188048 07/21/2010 CITY OF CARMEL, INDIANA VENDOR: 358894 Page 1 of 1
ONE CIVIC SQUARE SAFELITE AUTOGLASS CHECK AMOUNT: $64.95
CARMEL, INDIANA 46032 PO BOX 633197
CINCINNATI OH 45263 -3197 CHECK NUMBER: 188048
CHECK DATE: 7/21/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2201 4351000 01830- 148631 64.95 AUTO REPAIR MAINTEN
SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1 -800- 835 -2257
dba: Safelite AutoGlass, Elite Auto Glass,
Auto Glass Specialists, and IF YOU HAVE ANY QUESTIONS REGARDING
Diamond Triumph Glass PAYMENT OF THIS INVOICE: 1 835 2092
INVOICE 01830- 148631 INVOICE: 07/09/10 BD
ORDERED: 07/07/10 INSTALLED: 07/09/10
PLEASE REMIT PAYMENT TO: W.O. 326399 REFERRAL 0
SAFELITE FULFILLMENT, INC INSURED:
P.O. BOX 633197 CARMEL, CITY OF
CINCINNATI, OH 45263 3197 3400 W 131 ST
PLEASE WRITE INVOICE NUMBER ON CHECK WESTFIELD IN 46074
PH1:317 571 PH2:317 694
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074
POLICY# PO# /REF
CLAIM LOSS LOC:
AUTH /VER: GARY LOSS DATE /CAUSE:
2008 FORD F SERIES F150 2 DOOR SUPE ARR: MOBILE
MILEAGE: 1
VIN: 1PTRF12WSBKD60436 LICENSE /ST: 78329 IN STOCK 147
QTY PART LIST SELLING LABOR KIT MATERIAL EXTENSION
1 MWSREPAIR .00 .00 64.95 .00 .00 64.95
MOBILE WINDSHIELD REPAIR
PART TOTAL 0.00
LABOR TOTAL 64.95
SUB TOTAL 64.95
SALES TAX 0.00
P A Y T H I S A M O U N T 64 -95
TERMS: NET 30
ADDITIONAL INFO /CLAIMANT SERVICED BY: COUNTY /A
SAFELITE AUTOGLASS 01830
INDIANAPOLIS IN 46268
SAFELITE TAX ID 36
070910 062398 00590 062398 148631
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074 20100709 0000000020100709742
VOUCHER NO. WARRANT NO.
ALLOWED 20
Safelite Fulfillment, Inc.
IN SUM OF
P'. O. Box 633197
Cincinnati, OH 45263 -3197
$64.95
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members
2201 01830 148631 43- 510.00 $64.95 1 hereby certify that the attached invoice(s), or
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
Thci slay, July 15, 2010
Street Cornrnpssioner
Ift�,mi� Tiile"
�r classification if
highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev. 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
07/09/10 01830- 148631 $64.95
1 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
Clerk Treasurer