195079 03/02/2011 CITY OF CARMEL, INDIANA VENDOR: 148000 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF TRANSPORTATION CHECK AMOUNT: $35,572.14
CARMEL, INDIANA 46032 100 N SENATE AVE, RM N725
ATTN: CASHIER CHECK NUMBER: 195079
INDIANAPOLIS IN 46204
CHECK DATE: 312/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
206 R4462830 17788 10078 35,572.14 116TH COLLEGE- RANGELI
,ta INDIANA DEPARTMENT OF TRANSPORTATION
°o Driving Indiana's Economic Growth
INVOICE
100 North Senate Avenue
Mitchell E. Daniels, Jr., Governor
Room IGC -N 725
80 Indianapolis, Indiana 46204 -2216 Michael Cline, Commissioner
Customer No: CST000001811
Bill To: Invoice: 000010078
Invoice Date: 2/23/2011
City of Carmel Invoice Type: LPA
ATTN: Mike McBride
One Civic Square
Carmel IN 46032 AMOUNT DUE: $35,572.14
Payment is Due Upon Receipt of Invoice
Line Description Quantity Unit Amt Net Amount
1 Contract R -27495 1.00 35,572.14 35,572.14
Additional funds requested for contract R- 27495, project #B886007,
change order final (see attached). Questions regarding this project
should be directed to the Greenfield District project engineer.
Subtotal: 35,572.14
AMOUNT DUE: $35,572.14
/Ip
Please return this portion with your payment,
Department of Transportation
Invoice: 000010078
Attention: Agent Cashier
N725 IGCN
100 N. Senate Amount Paid:
Indianapolis, IN 46204
Visa Mastercard Discover Diners Club Check /Money Order
Name on Card Card Number
(Name must appear as exactly as on card)
CID (3 or 4 digit security code) Expiration Date
Billing Address
Signature Required: Dat
2s2,
M
r: VI=D o
t.AnMEL I
le ('IlY ENGINEER 'V
For billing questions, please call: 317 -232 -5384 p Invoice: 000010078
L-ZZ11 6 S Ggc>
Indiana Department of Transportation, 100 North Senate Avenue, Indianapolis, n iana 46204 -2216
i *a Purcha a Order Order Date Required Date Page
y3Q IiVDOT hg Order Construction 0011809852 02/21/2011 03/17/2011 1 of 1
Indiana Department of Transportation Requisition Number: 0000052122
State Farm 45449 (R616 -07) Vendor ID: 0000087540 REMIT001
e>s
Approved y statesaardafAa�aants. -2007; Agency: 00800 Indiana Dept of Transportation
Approaed by Auditor of Stala, -2007 Pay Terms: 35 Days in Arrears
Vendor 0000087540 REMIT001 1
BEATY CONSTRUCTION INC Ship To Dept Of Transportation
Remit to 5292 W CR 100 N Construction Management Divisi
BOGGSTOWN IN 46110 100 N SENATE AVE RM N925
INDIANAPOLIS IN 46204
BEATY CONSTRUCTION INC Bill To Indiana Dept of Transportation
Vendor 5292 W CR 100 N Dept Of Transportation
Name BOGGSTOWN IN 46110 Accounting
Address 100 N SENATE AVE RM N725
INDIANAPOLIS IN 46204
Vendor Name: Buyer Name: Tepner,Roger -800
Contact eMail: entail: RTEPNER @indot.IN.gov
Phone:
c� t. PurchasetOrderinst�uctions'8 EommentsN. r
100% LPA (NON PARTICIPATING ITEM). change order final PE Von HovenlLoveall orig po 06022484 item 0195 subgrade
treatment (230) excavation and stone subgrade
mm a£ l Purchase Order' Details a s gy m
w4, A N "t ''1` v';d'. u ,�t�v.. gaff, 9 2 'te 3, x l
Lide r„ k
.a Descri "tlon.. FOB Oestiiiatlon Q tOreretlO Recda �g Unit.Prlce�- Eztended�Amt=
1 1 R 27495 -A ADDED TRAVEL LANES 1.0000 0 EA 35,572.1400 35,572.14
GREENFIELD DISTRICT PCN:9785910
B886007 ADDED TRAVEL LANES
HAMILTON COUNTY ON 116TH STREET
FROM RANGELINE ROAD TO COLLAGE
AVENUE 0.5 MILE EAST OF US 31
Deliveries acceptable only between 8:00 AM and 3:00 PM, Monday through Friday, excluding State
Holidays.
TotalsSi °�natues�(t €W�
The following UN /CEFACT Unit of Measure Date Invoice Received: (MonthlDaylYear)
Common Codes are used in this document: Goods /Services Received Date: (MonthlDayNear)
EA Each Internal Contract Terms and Conditions Satisfied: (Month /Day/Year)
Exempt: I ntergovernmenta I (Pursuant to IC 5- 17 -5 -2)
Good Faith Dispute (Dispute Pursuant to IC 4- 13 -2 -20 IC 5- 11 -10 -2)
Total PO Amt. 35,572.14
Issued by the the Indiana Department of Transportation FUNDING ENCUMBERED BY THE AUDITOR OF STATE
I certify that there is sufficient unencumbered balance in the above
account to cover the amount of this order, and that funds have been set
aside for payment thereof.
CONFIRMATION of RECEIPT
r hat the items listed above were received. All commodities
d to conform to specifications and showed no patent
exce t 1 otherwise noted.
e of Receiver Date Signed(monthlDaylYear)
111111111111111111111111111 11111111111111111111111111111111111111111111111111111111111111111111 Indiana Department of Transponation
00800 0011809852
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
pra.ia per day, number of hours, rate per hour, number of units, price per unit, etc.
no
Attention: Agent Caghi&
N725 IGCN Purchase Order No.
100 North San2te evanlie Terms
'nidianapolus, 1N 46204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
2123111 000010078 116th Street; College to Range Line 35,572.14
Local Match, Final invoice I
Total $35,572.14
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
INDOT
ttentson: Agent Cashier IN SUM OF
N725 IGCN
100 North Senate Avenue
Indianapolis, IN 46204
$35,572.14
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
I Board Members
PO# 'r INVOICE NO. ACCT #!TITLE AMOUNT
DEPT I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
17788 000010078 06 84462830 $35,572.14 materials or services itemized thereon for
which charge is made were ordered and
received except
2 20
Signature
f
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund