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.
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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