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HomeMy WebLinkAbout324178 04/18/18 CITY OF CARMEL, INDIANA VENDOR: 147005 ONE CIVIC SQUARE INDIANA DEPT OF REVENUE CHECK AMOUNT: $*******262.50* x =q CARMEL, INDIANA 46032 FUEL&ENVIRONMENTAL DIVISION CHECK NUMBER: 324178 9MiroN�O` 5150 DECATUR BLVD CHECK DATE: 04/18/18 INDIANAPOLIS IN 46241-9564 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2201 4358300 262.50 OTHER FEES & LICENSES VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201 (Rev.1995) Vendor 147005 ALLOWED 20 ACCOUNTS PAYABLE VOUCHER # INDIANA DEPT OF REVENUE IN SUM of$ CITY OF CARMEL FUEL& ENVIRONMENTAL DIVISION An invoice or bill to be properly itemized must show:kind of service,where performed,dates service 5150 DECATUR BLVD rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. INDIANAPOLIS, IN 46241-9564 Payee $262.50 ON ACCOUNT OF APPROPRIATION FOR Purchase Order# Street Department Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 0 43-583.00 $262.50 1 hereby certify that the attached invoice(s),or 4/13118 0 $262.50 2201 2201 2201 2201 bill(s)is(are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except Friday,April 13,2018 Huffman, Dave Director I hereby certify that the attached invoice(s),or bill(s),is(are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 , 20— Cost 20Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer d,�• 4 Form Indiana Department of Revenue Mailing/Contact Information: $F-$�� Indiana Department of Revenue r = Alternative Fuel Decal Application Special Tax Division State Form 46292 P (R8/5-17) P.O.Box 6080 Indianapolis,IN 46206-6080 (317)615-2630 fetax@dor.in.gov Name(as shown on vehicle registration) Federal Identification or Social Security Number(must be provided) City of Carmel 356000972 Street Address City State ZIP Code 3400 W. 131st Street Carmel IN 46074 Telephone Number Email Address 317-733-2001 dhuffman@carmel.in.gov 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 Registration 1. 1 FTBF2B60FEC46708 2015 Ford F250 6/23/2015 LP 10,000 3 262.50 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 262.50 Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief it is true, come,and correct. M 9 Printed N Date Signature For Department Use Only Category Number From To Number of Decals Rate Tax Due 1 2 3 4 5 6 Total Tax Analyst Date