314341 07/31/2017 4�,�,,,,F� CITY OF CARMEL, INDIANA VENDOR: 148000
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� ONE CIVIC SQUARE INDIANA DEPT OF TRANSPORTATION CHECK AMOUNT: $****41,114.11 41,114.11-
ONE
CARMEL, INDIANA 46032 100 N SENATE AVE,RM IGC-N 725 CHECK NUMBER: 314341
+,y, INDIANAPOLIS IN 46204-2216 CHECK DATE: 07/31/17
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DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
203 4462200 000041613 8,224.00 SIDEWALK IMPROVEMENTS
202 4350900 00041044 32,890.11 OTHER CONT SERVICES
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INDIANA DEPARTMENT OF TRANSPORTATION
�o Driving Indiana's Economic Growth INVOICE
100 North Senate Avenue
� Eric Holcomb,Governor
Room IGC-N 749
O. � ' Indianapolis, Indiana 46204-2216 Joe McGuinness,Commissioner
T
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Customer No: CST000001811
Bill To: Invoice: 000041044
Invoice Date: 4/26/2017
City of Carmel Invoice Type: LPA
ATTN: Jeremy Kashman
One Civic Square
Carmel IN 46032 AMOUNT DUE: $32,890.11
*** Payment is Due Upon Receipt of Invoice ***
Line Description Quantity Unit Amt Net Amount
1 Contract#R-35550 1.00 32,890.11 32,890.11
Project#1297165;Change Order 10.(See Attached)
Subtotal: 32,890.11
AMOUNT DUE: $32,890.11
Payment Options
See Reverse Side
"�-oZ - 4-3SO9V0
For billing questions, please call: 317-234-2869 Invoice: 000041044
• Online website: https://secure.in.gov/apps/dot/accountsreceivables/
• To create an account, use Customer* CST000001811
• To make a credit card payment by telephone, call either:317-232-5364 or
317-232-5388
• OR RETURN THIS PORTION WITH YOUR PAYMENT
Department of Transportation Invoice: 000041044
Attention:Agent Cashier
N749 IGCN Amount Paid:$ 3��8 q 0• t
100 N. Senate Ave.
Indianapolis, IN 46204
❑ Visa ❑ Mastercard ❑ Discover �Check/Money Order
Name on Card Card Number
(Name must appear as exactly as on card)
CID(3 or 4 digit security code) Expiration Date
Billing Address
Signature Required: Date
For billing questions, please call: 317-234-2869 Invoice: 000041044
rRilat
yse Or a Order# Date Required Date Page
Q1 Order COf$�1'UCtIOn 0017817920 04/19/2017 05/13/2017 1 of 1
apartment o II ransportation Requisition Number:0000168846
+tlwrovadbyEneempwLs -rshlpTwe-M1 VendorlD: 0000051089REMIT001
• Agency: 00800 Transportation _
Pay Terms: 35 Days in Arrears
Fund/Ob ect/Center: 6320015716201467030
Vendor 0000051089 REMIT001 2
RIETH-RILEY CONSTRUCTION COMPANY INC Ship To Dept Of Transportation
Remit to RIETH-RILEY CONSTRUCTION Construction Management
PO BOX 276 100 N SENATE AVE RM N925
INDIANAPOLIS IN 46206 INDIANAPOLIS IN 46204
RIETH-RILEY CONSTRUCTION COMPANY INC Bill To Transportation
Vendor RIETH-RILEY CONSTRUCTION Dept Of Transportation
Name PO BOX 276 Accounting =
Address INDIANAPOLIS IN 46206 100 N SENATE AVE RM N749 _
INDIANAPOLIS IN 46204
Vendor Name: Buyer Name:Tepner,Roger-800
Contact eMail:• eMail: RTEPNER@indot.IN.gov
Phone:
Purchase Order'Instructions&`Comments
PO Closed R-35550 DES 1297165 800129716500LC3 Other Intersection Improvement on ST1001 Intersection of 111th ST&
Pennsylvania ST Carmel IN in Hamilton County Greenfield District(FR-0031754 CN)
Purchase Order irine_Dstafls
Item No. Descri tion FOB Destination .` .. Ordered =' Recd UOM Unit Price': Extended Amt
1- 1 100%LOCAL NON-PARTICIPATING. 1.0000 0 EA 32,890.1100 32,890.11
CHANGE ORDER 10 PLN 149.PE CHRIS
MILLER.APPROVED BY AE CHAD
NIERMAN.
