HomeMy WebLinkAbout304477 10/31/16 VENDOR: 371231
CHECK AMOUNT: S""'30,275.16"
CITY OF CARMEL, INDIANA ARBY'S RESTAURAUNT GROUP CHECK NUMBER. 304477
10131116
ONE CIVIC SQUARE 1155 PERIMETER CENTER WEST CHECK DATE:
ATLANTA GA 30338
s= CARMEL, INDIANA 46032 DESCRIPTION
'+• .oNAMOUNT
30,275.16 RIGHTS-OF-WAYS
DEPARTMENT 15VOI�E NUMBER
ACCOUNT PO NUMBER
202 4460500
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Carmel 2016 Bond Projects
Request for Payment
Project Name Carmel Dr.&Rangeline Rd.Roundabout
City Project Number 15-12
DES Number,if applicable 1296021
Project Parcel Number 3(001)
Owner Name Arby's
Hamilton Co.Tax I.D.Number
State Tax I.D. Number 29-09-36-000-028.000-018
Payee Name Arby's
Payee Address 1155 Perimeter Cricle West
City Atlanta,GA
Zip 30338
Relocation Business Self Move 6,180.16
PAYMENT TOTAL: 6,180.16
Owner Signature:
SPECIAL INSTRUCTIONS:
G APPROVAL SIGNATURES
Jeremy Kashman,P.E.
City Engineer
Christine Pauley
Clerk Treasurer
rev 071216 10:40am -
Prescribed by State Board of Accounts City Form No.201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL, INDIANA
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
Arby's Purchase Order No.
1155 Perimeter Center West Tern
Atlanta, GA 30338 Date Due
Invoice Invoice Description
Date number or note attached invoices or bills Amount
7/29/2016 PROJECT: 1296021
PARCEL: 3 001
Relocation Entitlement: Business Self-Move Misc PP $6,180.16
X
X
Six-thousand-one-hundred-eighty and 16/100 Total l • (LD
I 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
• y zti 120 ll- Sk'Ap . ZtAt E57+.f
11 3 Signature Title
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
Clerk-Treasurer
REAL ESTATE CODE PCI.
Form W'9 Request for Taxpayer Give Form to the
(Rev.December2014) Identification Number and Certification requester.Do not
DepartmentoftheTreasury send to the IRS.
Internal Revenue Service
1 Name(as shown on your Income tax return).Name is required on this line;do not leave this tine blank.
Arby's Restaurant Group
2 Business name/disregarded entity name,if different from above
NyF
n
ke
a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
wc certain entities,not individuals;see
Individualfsole proprietor or �C Corporation �S Corporation Partnership Trust/estate Instructions on e 3
ru c (single-member LLC l r !meg )
CL o Exempt payee code Of any)
w -Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P-partnership)►
p �
--'Note.For asingle-member LLC that Is disregarded,do not check LLC;cheek the appropriate box in theline a6weT0-r
Exemption from FATCA reporting
e the tax classification of the single-member owner. code(if any)
d v
0 other(seeinstructions)► (Mares 1.Mcow smsar.NwowsresaauS)
5 Address(number,street,and apt.or suite no.) Requesters name and address(optional)
a 1155 Perimeter Center West
m 6 City,state,and ZIP code
rn Atlanta, GA 30338
7 List account number(s)here(optional)
Taxpayer Identification Number TIN
Enter your TIN in the appropriate box.The TiN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see 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 How to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
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 I 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 out 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 retum.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 pag2 3.
Sign Signature of
Here U.S.person► I Date►8/2/16
General Instructions •Form 1098(home mortgage interest),1098-E(student loan Interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. -Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release IQ is at wwwArs.gov/Av9.
Use Form W-9 only If you are a U.S.person(Including a resident alien),to
Purpose of Form provide your correct TIN.
