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HomeMy WebLinkAbout200634 08/17/2011 CITY OF CARMEL, INDIANA VENDOR: 361528 Page 1 of 1 ONE CIVIC SQUARE STAPLES BUSINESS ADVANTAGE 19 CHECK AMOUNT: $2,192.78 CARMEL, INDIANA 46032 DEPT DET PO BOX 83689 CHECK NUMBER: 200634 CHICAGO IL 60696 -3689 CHECK DATE: 8/17/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1091 4230200 3157516220 492.82 OFFICE SUPPLIES 1091 4230200 3157791589 516.18 OFFICE SUPPLIES 1125 4230200 3157791590 98.74 OFFICE SUPPLIES 1125 4230200 3157791591 129.99 OFFICE SUPPLIES 1110 4230200 3158070558 178.45 OFFICE SUPPLIES 601 5023990 3158070559 115.40 OTHER EXPENSES 1125 4230200 3158070560 169.77 OFFICE SUPPLIES 1110 4230200 3158352388 102.97 OFFICE SUPPLIES 1301 4230200 3158352389 201.21 OFFICE SUPPLIES 1701 4230200 3158352390 187.25 OFFICE SUPPLIES iNVOiCE iD'A CUSTOMER' SlJf1!MMAWANVOiCEI u 7/30/11 DET 1061088 8019231514 8/29/11 Net 30 Days 491.43 I NV ®I LE DETAIL Staples Advantage Federal ID #:04- 3390816 CITY OF CARMEL -NJPA CITY OF CARMEL JIM SPELBRING ATTN: BONNIE LEWIS 1 CIVIC SQUARE 1 CIVIC SQUARE CARMEL, IN 46032 DELIVER BY 4PM CARMEL, IN 46032 Bill to Account: 1030382 Ship to Account: i CIVIC SQUARE Budget Ctr: 130 CITY COURT Invoice Ntmiber: 3158352389 P 0 Number: Release: Order: 7076031446 -000 -001 Ordered by: BONNIE LEWIS Job: Order Date: 7/29/11 U r der r. m r i ne `item Akmiber Descr,i ti on Qt Ot Meas Qt 1 r' Pri 1 565456 BROTHER TN -350 BLACK TONER 1 EA 1 43.86 43.86 2 516564 FOLDR 100% RECY POW 113 LTR ML 3 BX 3 24.41 73.23 3 VER96675 MOUSE.LASER.DSKTOP,WIRELESS 2 EA 2 42.06 84.12 rE`7 aX o a I a', E Total: 201.2/'' Customer Service inquiries 800 693 8080 Invoice Payment Inquiries 888 753 4104 Page: 1 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 -3689 0005398- 0046363 0000005 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 whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc. Payee Purchase Order No. Terms ,►o ,J,/ 60(,q14 Co �7 Date flue Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) Total f 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. ALLOWED 20 b n1►11o� IN SUM OF ?3��� X .2[ ON ACCOUNT OF APPROPRIATION FOR �kcs K 1� Board Members PO# or INVOICE NO. ACCT #!TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 30 Q 1 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 20 C Int Title Cost distribution ledger classification if claim paid motor vehicle highway fund 1NVQICE' DAT£ s ..CL1ST:UN{ER SIJ2a1tMARY; INVOICE 7730/11 DET 1061088 8019231514 P 8/29/11 Ne# 30 0a s 491.43 I WDICE DETAIL Staples Advantage Federal ID #:04- 3390816 CITY OF CARMEL -NJPA CITY OF CARMEL JIM SPELBRING ATTN: ANN DAVIS 1 CIVIC SQUARE 1 CIVIC SQUARE CARMEL, IN 46032 DELIVER BY 4PM CARMEL, IN 46032 Bill to Account: 1030382 Ship to Account: 1 CIVIC SQUARE Budget Ctr: 140 COMMON COUNCIL Invoice Number_ 3158352390 P 0 Number: Release: