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308407 2/22/17 � , <i ���`"� CITY OF CARMEL, INDIANA VENDOR: 371519 ��` ONE CIVIC SQUARE INDIANA DEPT OF REVENUE-SPECIAL TRb1ECK AMOUNT: $'"'""""175.00` a CARMEL, INDIANA 46032 PO Box 6080 CHECK NUMBER: 308407 +y«ON,.;� INDIANAPOLIS IN 46206-6080 CHECK DATE: 02/22/17 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2201 4358300 FUEL DECAL 175.00 OTHER FEES & LICENSES « « 0 R � O E � B § O U � 2 z ' � 0 n \ m \ c E q p 2 _ 7 o O t ° / ® z g R k m § > ƒ m 0 2 0 » % y c > / § \ \ § q � a © e 3 I 2 a � z \ O C: to | ■ k � g # ¥ a / FL = g � / x a f g - . � @ f ■ # � � ■ 9 \ R ƒ \ $ 2 & 3 ; 0 CD $ 7 k 23 % 2 4 a w a f g / Co k CD § | a E � to � o Q � / 7 CL M �J k § ® a ■ g 7 \ > J m i 0 g k j o z§ 0 \ o � 7 C a B � D Z ( 1c, 6� \� 0 $ § ( �k go g » > rn a� 2k 2 s m 2 < % ƒ C (Df f 2 c 2 { ƒ C o § 0 2 + ( m 0 o 0 \ 7 7 § m " \ CL U) 1p \ § § / n • tMailing/Contact Information: Form Indiana Department of Revenue Indiana Department of Revenue SF-801 Alternative Fuel Decal Application Special Tax Section State Form 46292 P.O.Box 6080 (R71 8-16) Indianapolis,IN 46206-6080 (317)615-2630 fetax@docin.gov Name(as shown on vehicle registration) Federal Identification or Social Security Number(must be provided) 3!5(1 Doc)�1 a Stre t dress City State ZIP Code r a. Telephone Number ' Email Address N»-`13.3-1Qoot al m to tr Registered Vehicle Year Make Model Date of Type Registered Vehicle Tax Rate Identification Purchase, of Gross Category from Rate Number Conversion, Fuel Weight Number Schedule or Used Reigistration 1.t V7 VEL'AbA tin 2. 3. 4. 5. 6. 7. 8. 9. 10. Keep a copy of this application in each vehicle until you receive the decals. Total Tax Due #t� GD Under penalties of perjury,I declare that I have examined this application and to the best of my knowledge and belief it is true, complete, and correct. A , 9 3 •� 7 QU1 0� Pri Name Date 1 '91g)wdure '-- ' i$ a 'nln:rc° ice° ,'i i ,�`ei,u _ _'. ".„p _ �s•a. r' -Q n�e Imp ii u 5e2 xr HE H -.6 , ���mw� "' e.•ii r° E. m e.. m'�.,oalnnr ,c,n._. - - Number of Decals Rate Tax Due Category Number From To 1 2 3 4 5 6L 44`HH j� ({ 1•If , C:. 'W p00 ` `CI[1if 'e@�a�'d'ercerc Vii,: To lGl 1 {�-i�li.IN i �tC .1�G etjC 9tl'0f1 I�,t6h1 666666 L•:[!„`= q-INrt'3 -mYSI e� ^� Tax Analyst Date