An Individual or entity(Forth W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer Identification number(TIN) to backup withholding.See What is backup withho(ding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number(ITiN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(E IN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of Information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
-Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.if
•Form 1099-DIV(dividends,Including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your afiocabfe share of
any partnership Income from a U.S.trade or business is not subject to the
•Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
-Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)Indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
-Form 1099-5(proceeds from real estate transactions) page 2 for further information.
-Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form till(-9(Rev.12-2014
Rangeline Rd 3 (001) Arby' s Move Bid INVENTORY ONLY-NO EQUIPMENT
Ametic" Superior Moving&Storage,Inc. Low Bid
flfAff NAII (800) 455-3500 (765) 362-6804
World Wide Movers ESTIMATE/ORDER FOR SERVICE
DATE 6/22/16 PHONE (H) 317-408-1224 (Cell)
W
SHIPPER Arby's ADDRESS 1224 S Rangeline Rd
Carmel, IN 46032
DESTINATION Carmel,IN
INTRASTATE CHARGES
EST WEIGHT 6000 lbs LBS. 50 MLES CWT
Cost to move chemicals
included(Mover does not
move chemicals) $200.00
OTHER INDIANA FUEL SURCHARGE 6% $195.29
INSURANCE SURCHARGE 2% $65.10
Refrigerator Trailer Rent 2 Days $485.00
Freezer Trailer Rent 2 Days $520.00
LOCAL CHARGES***
PER
TRANSPORTATION 1 VANS 3 KEN $116.24 HR 28 HRS $3254.72
PER
PACKING LABOR MEN HRS HR $0.00
CONTAINERS &PACKING MATERIALS
DISH PACK 3 @ $48.45 = $145.35 CRIB MATT 0 @ $18.00 = $0.00
1.5 CU, SM 37 @ $12.75 = $471.75 SGL MATT 0 @ $38.85 = $0.00
3.0 CU, IVE 18 @ $17.75 = $319.50 DBL MATT 0 @ $19.75 = $0.00
4.5 CU, LG 8 @ $21.40 = $171.20 K/Q MATT 0 @ $46.95 = $0.00
6.0 CU, XL 0 @ $16.75 = $0.00 MRR/PIC 5 @ $34.75 = $173.75
WARD 0 @ $37.35 = $0.00 Gfather Box 0 @ $32.00 = $0.00
MISCELLANEOUS
$0.00 $0.00
TOTAL CONTAINERS &PACKING MATERIALS $1281.55
MONTHLY STORAGE(IF NECESSARY) $0.00
Valuation#NX $21000.00 FULL VALUE,NO DEDUCTIBLE $178.50
TOTAL ESTIMATED CHARGES $6180.16
Per inventory date 02/08/2016 as provided by relocation personnel.
*"NOTE•THIS IS ONLY AN ESTIMATE. UNDERSTAND THE FINAL CHARGES COULD BE MORE OR THEY COULD BE LESS.
TOTAL CHARGES ARE PREDICATED ON ACTUAL HOURS WORKED,INCLUDING DRIVE TIME.OUR CREW
WILL DO AS MUCH OR AS LITTLE AS YOUR PREFER,AND WILL CHARGE BY THE HOUR.
#WNOTE-IN LIEU OF ANY DECLARED VALUE,CARRIERS MAXIMUM LIABILITY IS.60 CENTS PER POUND PER
ARTICLE,PROVIDED AT NO ADDITIONAL COST. THIS IS NOT INSURANCE. IF YOU WISH TO
DECLARE A SHIPMENT VALUE TO ESTABLISH MINIMUM CARRIER LIABILITY,A QUOTE WILL BE
PROVIDED FOR YOU. IF YOU ARE MORE COMFORTABLE W ITH INSURANCE COVERAGE,
CONTACT YOUR HOMEOWNERS AGENT FOR DETAILS.
YOUR SIGNATURE ACKNOWLEDGES YOU HAVE RECEIVED ACOPY OF THE ESTIMATE/ORDER FOR
SERVICE,AND WISH FOR THIS CARRIER TO PERFORM SERVICES AS DESCRIBED HEREIN.
SIGNED DATE
CITY OF CARMEL, IN
BID SPECIFICATIONS
Bidder Superior Moving&Storage,Inc. Bidder Phone (765)362-6804
Displacee Arby's(Joe Davitt-Manager) Project Rangeline Rd
Address 1224 S Rangeline Rd.,Carmel,IN 46032 Code LPA Parcel 3 001
Displacee Phone (317)408-1224 Displacee Email jdavitt@arbys.com
Bid specifications for moving personal property belonging to the displacee above, located at the address above,
as shown in the attached inventory dated 2/8/2016:
1.Follow only those instructions provided by the City of Carmel, IN Right of Way Agent(s) when preparing
the bid.
2.I nclude in the bid costs for moving only the personal property items in the attached inventory.
3.Bid must itemize costs associated with disconnects, disassembly,reconnects,reassembly,and resetting.
4.Bid must itemize costs associated with packing loading (at displacement location), and unloading (at
replacement location) all personal property.
5.Bid shall be based on mo ving items no more than 50 miles from the present location.
6.Bid must include breakdown of cost components(labor,materials,equipment,etc.)
7.Bid must include full replacement value insurance coverage with no deductible.
8.An y charges for preparing the bid shall be on a separate invoice and shall be submitted with the bid. Invoices
submitted later may not be honored.
9.Bid must include the following statement: "Per inventory dated 2/8/2016 as provided by relocation
personnel."
10. Other specifications/instructions: Submit bid fee invoice with mov o not bid tables chairs
booths or any a ui ment. Bid to include restaurant inventory ous items only.
Specifications prepared on 2/8/2016 by
Date Joe Gromosky,Right of Way Agent
Right of Way Agent's Phone# (371) 650-5489 Email jg(a)boomerangventures.com
Fax: (317)348-4155
Bidder's Certification:
I hereby acknowledge receiving a copy of thesespecifications and the inventory identified above. I have inspected
the items on the inventory and WAS (circle one)accompanied by the Right of Way Agent.
I understand that my bid will be used to determine the reasonable and necessary cost of relocating the personal
property involved. I will be prepared to perform this move as specified for the amount of my bid. I will prepare
this bid openly and independently without knowledge of other bids. Any knowledge I have of other bids will be
stated on my bid. It is the responsibility of the displacee to select the Professional Mover of their choice. The
City of Carmel will be the third party payor up to the amount of the low bid.
6/22/16 Lisa K Guckes
Date Lisa Guckes
Carmel 3 (001) Arby' s Move Bid INVENTORY ONLY-NO EQUIPMENT
. 4"nol d t High Bid
Wo�'tld Class Relocation "_~_1___1
LOCAL MOVE ESTIMATE
Displacee Arby's (Joe Davitt- Project Rangeline Rd
Manager)
Address 1224S Code LPA Parcel 3(001)
Rangeline
Rd.,
Carmel, IN
46032
Displacee Phone (317) 408-1224 Displacee Email jdavitt@arbys.com
Prepared by A. Arnold World Class Relocation
3/15/16
Move date TBD
Packinq & Containers
$3,685.00
Relocation Proiect
2 drivers /2 straight trucks/ 1 Project manager
6 movers @ $ 320 HR x 14 hours plus travel time
$ 5,120.00
Valuation Option:
Full Replacement Valuation $ 680.00
NOT TO EXCEE"9,485.00
Notes:
Per Photo Inventory dated 2/8/16 as provided by relocation
personnel.