Order: 7075961131- 000 -001 Ordered by: ANN DAVIS Job: Order Date: 7/27/11 r r;= n ip m x tended Line Item Nmt�er,r Descri 1 man" Qt Qt Meas.. Ot' Price Price 1 513096 SPLS 8.5X11 MULTIUSE 20196 CS 5 CT 5 37.45 187.25 rep ax o a 1 "Totals 187_28�� Customer Service inquiries 800 693 8080 Invoice Payment Inquiries 888 753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 -3689 0005399 0046363- 0000006 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 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)) Total 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. ALLOWED 20 IN SUM OF Q7C)'� ON ACCOUNT OF APPROPRIATION FOR Board Members PO# or INVOICE NO. ACCT #/TITLE AMOUNT DEPT. I hereby certify that the attached invoice(s), or 1 3!� o ?j OZ_ 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 20 Signatu 67 Title Cost distribution ledger classification if claim paid motor vehicle highway fund INVOICE.:QATE CUSTOMER. SUMMARIf':ANVOWE'' 7/30/11 DET 1061088 8019231514 8/29/11 Net 30 491.43 IWO RAE DETAIL Staples Advantage Federal ID #:04 3390816 CITY OF CARMEL -NJPA CITY OF CARMEL JIM SPELBRING ATTN: ROBERT ROBINSON 1 CIVIC SQUARE 3 CIVIC SQUARE CARMEL, IN 46032 DELIVER BY 4PM CARMEL, IN 46032 Bill to Account: 1030382 Ship to Account: 3 CIVIC SQUARE Budget Gtr: 110 POLICE DEPARTMENT Invoice Number: 3158352388 P 0 Number: Release: Order: 7075899112- 000 -001 Ordered by: ROBERT ROBINSON Job: Order Date: 7/26/11 r r° m m x Line .Item Number ©escri tion At Qt Meas Qt' Price ?r ice 1 782383 BOARD INIOUT -2X1.5 1 EA 1 102.97 102.97 re i ax -,Iota Total: X102:97 Customer Service inquiries 800 693 8080 Invoice Payment Inquiries 888 -753 -4104 Page: 7 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 3689 0005397- 0046363- 0000004 INVOICE :'DATE CUSTOMER SUMMARY INVOICE: 7/23/11 DET 1061088 8019175742 P.LtAgr= :PAY: w B 'M 872271 Net 30 Days 293.85 IWOICE DE Staples Advantage Federal ID #:04- 3390816 CITY OF CARMEL -NJPA CITY OF CARMEL JIM SPELBRING ATTN: ROBERT ROBINSON 1 CIVIC SQUARE 3 CIVIC SQUARE CARMEL, IN 46032 DELIVER BY 4PM CARMEL, IN 46032 Bill to Account: 1030382 Ship to Account: 3 CIVIC SQUARE Budget Ctr: 110 POLICE DEPARTMENT Invoice Number: 3158070558 P 0 Number: Release: Order: 7075816829 000 001 Ordered by: ROBERT ROBINSON Job: Order Date: 7/22/11 r r Order B/0 Uni ip Unit x e nded Line 4 tem Number Descr t:ion Qt ,::_Qt Meas °.�.Qt Price Price:.° 1 782383 BOARD INIOUT -2X1.5 1 EA 1 102.97 102.97 2 492072 SPLS 8.5X11 30% REC COPY CS 2 CT 2 37.74 75.48 F reight ax o a Total.: 178.45 Customer Service inquiries 800- 693 -8080 Invoice Payment Inquiries 888 753 4104 Page: 1 Make checks payable to Staples Advantage, Dept DET PO Box 83689, Chicago IL 60696 -3689 0019583- 0033278 0000004 VOUCHER NO. WARRANT NO. ALLOWED 20 Staples Advantage Detp DET IN SUM OF P.O. Box 83689 Chicago, IL 60696 -3689 $281.42 ON ACCOUNT OF APPROPRIATION FOR