308564 02/28/17 q; �! CITY OF CARMEL, INDIANA VENDOR: 360614 HECK AMOUNT: $""""""""15.00'
q ONE CIVIC SQUARE INDIANA BUREAU OF MOTOR VEHICLE
CARMEL, INDIANA 46032 100 N SENATE AVE ROOM N415 CHECK NUMBER: 308564
,M INDIANAPOLIS IN 46204 CHECK DATE: 02/28/17
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STATE OF INDIANA
B V. Michael R. Pence, Governor R. Scott Waddell, Commissioner
MUNICIPAL, ADMINISTRATIVE, AND LAW ENFORCEMENT
TITLE AND REGISTRATION APPLICATION CHECKLIST
Municipal,Administrative, and Law Enforcement title and registration applications are processed by BMV
Municipal Processing to improve the security and efficiency of these transactions. Prior to submitting
each application, please verify t h at all required information is included. Contact (888) 692-
6841 with any questions.
Title Application Requirements
M/Completed and signed Application for Certificate of Title—State Form 44049
d Original Certificate of Title or Certificate of Origin
❑ Physical Inspection of a Vehicle or Watercraft—State Form 39530. Required for vehicles
purchased outside of Indiana.
C,3/Odometer Disclosure Statement—State Form 43230, if odometer statement is not completed on
the certificate of title or certificate of origin. Trailers and motor vehicles over 16,000 lbs exempt.
I/Certificate of Gross Retail or Use Tax Exemption—ST108E
❑ $15 title application fee. Fees are payable by credit card (MasterCard or Visa), check, electronic
check, or money order. A$21.00 delinquent fee will be assessed on packets received 31 days
after the purchase date listed on the certificate of title or certificate of origin.
Registration Application Requirements
Application for Municipal,Administrative, or Law Enforcement License Plates—State Form 53565
❑ Report of School Bus Inspection (required for school bus applications)
❑ Copy of title or title application (if all ready titled to applicant)
If the Bureau of Motor Vehicles determines that sufficient credible evidence exists to substantiate the
applicant's claim of ownership, a title and registration will be issued. For your convenience, the required
forms are included with this checklist. The forms are also available at myBMV.com. Mail the completed
packet to:
Central Office Municipal Processing
100 North Senate Avenue, Room N415
Indianapolis, IN 46204
Note: Include this checklist on the top of your application with contact information provided
below. If all required documents are not submitted or information is incomplete the entire
application will be returned.
Print Name KC, Lu si; g
Phone Number 3l-:k- 51 I — 2432—Email (optional) klustig 0 co-r-r el. 1r,.90V
An Equal Opportunity Employer
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DATEiin
{:
DECEMBER 13,2 016 INVOICE NO.
UC54521 0
I VEHICLE IDENTIFICATION NO. YEAR
1FMCU9GD4HUC54521 MAKE
2017 FORD
BODY TYPE �.
�< - 105 ESCAPE SE 4WD 4DR SHIPPING WEIGHT
3577 LBS.
J I H.P.(S.A.E.) G.V.W.R,
15.48 4760 LBS N0.CYLS. SERIES OR MODEL ;
4 U9G7
NOMINAL TONNAGE 1/2 �:
CERTIFIED FOR SALE IN CALIFORNIA
�; 1!the undersigned authorized representative of the coni
tify that the new vehicle described above is the properhelsaid companyt,firm or�corpb mat on and iser- ,
transferred on the k;Fabove date and under the Invoice Number indicated to the following distributor or dealer.
f NAME OF DISTRIBUTOR,DEALER,ETC.
I
I� Pearson Ford, Inc.
10650 North Michigan Road
Zionsville IN 46077
( It is furth�7F0certiffied that this was the first transfer of such new motor vehicle in ordinary trade and
com51,merce.
} merce.
MEMO DATA
---------------------- B 4 3 2 6 ; .
FORD MOTOR 5
FINANCE SOURCE 000001 COMPANY
BY r ti�u��OIG..D�
W;qFord Motor Credit Co P 0 JONATHANARYBOX 1732, Room . , (AGENT)
r Dearborn MI `
48121 DEARBORN MICHIGAN
CITY-STATE
� _1.1111
_ _ 1 ll 111 111
. ':
J
Oar-
APPLICATION FOR NEW AND/OR TRANSFERRED BUREAU OF MOTOR VEHICLES
Municipal Processing
MUNICIPAL, ADMINISTRATIVE AND LAW ENFORCEMENT 100 North Senate Aveue
• >' LICENSE PLATES Room N415
*�+• State Form 53565(R2/8-11) Indianapolis,IN 46204
INDIANA BUREAU OF MOTOR VEHICLES
INSTRUCTIONS 1.Complete in blue or black ink or print form.
2.Complete application with all information in sections 1,2,3,and 4 as applicable and mail to the address listed above.
3. The application must be accompanied by a copy of each vehicle title,title application,or lease agreement.
4.A safety inspection completed by the Indiana State Police must accompany all school bus requests.
SECTION 1.APPLICANT INFORMATION
Official Name of entity that owns or leases the vehicle(s) State Board of Accounts number Federal Identification Number
CITY OF CARMEL 1 2930323 356000972
Entity's Executive Officers name and title Entity Telephone number
JAMES BRAINARD, MAYOR 317 571-2400571-2400
Entity street address(number and street)
1 CIVIC SQUARE
City State Zip Code County Township
CARMEL IN 46032 HAMILTON CLAY
SECTION-2.VEHICLE INFORMATION ..
Irstahe.folio"win "information for'eacFt Vehicle;'attach additional sheets if necessa
1 VEHICLE IDENTIFICATION NUMBER: (please enter in spaces below) Purchase or lease date
1 F M C U 9 G D 4 1 H I U C 5 4 1 5 2 1 1 1 (mm/dd/yyyy) 01/17/2017
Color Type Make Model Year :LGss Vehicle
ght(if applicable)
Oxford White Ford Escape 2017 3577 lbs
Description of official business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;or Insurance
vehicle Company Name and Policy number)
Official City Business CHARTER OAK FIRE INSURANCE CO.-H8103036P64ACOF15
The application is for(check one) License Plate Type: check one
✓ New License Plate ✓ Municipal Sheriff School Bus
_Transfer an Existing License Plate: State Owned
(plate number) City Police Administrative University
2 VEHICLE IDENTIFICATION NUMBER: (please enter in spaces below) Purchase or lease date
(mm/dd/yyyy)
Color Type Make Model Year Gross Vehicle
Weight(if applicable)
Description of official business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;or Insurance
vehicle Company Name and Policy number)
The application is for(check one) License Plate Type: check one)
New License Plate Municipal Sheriff School Bus
_Transfer an Existing License Plate: State Owned
(plate number) City Police Administrative University
3 VEHICLE IDENTIFICATION NUMBER: (please enter in spaces below) Purchase or lease date
(mm/dd/yyyy)
Color Type Make Model Year Gross Vehicle
Weight(if applicable)
Description of official business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;or Insurance
vehicle Company Name and Policy number)
The application is for(check one) License Plate Type: check one
New License Plate Municipal Sheriff School Bus
_Transfer an Existing License Plate: State Owned
(plate number) City Police Administrative University
'SECTION 3.ENTITY CLASSIFICATION ..
The entity shall indicate which one(1)of the following classifications the entity belongs,thus entitling the entity to a permanent municipal license plate.
The entity must also submit the following requested written documentation or meet the requirements that establish that the entity meets the classification
for which it qualifies for a municipal or law enforcement license plate.Please check one(1):
1. The State of Indiana
a)a state agency,
b)a state university,or
c)other state entity
2. A municipal corporation(as defined in IC 36-1-2-10)"Municipal corporation"means any of the following:
✓ a)a county,city,town,or township,
b)school corporation(Must be listed as a school corporation with the Indiana Board of Education),
c)library district(Must be listed as a library with the Indiana State Library),
d)local housing authority(Must provide a certified copy of the ordinance(s)that establishes the authority),
e)fire protection district(Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security),
f)public transportation corporation(Must provide a certified copy of the ordinance(s)that establishes the corporation),
g)local building authority(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority),
h)local hospital authority or corporation(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority),
i)local airport authority(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority),
j)special service district(Must provide a certified copy of the resolution or ordinance(s)that establishes the district),
k)other separate local governmental entity that may sue and be sued(Must provide a certified copy of the statute,ordinance or resolution that
establishes the entity)
3.A volunteer fire department(as defined in IC 36-8-12-2)(Must be listed with the Indiana State Fire Marshall or Department of Homeland
Security and provide a copy of the contract or resolution to provide firefighting services for a county,city,town,or township.)
4.A volunteer emergency ambulance service that meets the requirements of IC 16-31 and has only members that serve for no
compensation or a nominal annual compensation of not more than$3,500.00.(Must be registered as a Volunteer Emergency Ambulance Service
with the Indiana Emergency Medical Services and provide an official letter from the Indiana Emergency Medical Services Commission.)
5.A rehabilitation center funded under IC 12-12(Must be listed as a rehabilitation center with the Indiana Rehabilitation Bureau and provide a
letter from the Indiana Rehabilitation Bureau of the FSSA.)
6.A community action agency(IC 12-14-23)(Must be designated by the Governor or under Federal law as a community action agency.)
7.An area agency of aging and the aged(IC 12-10-1-6)and a county council on aging that is funded through an area agency(Must
provide a copy of the contract with the Bureau of Aging and In-Home Services.)
8.A community mental health center(IC 12-29-2)(Must provide a copy of the Division of Mental Health and Addiction's certificate to operate in
Indiana as a community mental health center.)
For Law Enforcement License Plate(only available to these entities pursuant to IC 9-18-3-6):
(Must provide official identification showing the representative is employed with the entity.)
9.The Indiana State Police Department
10.The Indiana Department of Natural Resources
11.A county police department
12.A city or town police department
__.
;.SECTION 4.AFFIRMATION AND SIGNATURE
The authorized representative submitting this application swears or affirms under the penalty of perjury that the answers and information contained in this
application are true and correct,that the entity for which this application is made owns or leases the above listed vehicle(s)and uses it for official
business pursuant to IC 9-18-3-1.A municipal license plate issued to a vehicle shall be permanently attached to the vehicle listed in this application in
accordance with IC 9-18-3-4.
Date(month,day,year) Signat t d ent' representative Typed or printed name of entity representative
02/23/2017
Jeremy Kashman
Typed or printed title of entity repr tati Office telephone number of entity representative
Cit Engineer (317) 571-2441
APPLICATION FOR CERTIFICATE OF TITLE FOR A VEHICLE CUST#5712500
' 1 State Form 205(R9 17-16) DEAL#84766
Approved by State Board of Accounts,2016
INDIANA BUREAU OF MOTOR VEHICLES
•
*This agency is requesting disclosure of your Social Security Number I Federal Identification Number in accordance with IC 4-1-8-1;disclosure is mandatory,and this record cannot be
processed without it.
To be completed by a police officer,BMV official,or BMV certified dealer I swear and affirm that I am authorized to perform this transaction,and I agree
signee for out-of-state titles.I hereby certify that I personally examined the to indemnify and hold harmless the Indiana BMV from any and all liability
following vehicle and find the identification number to be as follows. arising from this transaction.
Vehicle Identification Number I swear and affirm that the information that I have entered on this form is
correct.I understand that making a false statement on this form may
constitute the crime of perju
1 F M C U 9 G D 4 H U C 5 4 5 2 1 Applicant Signature:
Year Make Model Type Date(mm/dd/yyyy)
2017 FORD ESCAPE 01/17/2017 Printed Name: CITY OF CARMEL
Inspector's Printed Name and Title City
Applicant Signature: N/A
Inspectols Signature Badge,Branch,or Dealer Plate Number Printed Name:
Date (mm/dd/yyyy): 01/17/2017
Transaction Number Branch Number Invoice Number BMV Use Only
Social Security Number/Federal Identification Number* Name of Applicant BMV Use Only
CITY OF CARMEL
Residence Address(number and street) City State746032-251814
Code
1 CIVIC So CARMEL IN
Vehicle Identification Number Vehicle Year Vehicle Make Vehicle Model Vehicle Type Odometer
1 FMCU9GD4HUC54521 2017 FORD ESCAPE 7
Former Title Number Purchase Date(mm/dd/yyyy) Lien(Y/IV) Speed(YIN) Dealer Number BMV Use Only
01/17/2017
Holder of First Lien,Mortgage,or Other Encumbrance/Special Mailing Address Mailing Address(number and street)
q �h_ v S 4co
City StatetJ ZIP Code BMV Use Only
r AL 35203
Holder of Second Lien,Moqjge,or Other Encumbrance Mailing Address(number and street)
City State ZIP Code T77 ber License Year Forms Used BMV Use Only
Gross Retail and Use Tax Affidavit—IIWe hereby certify that sales or use tax on this vehicle was paid as indicated below.
Selling Price Less Trade-In/Discount Amount Subject to Tax Amount of Tax Dealer Branch Exempt Exemption Code
$ 22483.00 $ N/A $ 22483.00 $ N/A
53715*1*FI
A
ODOMETER DISCLOSURE STATEMENT 84766
State Form 43230(R3 15-13)
►, INDIANA BUREAU OF MOTOR VEHICLES
ins �
INSTRUCTIONS: f. In accordance with federal and state law, the seller of a motor vehicle must disclose the current mileage to a purchaser in
writing upon transfer of ownership. The disclosure must be signed by the seller,including the printed name. If more than one
person is a seller,only one seller is required to sign the written disclosure.
2. The purchaser must sign the disclosure statement,including printed name and address,and return a copy to the seller.
3. Complete this form in its entirety,in blue or black ink.
Federal and State law requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false
statement may result in fines, imprisonment,or both.
I, PEARSON FORD, INC. residing at:
Printed name(s)of Seller(s)
10650 N. MICHIGAN RD.ZIONSVILLE IN 46077 certify to the best of my knowledge that the
Address of Seller(s)(number and street,city,state,and ZIP code)
odometer reading is the actual mileage of the vehicle described below unless one of the following statements is checked:
Miles(no tenths) ❑ 1. 1 hereby certify that to the best of my knowledge the odometer reading reflects the amount of
mileage in excess of its mechanical limits.
7 ❑ 2. 1 hereby certify that the odometer reading is NOT the actual mileage and should not be relied upon.
WARNING-ODOMETER DISCREPANCY.
Vehicle Make Vehicle Model Vehicle Year Vehicle Body Type
FORD ESCAPE 2017
Vehicle Identification Number(VIN) Transfer Date(month,day,year)
1 1 F I M I C I LI 1 9 1 G I D 1 4 1 H I U C 1 5 1 4 5 1 2T-1 01/17/2017
1 will not hold the Bureau of Motor Vehicles or the Bureau of Motor Vehicles Commission responsible for any discrepancy shown on
the odometer reading. I,the undersigned,swear or affirm that the information entered on this form is correct. I understand that
making a false statement may constitute the crime of perjury.
Signature(s)of Seller(s) Date(month,day,year)
01/17/2017
PURCHASER'S INFORMATION
I am aware of and acknowledge the above odometer certification made by the seller(s).
Signature(s)of Purchaser(s) Dale(month,day,year)
01/17/2017
Pri ame(s)of Purchaser(s)
CITY OF CARMEL
Address of Purchaser(s)(number and street)
1 CIVIC SO,
City State ZIP Code
CARMEL IN 46032-2584
Form Indiana Department of Revenue
ST-108E Certificate of Gross Retail or Use Tax
State Form 48841
(R4 13-08) EXEMPTION for the Purchase of a
Motor Vehicle or Watercraft
NAME OF DEALER Dealer's RRMC#(Registered Retail Merchant Certificate Number)
PEARSON FORD INC I 0001878190 I1 001
TID#(10 digits) LOC#(3 digits)
Dealer's FID#(Federal Identification Number,9 digits) Dealer's License Number(seven digits)
35.1053374 0401267
Address of Dealer City State Zip Code
10650 N MICHIGAN ROAD ZIONSVILLE IN 46077
NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TID,OR FID#(Mandatory)
CITY OF CARMEL
Address of Purchaser City State Zip Code
1 CIVIC SQUARE CARMEL IN 46032
Vehlcles'Identification Information of Purchase
VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) Year Make Model/Length
1 FMCU9GD4HUC54521 2017 FORD ESCAPE
Calculation Of Purchase Price 'x f� Trade in Information '
1. Total Purchase Price......................... 1.
22483.00 VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number)
2. Trade-Allowance N/A
(Like-kind exchanges only)................ 2. Year Make Modell Length
3. Net Purchase Price 22483.00
(Line 1 minus Line 2)......................... 3.
CALCULATION OF PURCHASE PRICE LINES 1 2&3 MUST BE COMPLETED FOR ALL EXEMPTED PURCHASES
NEW RESIDENT STATEMENT Must Be Completed if Exemption#8 is claimed,see reverse side.
I certify that I became a resident of INDIANA on(month&year)
My previous State of Residence was I hereby certify that the above statement is true and correct.