Carmel 3 (001) Arby' s Move Bid
NOTES & CONDITIONS:
• Service Provider will have reasonable access to conduct continuous moving
operations within the scope and time frames outlined herein
• All services are based on four hour minimum and one hour travel time
• Service Provider will not be encumbered by working in conjunction with other
contractors or facilities restrictions
• Service Provider will not be required to delay operations while in progress or
be required to handle the contents of the move on multiple occasions
• Service Provider will be moving only the furniture, fixtures, supplies and
materials made known to service provider at the time of this estimate
• Packing and labeling of contents will be performed by A. Arnold Relocation
Contacts:
Robert Rhodes
Robert.rhodesC&-a-arnold.com
A. Arnold World Class Relocation
317-870-5777 - Indianapolis Offices
The Order for Service will be forwarded from our corporate offices to confirm this
move
Itemized Packing
CITY OF CARMEL, IN
BID SPECIFICATIONS
Bidder A Arnold World Class Relocation Bidder Phone (317)870-5777
Displacee Arby's(Joe Davitt-Manager) Project ,Rangeline Rd
Address 1224 S Rangeline Rd.,Carmel,IN 46032 Code LPA Parcel 3 001
Displacee Phone (317)408-1224 Displacee Email jdavitt@arbys.com
Bid specifications for moving personal property belonging to the displacee above, located at the address above,
as shown in the attached inventory dated 2/8/2016:
1. Follow only those instructions provided by the City of Carmel, IN Right of Way Agent(s)when preparing
the bid.
2. Include in the bid costs for moving only the personal property items in the attached inventory.
3. Bid must itemize costs associated with disconnects,disassembly,reconnects,reassembly,and resetting.
4. Bid must itemize costs associated with packing, loading (at displacement location), and unloading (at
replacement location)all personal property.
5. Bid shall be based on moving items no more than 50 miles from the present location.
6. Bid must include breakdown of cost components(labor,materials,equipment,etc.)
7. Bid must include full replacement value insurance coverage with no deductible.
8. Any charges for preparing the bid shall be on a separate invoice and shall be submitted with the bid.Invoices
submitted later may not be honored.
9. Bid must include the following statement: "Per inventory dated 2/8/2016 as provided by relocation
personnel."
10.Other specifications/instructions: Submit bid fee invoice with move bid. o not bid tables chair
booths or atty gquipment.Bid to include restaurant inventory an s aneous items only.
Specifications prepared on 2/812016 by
Date Joe Gr osky,Right of Way Agent
Right of Way Agent's Phone# (371)650-5489 Email jg@boomerangventures.com
Fax: (317) 348-4155
Bidde?s Certification:
I hereby acknowledge receiving a copy of ns and the inventory identified above. I have inspected
the items on the inventory and WAS WA�N� (
circle one) accompanied by the Right of Way Agent.
I understand that my bid will be used to d sonableand necessary cost of relocating the personal
property involved. I will be prepared to perform this move as specified for the amount of my bid. I will prepare
this bid openly and independently without knowledge of other bids. Any knowledge I have of other bids will be
stated on my bid. It is the responsibility of the displacee to select the Professional Mover of their choice. The
City ofCar el will a the third party payor up to the amount of the low bid.
NAG- Robert Rhodes
Boomerang Ventures, LLC Mail - Fwd: LPA Rangeline Rd - Carmel P3(001)Arby's: Mo... Page 1 of 2
t Teri Prevatt<tp@boomerangventures.com>
Fwd: LPA Rangeline Rd - Carmel P3(001) Arby's: Move bids for approval -
Need for Friday Meeting
1 message
Ande Gromosky<ag@boomerangventures.com> Thu, Jul 28, 2016 at 11:27 AM
To: Teri Prevatt<tp@boomerangventures.com>
---Forwarded message-----
From: Wagner,Suzi<SWAGNER@indot.in.gov>
Date: Thu, Jul 28, 2016 at 9:07 AM
Subject: RE: LPA Rangeline Rd-Carmel P3(001)Arby's: Move bids for approval-Need for Friday Meeting
To:Ande Gromosky<agCia boomerangventures.cam>
Cc: "Stout, Beverly-INDOT"<BSTOUT a@indot.in.gov>
(:Superior Moving approved for Low Bid of$6,180.16
FYI Des #1296021
From:Ande Gromosky[mailto:ag@boomerangventures.comj
Sent:Wednesday,July 27, 2016 4:04 PM
To:Wagner,Suzi<SWAGNER@indot.IN.gov>
Cc:Stout, Beverly-INDOT<BSTOUT@indot.IN.gov>
Subject: LPA Rangeline Rd-Carmel P3(001)Arby's: Move bids for approval-Need for Friday Meeting
..I.n s s an rE::X.t..ERNAL ..mail. Exeinse cau`ion. DO NO opera atr;r;hnlents r click, links f-,rn >.inknown
senders or unexpccte'01 email, ..at
Suzi and Bev,
Joe is planning to meet Arbys for the move out on Friday. We finally have both move bids.
