199972 08/03/2011 CITY OF CARMEL, INDIANA VENDOR: 148000 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF TRANSPORTATION CHECK AMOUNT: $121,000.00
CARMEL, INDIANA 46032 100 N SENATE AVE, RM N725
ATTN: CASHIER CHECK NUMBER: 199972
INDIANAPOLIS IN 46204
CHECK DATE: 8/3/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1205 R4462862 21370 11519 121,000.00 HAZEL DELL ROAD
INDIANA DEPARTMENT OF TRANSPORTATION
Driving Indiana's Economic Growth INVOICE
100 North Senate Avenue
Mitchell E. Daniels, Jr., Governor
Room IGC -N 725 Michael Cline, Commissioner
T Indianapolis, Indiana 46204 -2216
Customer No: CST000001811
Invoice: 000011519
Bill To: Invoice Date: 6/2212011
Invoice Type: LPA
City of Carmel
ATTN:
One Civic Square
Carmel IN 46032 AMOUNT DUE: $121,000.00
Payment is Due Upon Receipt of Invoice
Line Description quantity Unit Amt Net Amount
1
Contract SRS-32650 1.00 121,000.00 121,000.00
Additional funds requested for contract SRS- 32650, project #0901163,
change order #3 (see attached). Questions regarding this project
should be directed to Bret Waddy at the Greenfield District office.
Subtotal: 121,000.00
AMOUNT DUE: $121,000.00
Please return this portion with your payment,
Department of Transportation Invoice: 000011519
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
For billing questions, please call: 317- 232 -5384 Invoice: 000011519
Indiana Department of Transportation, 100 North Senate Avenue, Indianapolis, Indiana 46204 -2216
P Order O rder Date equired Date P age
N Order Construct 0011815001 0512412011 06!1912011 1 of 1
ndiana Department of Transportation Requisition Number: 0000057462
Approved by Encompass Leadership Team -2077 Vendor ID: 00000$1089 REMIT001
Agency: 00800 Indiana Dept of Transportation
Pay Terms: 35 Days in Arrears
Vendor 0000051089 REMIT001 2
ETH -RILEY CON97RUCT INC Ship To Dept Of Transportation
Remit to RIETH RILEY CONSTRUCTION Construction Management Divisi
PO BOX 276 100 N SENATE AVE RM N925
INDIANAPOLIS IN 46206 INDIANAPOLIS IN 46204
RIE F -RILEY CONSTIR TiON COMPARY INC Bill To Indiana Dept of Transportation
Vendor RIETH -RILEY CONSTRUCTION Dept Of Transportation
Name PO BOX 276 Accounting
Address INDIANAPOLIS IN 46206 100 N SENATE AVE RIM N725
INDIANAPOLIS IN 46204
Vendor Name: Buyer ame:Tepn ir, oger -800
Contact eMall: entail: RTEPNER @indot.IN.gov
Phone:
ti- ,haip C s" 1JFde'Ylntt[CtTu7 Stye RI(rl ;_0
100% LPA, change order 3 PE Andy Wolf crig po OD10BOSS94
w
e tin tinat` F Y r r re d 0 IJ G tEx3d 7.
1- 1 SRS 32650 -A ASPHALT RESURFACE 1.0000 EA 121,000.0000 121,000.00
GREENFIELD DISTRICT PCN:0901163
0901163 PARTIAL 3R HAMILTON COUNTY
ON HAZEL DELL PARKWAY FROM 116TH
STREET TO 146TH STREET
Deliveries acceptable only between 8:00 AM and 3:00 PM, Monday through Friday, excluding State
Holidays.
The following UNJCEFACT Unit of Measure
Common Codes are used in this document:
EA Each
I
This area left blank
Total PO Amt. 121,000.00
ksued by the Indiana Department or Transportation CON nRMAT= of RECEIPT
I certify that the Items listed above were toouhred- All commodities appeared to ccnfomt to
a oefficatiorm and showed no patent defects except as otherwise noted.
54wwra of tteoever Date Slgned@AonWDayN -are
FUNDING ENCUI49ERED BY THE AUDITOR OF STATE
I tik that there is sufficient unencumbered balance in the above account to cover the onmunt or ties order, and that rends have been set aside for Rayment thereof-
1111111 fill I 111111 Ills1 1111IIIII111111111111111111111IIIII11 111111111111IIII wi.- D.Vartntem orr pef.a-
00800 0011815001
Prescribed by State Board of Accounts City Form No. 201 (Rev, 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
.,s ce or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
ates per day, number of hours, rate per hour, number of units, price per unit, etc.
A ttention: Agent Ca aa ye�
N7251GCN
Purchase Order No.
100 North Senate Avenue Terms
Indianapolis, IN 4 6204 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
6122111 000011519
Local Match; Final inv
Toi$0 2 ,000.00
I 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.
INDOT ALLOWED 20
AffUntion: Agent Cashier IN SUM OF
N725 IGCN
100 North Senate Avenue
Indianapolis, IN 46204
$121,000.00
ON ACCOUNT OF APPROPRIATION FOR
Department of Engineering
Board Members
Po# or 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
21370 000011519 205- R4462862 111121,000.00 materials or services itemized thereon for
which charge is made were ordered and
received except
Z 20
r
Signature
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund