HomeMy WebLinkAbout155911 01/23/2008 CITY OF CARMEL, INDIANA VENDOR: 360479 Page 1 of 1
ONE CIVIC SQUARE STENZ CONSTRUCTION CORPORATION AMOUNT: $35,918.25
CARMEL, INDIANA 46032 429 N PENNSYLVANIA ST
INDIANAPOLIS IN 46204 CHECK NUMBER: 155911
CHECK DATE: 1/23/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460856 35,918.25
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APPLICATI,ON CERTIFICATE F AIA DOCUMENT G702 PAGE 1 OF 2 PAGES
TO (OWNER). PROJECT: Parcel #56 Sitework Application No. 2 Distribution to:
Carmel Redevelopment Committee OWNER
Date from 11/1/2007 ARCHITECT
Date to: 11130/2007 CONTRACTOR
FROM (CONTRACTOR): ARCHITECT:
Stenz Cons't'ruction Corporation CSO Architects
429 N.`Pennsylvania Street 280 E 96th Street, Suite 200
Indianapolis; ]N Indianapolis, IN 46240
CONTRACT FOR: General Construction
Application is made for Payment, as shown below, in connection with the Contract.
CONTRACTOR'S APPLICATION FOR PAYMENT Continuation Sheet, AIA Document G703, is attached.
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM 313,362.00
Change Orders approved in 2. Net change by Change Orders 0.00
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 +2) 313,362.00
165175 TOTAL 4. TOTAL COMPLETED STORED TO DATE 313 ,362.00
Approved this Month (Column G on G703)
Number Date Approved 5. RETAINAGE:
a. of Compl
(Column D +E on
b. of Store 0.00
(Column F on G703)
Total Retainage (Line 5a +5b or
165175 TOTALS Total in Column I of G703 0.00
Net change by Change Orders 6. TOTAL EARNED LESS RETAINAGE 313 ,362.00
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATE FOR PAYMENT
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate) 277,443.75
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE 35,918.25
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE 0.00
herein is now due. (Line 3 less Line 6)
State of: Indiana County of: Marion
CON TOR: Subscribed and wor x n t before me this day of 200
Notary Public:
By: My Commission ires: (9
STE Z CONSTRUCTION CORPORATION
AMOUN TIFIED: n 9t s -11j
ARCHITECT'S CERTIFICATE FOR PAYMENT (Alta exp nation o ertified differs from the amount applied for.)
A HI
In accordance with the Contract Documents, based on •n -site observations and the 6y: Date: 3
data comprising the above application, the Architect certifies to the Owner that to the
best of the Architect's knowledge, information and belief the Work has progressed as
indicated, the quality of the Work is in accordance with t This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CE Contractor named herein. Issuance, payment and acceptance of payment are without
CONTINUATION SHEET Application No: 2 JOB NAME: Parcel #56 Sitework
APPLICATION DATE: 11130/2007
A B D E F G H I J
WORK COMPLETED
THIS APPLICATION
STORED TOTAL
ITEM DESCRIPTION SCHEDULED PREVIOUS THIS MATERIAL COMPUSTORED i BALANCE RETAINAGE
NO. OF WORK VALUE APPLICATION APPLICATION (NOT IN D OR E) TO DATE COMPL. TO FINISH
1 (D +E +F) (C -G)
01 Scope "A" 108,165.00 102,756.75 5,408.25 0.00 108,165.00 100.00% 0.00 0.00
02 Scope "B" 74,010.00 70,000.00 4,010.00 0.00 74,010.00 100.00% 0.00 0.00
03 Scope "C 25,000.00 0.00 25,000.00 0.00 25,000.00 x100:00% 0.00 0.00
05 Scope "E" 76,187.00 76,187.00 0.00 76,187.00 100.00% 0.00 0.00
07 Fee 30,000.00 28,500.00 1,500.00 0.00 30,000.00 <,100,.00% 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL 313,362.00 277,443.75 35,918.25 0.00 313,362.001, 100.00%1 0.001 0.00
AFFIDAVIT AND WAIVED OF LIEN
Final Partial Payment to Follow
State of Indiana, County of Marion SS:
Rebecca Sinders being duly sworn states that he /she is the CFO /Controller of
Name of Officer Title
stenz Construction Corporation having contracted with Carmel Redevelopment Committee
Const. Mgr. /Contractor Subcontractor /Owner
to furnish certain materials and /or labor as follows: parcel 56 Sitework Scopes A, B, C and E
Description
for a project known as Carmel North Lot
located at Main Street, Carmel, Indiana and owned by Carmel Redevelopment Committee
and does hereby further state on behalf of the aforementioned subcontractor /supplier:
(PARTIAL WAIVER) that there is due from the contractor the sum of
T Dollars
Receipt of which is hereby acknowledged, or
the payment of which has been promised as the sole consideration of this Affidavit and Partial
Waiver of Lien, which is given soley with respect to said amount, and which waiver shall be
effective only upon receipt of payment thereof by the undersigned.
(FINAL WAIVER) that the final balance due from the contractor is the sum of
Thirty -Five Thousand Nine- Hundred Eighteen dollars and 25/100 Dollars 35, 918.25
Receipt of which is hereby acknowledged, or
the payment of which has been promised as the sole consideration for this Affidavit and Final
Waiver of Lien which shall become effective upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the owner of said premises, any and all lien or claim
whatsoever on the above described property and improvements thereon on account of LABOR or material or both,
furnished by the undersigned thereto, subject to imitations or conditions expressed herein, if any; and further certifies that
no other party has any claim or right to a lien on account of any work performed orriterial furnished to the undersigned
for said project, and within the scope of this affidavit and ver.
Stenz Construction Corporation BY Title CFO /Controller
Firm Authorized Representative
WITNESS MY HAND AND NOTARIAL SEAL, this day of I tJv 1 je,-v,,4e_- 200
My Commission Expires
Notary Public
Residing in County Printed ik a L_
APPLICATION AND CERTIFICATE f AIA DOCUMENT G702 PAGE 1 OF 2 PAGES
TO (OWNER): PROJECT: Parcel #56 Sitework Application No. 2 Distribution to:
Carmel Redevelopment Committee OWNER
Date from 111112007-1 ARCHITECT
Date to: 11130/2007, CONTRACTOR
FROM (CONTRACTOR): ARCHITECT:
$tent Construction Corporation CSO Architects
429 N: Pennsylvania Street. 280 E 96th Street Suite 200
Ihdianapolis IN 46204 Indianapolis, IN 46240
CONTRACT FOR: General-Construction
Payment, as shown below, in connection with the Contract.
CONTRACTOR'S APPL ICATION FO R PAYMENT 3ument G703, is attached.
CHANGE ORDER SUMMARY iM 313,362.00
Change Orders approved in rders 0.00
previous months by Owner +TE (Line 1 +2) 313,362.00
165175 TOTAL STORED TO DATE 313,362.00
Approved this Month
Number Date Approved V
re 0.00
(Colu,. G703)
Total Retainage (Line 5a +5b or
165175 TOTALS Total in Column I of G703 0.00
Net change by Change Orders 6. TOTAL EARNED LESS RETAINAGE 313,362.00
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATE FOR PAYMENT
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate) 277,443 75
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE 35,918.25
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE 0.00
herein is now due. (Line 3 less Line 6)
State of: Indiana County of: Marion
CON TOR: Subscribed and worn t before me this Z9 day of 20_a7 Notary Public: 4&L By: My Commission x ires: r
STENZ CONSTRUCTION CORPORATION
AMOU TIFIED:
ARCHITECT'S CERTIFICATE FOR PAYMENT (Att h ex anatio certified differs frof(the amount applied for.)
A C
In accordance with the Contract Documents, based on on -site observations and the B Date: 0
data comprising the above application, the Architect certifies to the Owner that to the
best of the Architect's knowledge, information and belief the Work has progressed as
indicated, the quality of the Work is in accordance with t This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CE Contractor named herein. Issuance, payment and acceptance of payment are without
r-
CONTINUATION SHEET Application No: 2 JOB NAME: Parcel #56 Sitework
APPLICATION DATE 11/3012007
A B D E F G H I J
WORK COMPLETED
THIS APPLICATION
STORED TOTAL
ITEM DESCRIPTION SCHEDULED PREVIOUS THIS MATERIAL COMPUSTORED BALANCE RETAINAGE
NO. OF WORK VALUE APPLICATION APPLICATION (NOT IN D OR E) TO DATE COMPL. TO FINISH
1 (D +E +F) (C -G)
01 Scope "A" 108,165.00 102,756.75 5,408.25 0.00 108,165.00 `100:00 %0 1001 0.00 0.00
02 Scope "B" 74,010.00 70,000.00 4,010.00 0.00 74,010.00 100:00% 0.00 0.00
03 Scope "C 25,000.00 0.00 25,000.00 0.00 25,000 00 100.00 %0 0.00 0.00
05 Scope "E" 76,187.00 76,187.00 0.00 76,187.00 100.00% 0.00 0.00
07 Fee 30,000.00 28,500.00 1,500.00 0.00 30,000.00 ='100:00% 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL 313,362.00 1 277,443.75 35,918.251 0.00 1 313,362.00 `100:_00 %0 0.001 0.00
AFFIDAVIT AND WAIVER OF LIEN
❑x Final F-1 Partial ❑x Payment to Follow
State of Indiana, County of Marion SS.
Rebecca Sinders being duly sworn states that he /she is the CFO /Controller of
Name of Officer Title
Stenz Construction Corporation having contracted with Carmel Redevelopment Committee
Const. Mgr. /Contractor Subcontractor /Owner
to furnish certain materials and /or labor as follows: Parcel 56 Sitework Scopes A, B, C and E
Description
for a project known as Carmel North Lot
located at Main Street, Carmel, Indiana and owned by Carmel Redevelopment Committee
and does hereby further state on behalf of the aforementioned subcontractor /supplier:
(PARTIAL WAIVER) that there is due from the contractor the sum of
IT Dollars
Receipt of which is hereby acknowledged, or
the payment of which has been promised as the sole consideration of this Affidavit and Partial
Waiver of Lien, which is given soley with respect to said amount, and which waiver shall be
effective only upon receipt of payment thereof by the undersigned.
(FINAL WAIVER) that the final balance due from the contractor is the sum of
Thirty -Five Thousand Nine Hundred Eighteen dollars and 25/100 Dollars 35, 918.25
Receipt of which is hereby acknowledged, or
F x the payment of which has been promised as the sole consideration for this Affidavit and Final
Waiver of Lien which shall become effective upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the owner of said premises, any and all lien or claim
whatsoever on the above described property and improvements thereon on account of LABOR or material or both,
furnished by the undersigned thereto, subject to imitations or conditions expressed herein, if any; and further certifies that
no other party has any claim or right to a lien on account of any work performed or terial furnished to the undersigned
for said project, and within the scope of this affidavit and iver.
Stenz Construction Corporation BY l Title CFO /Controller
Firm Authorized Representative
WITNESS MY HAND AND NOTARIAL SEAL, this Zq day of 200
My Commission Expires 1 I ��'Zp� r�
Notary Public
Residing in �hlj County Printed
APPLICATION AND CERTIFICATE F AIA DOCUMENT G702 PAGE 1 OF 2 PAG
TO (OWNER). PROJECT: Parcel #56 Sitework Application No. 2 Distribution to:
Carmel Redevelopment Committee OWNER
Date from 11/112007 ARCHITECT
Date to: 11/3012007 CONTRACTOR
FROM (CONTRACTOR): ARCHITECT:
Stenz Construction Corporation CSO Architects
429 N. Penrisylvania Street 280 E 96th Street, Suite 200
Indianapolis; IN 46204 Indianapolis, IN 46240
CONTRACT FOR: General Construction
Application is made for Payment, as shown below, in connection with the Contract.
CONTRACTOR'S APPLICATION FOR PAYMENT Continuation Sheet, AIA Document G703, is attached.
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SUM 313,362.00
Change Orders approved in 2. Net change by Change Orders 0.00
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 +2) 313,362.00
165175 TOTAL 4. TOTAL COMPLETED STORED TO DATE 313,362.00
Approved this Month (Column G on G703)
Number Date Approved 5. RETAINAGE:
a: of Compl
(Column D +E on
b. of Store 0.00
(Column F on G703)
Total Retainage (Line 5a +5b or
165175 TOTALS Total in Column I of G703 0.00
Net change by Change Orders 6. TOTAL EARNED LESS RETAINAGE 313,362.00
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been 7. LESS PREVIOUS CERTIFICATE FOR PAYMENT
completed in accordance with the Contract Documents, that all amounts have been PAYMENT (Line 6 from prior Certificate) 277,443.75
paid by the Contractor for Work for which previous Certificates for Payment were 8. CURRENT PAYMENT DUE 35,918.25
issued and payments received from the Owner, and that current payment shown 9. BALANCE TO FINISH, PLUS RETAINAGE 0.00
herein is now due. (Line 3 less Line 6)
State of: Indiana County of: Marion
CON 'TOR: l Subscribed and worn t before me this day of 200
Notary Public:
By: My Commission Ores: {fa
STENZ CONSTRUCTION CORPORATION
AMOUN T IED: 3tgjg 'ZCj
ARCHITECT'S CERTIFICATE FOR PAYMENT (Attac expla ti i unt certified differs from the amount applied for.)
ARC IT
In accordance with the Contract Documents, based on on -site observations and the By: Date: 3 v
data comprising the above application, the Architect certifies to the Owner that to the
best of the Architect's knowledge, information and belief the Work has progressed as
indicated, the quality of the Work is in accordance with t This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
the Contractor is entitled to payment of the AMOUNT CE Contractor named herein. Issuance, payment and acceptance of payment are without
CONTINUA'riON SHEET Application No: 2 JOB NAME: Parcel #56 Sitework
APPLICATION DATE: 1113012007
A B D E F G H I J
WORK COMPLETED
THIS APPLICATION
STORED TOTAL
ITEM DESCRIPTION SCHEDULED PREVIOUS THIS MATERIAL COMPUSTORED BALANCE RETAINAGE
NO. OF WORK VALUE APPLICATION APPLICATION (NOT IN D OR E) TO DATE COMPL. TO FINISH
1 (D +E +F) (C -G)
01 Scope "A" 108,165.00 102,756.75 5,408.25 0.00 108,165.00 '100.00% 0.00 0.00
021 Scope "B" 74,010.00 70,000.00 4,010.00 0.00 74,010.00 100.00% 0.00 0.00
03 Scope "C 25,000.00 0.00 25,000.00 0.00 25,000.00 100:00 %0 0.00 0.00
05 Scope "E" 76,187.00 76,187.00 0.00 76,187.00 100.00% 0.00 0.00
07 Fee 30,000.00 28,500.00 1,500.00 0.00 30,000.00 100.00% 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TOTAL 313,362.00 1 277,443.75 35,918.25 0.00 313,362.00 100.00% 0.00 0.00
AFFIDAVIT AND WAIVER OF LIEN
a Final 17 Partial F X I Payment to Follow
State of Indiana, County of Marion SS:
Rebecca Sinders being duly sworn states that he /she is the CFO /Controller of
Name of Officer Title
stem Construction Corporation having contracted with Carmel Redevelopment Committee
Const. Mgr. /Contractor Subcontractor /Owner
to furnish certain materials and /or labor as follows: Parcel 56 Sitework Scopes A, B, C and E
Description
for a project known as Carmel North Lot
located at Main Street, Carmel, Indiana and owned by Carmel Redevelopment Committee
and does hereby further state on behalf of the aforementioned subcontractor /supplier:
(PARTIAL WAIVER) that there is due from the contractor the sum of
I T Dollars
Receipt of which is hereby acknowledged, or
the payment of which has been promised as the sole consideration of this Affidavit and Partial
Waiver of Lien, which is given soley with respect to said amount, and which waiver shall be
effective only upon receipt of payment thereof by the undersigned.
(FINAL WAIVER) that the final balance due from the contractor is the sum of
Thirty -Five Thousand Nine Hundred Eighteen dollars and 25/100 Dollars 35, 918.25
Receipt of which is hereby acknowledged, or
P the payment of which has been promised as the sole consideration for this Affidavit and Final
Waiver of Lien which shall become effective upon receipt of such payment.
THEREFORE, the undersigned waives and releases unto the owner of said premises, any and all lien or claim
whatsoever on the above described property and improvements thereon on account of LABOR or material or both,
furnished by the undersigned thereto, subject to imitations or conditions expressed herein, if any; and further certifies that
no other party has any claim or right to a lien on account of any work performed or terial furnished to the undersigned
for said project, and within the scope of this affidavit and 1 ver.
Stenz Construction Corporation BY agft Title CFO /Controller
Firm Authorized Representative
WITNESS MY HAND AND NOTARIAL SEAL, this Zq day of
My Commission Expires
Notary Public
Residing in County Printed (,l')
f cdbed 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
Z Ccnr�w.�1o.. C'o�Por «d Purchase Order No.
L4 N. Pe.., fv(W .W Sera -F Terms
r .4«- .p01 .I, rA/ y4Zoy Date Due
Invoice Invoice Description Amount
J Date �j Number P (or note attached or bill(s)) 9 ^y,
3� 1' O• Z�
111
0
Total 3 �S' 1 8. ZS
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in .ccordance
with IC 5- 11- 10 -1.6.
20
Clerk- Treasurer
f�
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
kj
zs
3s, 9►g
ON ACCOUNT OF APPROPRIATION FOR
X
Board Members
PO# or VOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
9 °Z 4g6agslo 3S yrg, zs 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
J l� 2,V D
C---�LvuN� 11 4
r Sign
Cost distribution ledger classification if e
claim paid motor vehicle highway fund