Deliveries acceptable only between 8:00 AM and 3:00 PM,Monday through Friday,excluding State
Holidays.
71
finita of Measure Handlin Totals Signatures.
The following UN/CEFACT Unit of Measure
Common Codes are used in this document:
EA Each
This area left blank
Total PO Amt. $ 32,890.11
issued by the Indiana Department of Transportation CONFIRMATION OF RECEIPT
I certify that the llama listed above were received.All commodities appeared to conform to
specifications and showed no patent defects,except as otherwise noted.
Signature of State Employee Receiver Date Signed(MonthlDay/Year)
FUNDING ENCUMBERED BY THE AUDITOR Of STATE
I certify that there is sufficient unencumbered balance In the above account to cover the amount of this order,and that funds have been set aside for payment thereof.
1111111111111111{11111111111111111111111111111111111111111111111111111111111111111111111111 IN Indiana Dopvsnant of Trarapodallon
00800 0017817920
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INDIANA DEPARTMENT OF TRANSPORTATION
+� Driving Indiana's Economic Growth
y� INVOICE
100 North Senate Avenue
Room IGC-N 749 Eric Holcomb,Governor
Indianapolis, Indiana 46204-2216 Joe McGuinness, Commissioner
Customer No: CST000001811
Bill To: Invoice: 000041613
Invoice Date: 6/7/2017
City of Carmel Invoice Type: ROE
ATTN: Jeremy Kashman
One Civic Square
Carmel IN 46032 AMOUNT DUE: $8,224.00
*** Payment is Due Upon Receipt of Invoice ***
Line Description Quantity Unit Amt Net Amount
1 Project#1006027 Overpayment 1.00 8,224.00 8,224.00
Subtotal: 8,224.00
AMOUNT DUE: $8,224.00
Payment Options
See Reverse Side
z03- 4L4tt2-2 oL�
For billing questions, please call: 317-234-7727 Invoice: 000041613
• Online website: https:Hsecure.in.gov/apps/dot/accountsreceivables/
• To create an account, use Customer #: CST000001811
• To make a credit card payment by telephone, call either:317-232-5364 or
317-232-5388
• OR RETURN THIS PORTION WITH YOUR PAYMENT
Department of Transportation Invoice: 000041613
Attention:Agent Cashier 0 0
N749 IGCN Amount Paid: $
100 N. Senate Ave.
Indianapolis, IN 46204
❑ Visa ❑ Mastercard ❑ Discover Check/Money Order
Name on Card Card Number
(Name must appear as exactly as on card)
CID(3 or 4 digit security code) Expiration Date
Billing Address
Signature Required: Date
For billing questions, please call: 317-234-7727 Invoice: 000041613
Report Summary
Printed On: 6/7/2017 9:15:16 AM
Number of Invoices: 1
Process Instance: 16768438
For billing questions, please call: 317-234-7727 Invoice: 000041613
Indiana Department of Transportation
Billing Request Form
Date:
6/712017
From. GREENFIELD DISTRICT
To: Ben Mauger
Accounts Receivable Supervisor
Division of Accounting&Control
RE: Billing Request
Overpayment ❑ Errors&Omissions
Type of billing(check one): ❑ Audit Citation ❑ Miscellaneous
Local Portion of Agreement
Entity to be Billed CITY OF CARMEL
Billing Street Address ONE CIVIC SQUARE
Billing City,State,Zip. CARMEL,IN 46032
INDOT Point of Contact: SARAH SOBIESKI
Phone#: 317-467-3477
Customer Point of Contact: KATE LUSTIG c
Phone#: 317-571-2432
❑ Reduction of Expenditures
Type of funding(check one). Q
Local Revenue
State Revenue
Other
Chartfield Information
Project A 1006027
Activity: " 17CSMIF
Fund: 63200
Account: 583110 "
Department: 65313
Program: ,`"46702
Locality: MP,1IN
Amount to be billed: $ <'- 8,224.00
Reference PO#: 16802876
Attached supporting documents(e.g.
Purchase Orders, Contracts,Letters of
Agreement,Schedules or Spreadsheets,
etc.)