All items accounted for.
Thanks!
https:Hmail.google.com/mail/u/0/?ui=2&ik=3c9938fDba&view=pt&search=inbox&th=156... 7/28/2016
Boomerang Ventures, LLC Mail - Fwd: LPA Rangeline Rd - Carmel P3(001)Arby's: Mo... Page 2 of 2
Ande
Ande Gromosky
Boomerang Ventures, LLC
411 E Northfield Dr,#426
Brownsburg, IN 46112
Cell: (317)435-6004
Fax: (317) 348-4155
Ande Gromosky
Boomerang Ventures, LLC
411 E Northfield [fir, #426
Brownsburg, IN 46112
Cell: (317)435-6004
Fax: (317) 348-4155
https:Hmail.google.com/mail/u/0/?ui=2&ik=3c993 8fDba&view=pt&search=inbox&th=156... 7/28/2016
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
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Arby's Trash cans
3 4
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Picture Picture/high chairs
5 6
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Personal Property Photos Page 1 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
7 8
Food/dining inventory only Food/dining inventory only
9 10
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Trash can Food/dining inventory only
11 12
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Food/dining inventory only Food/dining inventory only
Personal Property Photos Page 2 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
13 14
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15 16
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17 18
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Personal Property Photos Page 3 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
19 20
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Personal Property Photos Page 4 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
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Personal Property Photos Page 5 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
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Personal Property Photos Page 6 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
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Personal Property Photos Page 7 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
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Personal Property Photos Page 8 of 9
Pictures taken:02/08/16 Project:Rangeline Rd,Code:LPA,Parcel:3(001)
Inventory of Personal Property
Arby's
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Personal Property Photos Page 9 of 9
Carmel 2016 Bond Projects
Request for Payment
Project Name Carmel Dr.&Rangeline Rd.Roundabout
City Project Number 15-12
DES Number,if applicable 1296021
Project Parcel Number 3(001)
Owner Name Arby's
Hamilton Co.Tax I.D.Number
State Tax I.D. Number 29-09-36-000-028.000-018
Payee Name Arby's
Payee Address 1155 Perimeter Cricle West
City Atlanta,GA
Zip 30338
Relocation Business Self Move 24,095.00
PAYMENT TOTAL: 24,095.00
,.
Owner Signature:
SPECIAL INSTRUCTIONS:
., i% H Cl if 1�1APR(tVl tG, URES, r
Jeremy Kashman,P.E.
City Engineer
Christine Pauley �--'
Clerk Treasurer
rev 071216 10:40am
l,:
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201 (Rev. 1995)
CITY OF CARMEL, INDIANA
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
Arby's Purchase Order No.
1155 Perimeter Center West Tern
Atlanta, GA 30338 Date Due
Invoice Invoice Description
Date number or note attached invoices or bills Amount
7/29/2016 PROJECT: 1296021
PARCEL: 3 001
Relocation Entitlement: Business $24,095.00
X
Twenty-four-thousand-ninety five and no/100 Total 2-`1 .OciS,00
I 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
�
—
=1 L) 2y 20 1 �i:•�)r �c!fl_ CSir4i
Signature Title
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
Clerk-Treasurer
REAL ESTATE CODE PCL
Form W'9 Request for Taxpayer Give Form to the
(Rev.Dec tofthe real Identification Number and Certification requester.Do not
Departrtarttoflhe7teasury send to the IRS.
Internal Revenue Service
1 Name(as shown on your Income tax return).Name Is required on this line;do not leave this line blank.
Arby's Restaurant Group
kV 2 Business name/disfegarded entity name,if different from above
Fn
M
r 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
UO Individualfsolsproprietor or C C certain entities,not Individuals;see
Corporation 4S Corporation Partnership Trust/estate y c r p Instructions on page 3):
❑; " le member LLC ® '❑t I❑ ❑'
EL oExempt payee code(if any)
❑iLimited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)�
Note.For asingle-member LLC that Is disregarded,do not check LLC;check the appropriate box in the line above for
Exemption from FATCA reporting
the tax classification of the single-member owner, code(if any)
= e Other see instructions ►
tl �, Q' ( ) (Appisa to oxgNsm�FN aW ow US.)
5 Address(number,street,and apt.or suite no.) Requesters name and address(optional)
0 1155 Perimeter Center West
d 6 City,state,and ZIP code
in Atlanta, GA 30338
7 List account number(s)here(optional)
Taxpayer Identification Number TIN
Enter your TIN In the appropriate box.The TIN provided must match the name given on line 1 to avoid Social security number
backup withholding.For individuals,this is generally your social security number(SSN).However,for a
resident alien,sole proprietor,or disregarded entity,see 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 How to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer Identification number
guidelines on whose number to enter.
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 I 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 out 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
Here U.S.person► / M Date►8/2/16
General Instructions •Form 1098(home mortgage interest),1098-E(student loan Interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. -Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release 11)is at www.irs.gov//w9.
Use Form W-9 only If you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An Individual or entity(Form W-9 requester)who is required to file an information it you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer Identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
Identification number(EIN),to report on an information return the amount paid to to be Issued),
you,or other amount reportable on an Information return.Examples of Information
returns include,but are not limited to,the following: 2.Certify that you are not subject to backup withholding,or
-Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding if you are a U.S.exempt payee.If
-Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership Income from a U.S.trade or business is not subject to the
Form 1099-MISC(various types of income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected income,and
-Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)Indicating that you are
brokers) exempt from the FATCA reporting,is cored See What is FATCA reporting?on
-Form 109"(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form w-9(Rev.12-2014
Carmel 3 (001) Arby' s Move Bi Equipment O
Inventory o 'ersonal Property
Arbys #7113
Items to move Cost to move items Items to move
1 All Pictures&Chairs $500.00 41 DT Headsets
2 Lobby Drink station&Ice Machines $2,000.00 42
3 DT Drink Station $1,000.00 43
4 Lobby Condiment Counter $500.00 44
5 POSBOS Equipment $2,500.00 45
6 Bathroom-Trash cans, &misc. $500.00 46
7 Turnover Displays&Chutes $100.00 47
8 Coffee Machine $200.00 48
9 Makeline $2,000.00 49
10 Fronline Menu Board $1,000.00 50
11 Frontline Counters& Shelves $500.00 51
12 Shake Machine&Table $500.00 52
13 DT Counters& Shelves $200.00 53
14 Fry Dump Station&Shelf $400.00 54
15 Fryers $500.00 55
16 Fryer Hoods-Fryers and oven $3,000.00 56
17 Fry Freezer $200.00 57
18 Ovens $400.00 58
19 Ice Machine $600.00 59
20 Office Area $150.00 60
21 All Shelves in Back of Store $500.00 61
22 Dish&Prep Sinks $600.00 62
23 Hand Sinks -Fronline and Backline $300.00 63
24 Microwaves-3 of them $100.00 64
25 Smallwares $300.00 65
26 Toaster-3 of them $200.00 66
27 Cheese Pump $25.00 67
28 Slicers-2 of them $300.00 68
29 Beef Holding Cabinet $100.00 69
30 Cook n Hold ovens $150.00 70
31 Prep Table $100.00 71
32 Bun Racks $50.00 72
33 Shelve above Prep Table $150.00 73
34 Shelves in Walk-in Cooler $300.00 74
35 Shelves in Walk-in Freezer $300.00 75
36 Pepsi Shelve-All Parts $700.00 76
37 Grease Tank-Fry oil $1,500.00 77
38 CO2 Tank $500.00 78
39 Employee Lockers $150.00 79
40 AuJus Pot $20.00 80
Grand Total
Cost to move items
$1,000.00
$24,095.00
Teri Prevatt<tp@boomerangventures.com>
LPA 1296021 P3(001) Arby's: Business Self-Move Inventory Only voucher
packet
2 messages
Ande Gromosky <ag@boomerangventures.com> Mon, Aug 1, 2016 at 12:18 PM
To: "Wagner, Suzi" <swagner@indot.in.gov>
Cc: Ryan Perry <rperry@crossroadengineers.com>
Bcc: tp@boomerangventures.com
Suzi,
Here is a BSM voucher packet for Arby's inventory items only.
Voucher on its way to Mr. Perry.
Thanks,
Ande
Ande Gromosky
Boomerang Ventures, LLC
411 E Northfield Dr, #426
Brownsburg, IN 46112
Cell: (317)435-6004
Fax: (317) 348-4155
Carmel 3(001)Arby's Packet BSM-Equip.pdf
159K
Ande Gromosky <ag@boomerangventures.com> Mon, Aug 8, 2016 at 2:10 PM
To: Teri Prevatt<tp@boomerangventures.com>
- — Forwarded message----
From: Wagner, Suzi <SWAGNER@indot.in.gov>
Date: Thu, Aug 4, 2016 at 3:09 PM
Subject: FW: LPA 1296021 P3(001)Arby's: Business Self-Move Inventory Only voucher packet
To: Ande Gromosky <ag@boomerangventures.com>, "Joe Gromosky- Boomerang Ventures
Qg@boomerangventures.com)" <jg@boomerangventures.com>
Cc: "Wagner, Suzi" <SWAGNER@indot.in.gov>
Per my conversation with Ande G......
Charging to Actual cost move....approved for$24,095.00.
Need additional documentation showing that
Arby's is charging 24,095.00 for the move and that
Arby's requires to move and have their own movers.
Any questions feel free to contact me.
suzi
Thank you,
Suzi Wagner
LPA Right of Way Specialist
100 N.Senate Ave. N642
Indianapolis, IN 46204
Office:(317)-232-5061
Fax:(317)-233-3055
Email:swag ner(aD_indot.in.gov
YOO 0 Iridialna
From:Ande Gromosky[mailto:ag@boomerangventures.com]
Sent: Monday,August 01, 201612:18 PM
To:Wagner, Suzi<SWAGNER@indot.IN.gov>
Cc: Ryan Perry<rperry@crossroadengineers.com>
Subject: LPA 1296021 P3(001)Arby's: Business Self-Move Inventory Only voucher packet
,..,.,.x.
Tris is an EXT�..PNA er lafl. Exercise ca:i:ion. O NO7 auraen atl-�chry)e.-s or cI:c; I r)ks fr^T uknow-
senders or t.nexpected elTlail. y
�....... .............._...._._.___.............. ...._...._............._..............._..---------.........__.........................................._........................................................................__.........._.._.._...._...................................................__..._.......................
[Quoted text hidden]
[Quoted text hidden]
Carmel 3(001)Arby's Packet BSM-Equip.pdf
159K
Pictures taken:02/08/16 Project:Rangeline Rd,Code: LPA,Parcel: 3(001)
Inventory of Personal Property
Arby's
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Personal Property Photos Page 1 of 13
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Personal Property Photos Page 2 of 13
Pictures taken:02/08/16 Project:Rangeline Rd,Code: LPA,Parcel: 3(001)
Inventory of Personal Property
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Personal Property Photos Page 3 of 13
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