schools,and state universities). CI Sales to the United States Federal Government-show agency name. Note:A U.S.Government agency should enter its Federal Identification Number(FID#)in Section#1 in lieu of a State ID#. 3;r ❑ Other-explain. i Y Y P perjury property P Y P { I hereby certify under the penalties ofthat theurchased b the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act,Indiana Code 6-2.5,and the item purchased is not a utility,vehicle,watercraft,or aircraft. etwY= vq I confirm my understanding thh t-sgse,(either negligent or intentional),and/or fraudulent use of this certificate may subject both me personally and/or the business entity I p to the imposition of x,int a ,and civil and/or criminal penalties. :W Signature of PurchaserDate 1/1/2016 Printed Name CHRISTINE S. PAULEY Title CLERK-TREASURER The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller must keep this certificate on file to support exempt sales.