315489 8/30/2017 CITY OF CARMEL, INDIANA VENDOR: 148000
e ONE CIVIC SQUARE
INDIANA DEPT OF TRANSPORTATION CHECK AMOUNT: $*******851.2
s• Via, CARMEL, INDIANA 46032 too N SENATE AVE, IGC-N 725 CHECK NUMBER: 315489
� INDIANAPOLIS IN as202oa-22is CHECK DATE: 08/30/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
211 4350900 42623 851.29 OTHER CONT SERVICES
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INDIANA DEPARTMENT OF TRANSPORTATION
Driving Indiana's Economic Growth INVOICE
100 North Senate Avenue
Eric Holcomb,Governor
' = Room IGC-N 749 Joe Mc Guinness,Commissioner
tri$ ' Indianapolis, Indiana 46204-2216
Customer No: CST000001811
Bill To: Invoice: 000042623
Invoice Date: 8/9/2017
City of Carmel Invoice Type: LPA
ATTN: Jeremy Kashman
One Civic Square
Carmel IN 46032 AMOUNT DUE: $851.29
*** Payment is Due Upon Receipt of Invoice***
Line Description Quantity Unit Amt Net Amount
1 Contract#R-35550 1.00 851.29 851.29
Project#1297165;Change order 8.(See Attached)
Subtotal: 851.29
AMOUNT DUE: $851.29
Payment Options
See Reverse Side
211— Hssogcao
For billing questions, please call: 317-234-7727 Invoice: 000042623
• 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: 000042623
Attention:Agent Cashier
N749 IGCN Amount Paid: $ OG t. 29
100 N. Senate Ave.
Indianapolis, IN 46204 /
❑ Visa 11 Mastercard ❑ Discover 12 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: 000042623
%Ig
OC a Order# Date Required Date Page
1 � (7rc�er Construction 0018802042 08/04/201-7 09/01/2017 1 of 1
ngiaepartment of Transportation Requisition Number:0000174329
8: App—d byEnwmp"sWilmhlpTom-2011 Vendor ID: 0000051089REMIT001
eK Agency: 00800 Transportation
Pay Terms: 35 Days in Arrears
Fund/Obiect/Cent@r: 632001571620/897030
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 eMaii: entail: RTEPNER@indotlN.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-0036647 CN)
< ?.. ;Purchase:Order'Llne'D.etalis
Item No Description;:`.' FOB Destination :` Ordered `.` Q "Recd `110M 'Unit Price : Extended Amt"
1- 1 100%LOCAL NON-PARTICIPATING. 1.0000 EA 851.2900 851.29
CHANGE ORDER 8 PLN 148.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.
Units of:Measiurei Handling,'Totals`Si natures
The following UN/CEFACT Unit of Measure
Common Codes are used in this document:
EA Each
This area left blank
Total PO Amt. $ 851.29
Issued by the Indiana Department of Transportation CONFIRMATION OF RECEIPT
I certify that the items 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 Slgned(MontlVDayNear)
FUNDING ENCUMBERED BY THE AUDITOR OF STATE
1 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 payrnerd thereof.
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00800 0018802042