190944 10/13/2010 CITY OF CARMEL, INDIANA VENDOR: 358894 Page 1 of 1
ONE CIVIC SQUARE SAFELITE AUTOGLASS
i 0 CHECK AMOUNT: $64.95
CARMEL, INDIANA 46032 PO BOX 633197
CINCINNATI OH 45263 -3197 CHECK NUMBER: 190944
CHECK DATE: 10/13/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4351000 01830 152854 64.95 AUTO REPAIR MAINTEN
C
J
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: 1 800 835 2092
INVOICE 01830- 152854 INVOICE: 09/24/10 BD
ORDERED: 09/24/10 INSTALLED: 09/24/10
PLEASE REMIT PAYMENT TO: W.O. 341594 REFERRAL 0
SAFELITE FULFILLMENT, INC INSURED:
P.O. BOX 633197 CARMEL FIRE DEPT
CINCINNATI, OH 45263 2 CIVIC SQUARE
PLEASE WRITE INVOICE NUMBER ON CHECK CARMEL IN 46032 -0000
PH1:317 -4283 PH2:
CARMEL FIRE DEPT
2 CIVIC SQUARE
CARMEL IN 46032
POLICY# P0#/REF 4561
CLAIM LOSS LOC:
AUTH /VER: JASON LOSS DATE /CAUSE:
2003 CHEVROLET IMPALA 4 DOOR SEDA ARR: MOBILE
MILEAGE: 50,000
VIN: 2G1WF52K3 LICENSE /ST: 64549 IN STOCK 4561
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
SUBTOTAL 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
JASON FORCE SAFELITE AUTOGLASS 01830
2 CIVIC SQ INDIANAPOLIS IN 46268 0000
CARMEL IN 46032-0000 SAFELITE TAX ID 36
092410-160295 160295 00513 160295-152854
CARMEL FIRE DEPT
2 CIVIC SQUARE
CARMEL IN 46032 20100924 0000000020100924742
VOUCHER NO. WARRANT NO.
ALLOWED 20
Safelite Auto Glass
IN SUM OF
4625 W.86th Street, Ste. 100
Indianapolis, IN 46268
$64.95
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# 1 Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members
1120 01830 152854 43- 510.00 $6495 I 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
OCT 1 1 2010
1 7
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle 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))
01830- 152854 4561 $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