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ELEVATOR OPERATING CERTIFICATE INVOICE
ARMEL/CLAY BOARD OF PARKS & RECREATION 1411 E 116TH ST Pat Schlemmer CARMEL IN 46032
l.If Code =. * Annual test report is due before a permit is issued.
2.If Code = # A 5 year Test report is due before a permit is issued.
3.Over due fees must be paid before a permit is issued.
If elevator(s) are not in service please request an "ELEVATOR OUT OF SERVICE
AFFIRMATION" form.
State No.Code Due Over Due Location Address
111704 * $120.00 $ 0.00 1235 CENTRAL PARK DR EAST, CARMEL IN 46032
111978 * $120.00 $ 0.00 1235 CENTRAL PARK DR EAST, CARMELi ,IN 46032`
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Reference Number Invoice Date Please submit ENTIRE document with payment
734241-11292016 -1 11/29/2016 Unit(s) 2 Total Due upon receipt
of 2 $ 240.00 of $ 240.00
Owner id 734241
Ref.Num. :734241-11292016 - 1 $240 of $ 240.00 Invoice Date 11/29/2016
if Paying by check, include a check made payable to the Department of Homeland security. You can pay all your
payments online at IDHS web site https://myoracle.in.gov/dfbs/idhsFeesFines/start.do with Visa/Master
Card/Discover cards. Use Owner Id on this letter or State Number on the invoice to pull up information when
paying the dues online.OR complete the following information and return by mail :Indiana Department of
Homeland Security, Fiscal Department, 302 W.Washington St., Rm : E221,Indianapolis, IN 46204 or fax to
(317)233-0401. Questions? call(317)232-6427 or 8-mail:elevator-invoiceodhs.in.gov 2.25% convenience fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address: Street
City State Zip Code
CC type:Visa/Am.Express/Discover/Master Card ONLY (circle one)
Acct. Number
Exp.Date (mm/yy)
CVV2 Number Contact Phone Number Signature
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
Invoice Date 11/29/2016
Ref.Num. :734241-11292016 - 1 $240 of $ 240.00