306730 01_05_17J
M`F CITY OF CARMEL, INDIANA VENDOR: 229400
INDIANA DEPT OF HOMELAND SECURIWECK AMOUNT: $.....""120.00"
ONE CIVIC SQUARE DIV OF ELEVATOR SAFETY-FISCAL OFFIC CHECK NUMBER: 306730
a: CARMEL, INDIANA 46032 302 W WASHINGTON ST,RM E221 CHECK DATE: 01/05/17
yi oN=':
INDIANAPOLIS IN 46204
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOi OT
DESCRIPTION
00 734241122720161
1093 4350100
Warrant No.
Voucher No.— 20
Indiana Department Allowed
229400 of Homeland Security
Fiscal Department
302 W Washington St., Rm E221
in Sum of$
Indianapolis, IN 46204
120.00
ON ACCOUNT OF APPROPRIATION FOR
109 -Monon Center
Board Members
PO#
orAMOUNT
INVOICE NO. CCT#/TITL
Dept#
4350100 $ 120.00 1 hereby certify that the attached invoice(s), or
1093 oa24tt2272o s 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
Janua 3, 2017
Signature
Accounts Payable Coordinator
120.00 Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
ELEVATOR OPERATING CERTIFICATE INVOICE
ARMEL/CLAY BOARD OF PARKS & RECREATION 1411 E 116TH ST Pat Schlemmer CARMEL IN 46032
1.If Code = * An annual test report is due before a permit is issued.
2.If Code = # A 5 year Test report is due before a permit is issued.
3.Over due fees must be paid before a permit is issued.
If elevator(s) are not in service please request an "ELEVATOR OUT OF SERVICE
AFFIRMATION" form.
State No.Code Due Over Due Location Address
111703 * $120.00 $ 0.00 1235 CENTRAL PARK DR EAST, CARMEL IN 40632
DEC 2.9 2.016
i
41
ReferenceReference Number Invoice Date Please submit ENTIRE document with payment
734241-12272016 -1 12/27/2016 Unit(s) 1 Total Due upon receipt
of 1 120.00 of $ 120.00
Owner Id 734241
Ref.Num. :734241-12272016 - 1 $120 of $ 120.00 Invoice Date 12/27/2016
If Paying by check, include a check made payable to the Department of Homeland security. You can pay all your
payments online at IDHS web site https://myoracle.in.gov/dfbs/idhsFeesFines/start.do with Visa/Master
Card/Discover cards. Use Owner Id on this letter or State Number on the invoice to pull up information when
paying the dues online.OR complete the following information and return by mail :Indiana Department of
Homeland Security, Fiscal Department, 302 W.Washington St., Rm : E221,Indianapolis, IN 46204 or fax to
317)233-0401. Questions? call(317)232-6427 or E-mail:elevator-invoice®dhs.in.gov 2.25% convenience fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address: Street
City State Zip Code
CC type:Visa/Am.Express/Discover/Master Card ONLY (circle one)
Acct. Number Exp.Date (mm/yy)
CVV2 Number Contact Phone Number Signature
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
Ref.Num. :734241-12272016 - 1 $120 of $ 120.00 Invoice Date 12/27/2016