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307374 1/20/17 CITY OF CARMEL, INDIANA VENDOR: 358894 CHECK AMOUNT: S'""""""236.90• ONE CIVIC SQUARE SAFELITE FULFILLMENT INC ?� CARMEL, INDIANA 46032 PO BOX 633197 CHECK NUMBER: 307374 •y CINCINNATI OH 45263-3197 CHECK DATE: 01/20/17 LION DEPARTMENTACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 651 5023990 236.90 01830-272791 N N m O m LL 0UJ D co d UJ O i J � 8i I- o Z 04 Z .� N Z i+ p ft fl >% CO cc p a UJ N 3 LO �Lf) + a co LL 16- co J M Q Q o N rnt �k LL (,,, a p o c WcoQp Z >� � 2 '= XZ V � V cl W 0 COU. V z :ftn �j Ln or) U p COa � � SAFELITE FULFILLMENT,INC. �w� CUSTOMER SERVICE CENTER 1-800-835-2257 w7 AutoGiass IF YOU HAVE ANY QUESTIONS REGARDING PAYMENT OF THIS INVOICE: 1-800-835-2092 INVOICE 01830-272791 INVOICE: 12/14/16 BD __. ...� r.. . _,.� . ._ �, ORDERED: 12/14/16 INSTALLED: 12/14/16 PLEASE REMIT PAYMENT TO: W.O. # : 797214 REFERRAL#: 000000 SAFELITE FULFILLMENT, INC INSURED: P.O. BOX 633197 CARMEL, CITY OF CINCINNATI, OH 45263-3197 211 2ND ST SW PLEASE WRITE INVOICE NUMBER ON CHECK CARMEL IN 46032-0000 PH1:317-716-5882 PH2 : CARMEL, CITY OF Acct #: 936912 211 2ND ST SW CARMEL IN 46032 POLICY# PO#/REF : S16765 CLAIM # 168 LOSS LOC: AUTH/VER: JEFF LOSS DATE/CAUSE: 12/14/16 2016 FORD F SERIES F2 2 DOOR SUPE ARR: INSTORE MILEAGE: 111 VIN: 1FT7X2B66GED14983 LICENSE/ST: 40752 IN STOCK #: 168 QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION 1 DQ09331 YPN 173.74 178.95 50.00 .00 .00 228.95 SOLAR-RIGHT-MOVABLE-REAR ACCESS DOOR-3 H 1 DISPOSAL FEE 4.95 .00 7.95 .00 .00 7.95 DISPOSAL FEE PART TOTAL 178.95 LABOR TOTAL 57.95 SUB-TOTAL 23 0 SALES TAX ���� QQ 12�I`� P A Y T H I S A M O U N T E TERMS: NET 30 ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/ SAFELITE AUTOGLASS # 01830 INDIANAPOLIS IN 46268-0000 SAFELITE TAX ID #: 36-4523816 122816-936912-936912 00318-936912-272791 CARMEL, CITY OF 211 2ND ST SW CARMEL IN 46032 00001-537-THW -954