Date Signature of Owner
SALES/USE TAX WORKSHEET To be completed if Sales and/or Use Tax was paid to a state other than Indiana,Exemption#15.See reverse side.
Date of Purchase
1.Purchase price of property subject to sales/use tax..........................................................................1._$
2.Indiana sales/use tax due:Multiply Line 1 by sales/use tax percentage(7%)..................................2.
3.Credit for sales tax previously paid to another state..........................................................................3.
(Do not include flat fees,local,and/or excise taxes.)In what state was the tax paid?
4.Total amount due:Subtract Line 3 from Line 2. 4. $
(Line#3 can not exceed Line#2)
DIRECT RELATIVE IDENTIFICATION EXEMPTION(Must Be Completed if Exemption#11 is claimed,see reverse side).
Name(s)on original title Relationship of above parties
Name(s)being added/deleted
PUBLIC TRANSPORTATION EXEMPTION(Must be completed if exemption#6 is claimed and you are not a school bus operator.)
USDOT#(U.S.Department of Transportation Number)
1 certify that the above vehicle or watercraft is exempt from sales/use tax under exemption# SC (see reverse si e). I also certify
that any sales tax credit shown as paid to an out of state dealer using exemption#15 was actually collected by the dealer and the dealer has
not provided the buyer with a check to be paid to the BMV.I understand that ma a se statement on this form may constitute the crime
of perjury.
Date 1.17.2017 Signature of Purchaser \
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 valid for purchases from Indiana vendors. This exemption certificate can not be issued for the
purchase of IN"idVehicles FatgrcLa&or Aircraft, 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
information must pay the tax and may file a claim for refund(Form GA-110L)directly with the Department of Revenue.
e111, Name of Purchaser CITY OF CARMEL
2 Business Address ONE CIVIC SQUARE Cit, CARMEL State IN Zip 46032
'C Purchaser must provide minimum of one ID number below.*
Provide your Indiana Registered Retail Merchant's Certificate
X 0031201550
�- TID and LOC Number as shown on your Certificate............................... 020
TID#(10 digits) LOC#(3 digits)
If not registered with the Indiana DOR,provide your State Tax
ID Number from another State................................................................
*See instructions on the reverse side if you do not have either number. State ID# State of Issue
�o.
Is this a ®blanket purchase exemption request or a ❑single purchase exemption request? (check one)
Description of items to be purchased.
Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain)
❑ Sales to a retailer,wholesaler,or manufacturer for resale only.
❑ Sale of manufacturing machinery,tools,and equipment to be used directly in direct production.
❑ Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin#10.
(May not be used for personal hotel rooms and meals.)
❑ Sales of tangible personal property predominately used(greater then 50 percent)in providing public transportation-provide USDOT#.
s A person or corporation who is hauling under someone else's motor carrier authority,or has a contract as a school bus operator,must
o` provide their SS#or FID#in lieu of a State ID#in Section#l. USDOT#
{3
�y
r `❑ Sales to persons,occupationally engaged as farmers,to be used directly in production of agricultural products for sale.
Note:A farmer not possessing a State Business License#may enter a FID#or a SS#in lieu of a State ID#in Section#1.
❑ Sales to a contractor for exempt projects(such as public schools,government,or nonprofits).
x ® Sales to Indiana Governmental Units(agencies,cities,towns,municipalities,public schools,and state universities).
❑ 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#.
y [3 Other-explain.
I hereby certify under the penalties of perjury that the property purchased by 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.
o" I confirm m understanding tb t- se,(either negligent or intentional),and/or fraudulent use of this certificate may subject both me personally
Y 9 //
and/or the business entity I dpres to the imposition off�a�ic,int�hand civil and/or criminal penalties.
Signature of Purchaser ! uJ• �/ , Date 1/1/2016
?' CHRISTINE S. PAULEY
Printed Name 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 rile to support exempt sales.
BMV
Payment Information
Pay b,�:
Check or money order
❑ Credit Card(MasterCard or Visa)
❑ Electronic check
❑ I hereby authorize the Indiana Bureau of Motor Vehicles to charge the credit card indicated
below:
Type of card: ❑ MasterCard ❑ Visa
Name of cardholder:
Account
Number:
Expiration
Date:
❑ I hereby authorize the Indiana Bureau of Motor Vehicles to charge the checking account
indicated below:
Routing Number Account Number
An Equal Opportunity Employer