Carmel Police Department PO# Dept. INVOICE NO. ACCT #!TITLE AMOUNT Board Members 1110 3158070558 42- 302.00 $178.45 I hereby certify that the attached invoice(s), or bill(s) is (are) true and correct and that the 1110 3158352388 42- 302.00 $102.97 materials or services itemized thereon for which charge is made were ordered and received except Thursday, August 11, 2011 Chief of Police 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)) 07123/11 3158070558 payment for office supplies $178.45 07/30/11 3158352388 payment for office supplies $102.97 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 1M1IVOICE >DA1E CUSTOMS i SIJIIItMARW:INVOICE: 7/ 09/11 DET 1061088 8019063837 8738711 Net 30 Days 636.16 IW DICE DETAIL Staples Advantage Federal ID #:04 3390816 CARMEL CLAY PARKS AND RECREATION CITY OF CARMEL PAULA SCHLEMMER ATTN: MANDY SPADY 1411 E 116TH ST 1235 CENTRAL PARK DR E CARMEL, IN 46032 DLV BEFORE 4PM CARMEL, IN 46032 Bill to Account: 1030597 Ship to Account: 1235 CNTRL PK E Budget Ctr: 1091 4230200 Invoice Number: 3157516220 P 0 Number: Release: r Order: 7075271536 000 001 Ordered by: MANDY SPADY Job: Order Date: 7/05/11 r, m ip ni x Cine °Item :Number Tarr .Descriition� -Qt �Qt ideas" �Qt' Price Price` 1 452170 THERMAL POS ROLLS 101PK 10 PK 10 21.68 216.80 2 518126 BINDER -RING HANGING 3 BK 3 EA 3 26.33 78.99 3 434480 BINDER RING HANGING 1 BK 6 EA 6 6.16 36.96 4 807884 BIC Al RETRACTABLE GEL PEN 1 DZ 1 15.83 15.83 5 209882 AVY 1X2 518 _SR LBL 100SH 5 BX 5 22.50 112.50 6 UNV357156N PAPER,ROLLS.121PK.WHT 2 PK 2 11.34 22.68 7 440722 JACKET POLY LTR ASST 85750 2 PK 2 4.53 9.06 ax Sub7TOta;f, 492.82 Total. 49282 Purchase 4escriptian �e r• P.O. T9_ Budget r ck Line DeSCr BY: Purchaser ate Approval Customer Service inquiries 800 693 8080 Invoice Payment Inquiries 888 753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 3689 0006663 0037852- 0000004 —ONIONS INV:QICE <DAIE :.CUSTUNIER SUI+11N€AtiYINVOICE: 7716711 DET 1061088 8019118579 8 15 11 Net 30 Days 744.91 IN VOICE DETAIL Staples Advantage Federal ID #:04- 3390816 CARMEL CLAY PARKS AND RECREATION CITY OF CARMEL PAULA SCHLEMMER ATTN: MANDY SPADY 1411 E 116TH ST 1235 CENTRAL PARK DR E CARMEL, IN 46032 DLV BEFORE 4PM CARMEL, IN 46032 Bill to Account: 1030597 Ship to Account: 1235 CNTRL PK E Budget Ctr: 1091- 4230200 Invoice Number: 3157791589 P 0 Number: MC001882 Release: Order: 7075482414- 000 -001 Ordered by: MANDY SPADY Job: Order Date: 7/12/11 r r r m Ship n1 x Line Lfem Number n 1 '.DeSCr r #ton. Qt Qt IAeas Qt Price Price 1 433263 PILOT VRAZOR LIO INK AST 08 1 PK 1 10 38 10.38 2 491209 HP 58 PHOTO INK 3 EA 3 22.68 68.04 3 SASML2525W SAMSUNG ML -2525W LASER PRINTER 1 EA 1 204.73 204.73 4 817096 SAMSUNG BLK MLTD105L HIGH YLD 2 EA 2 72.74 145.40 5 578480 VISION ELITE SUPERFINE ASST 8 1 PK 1 16.34 16.34 6 039210 STAPLE SF3 5M /BOX 35440 4 BX 4 3.52 14.08 7 211318 POST -IT 3X3 ASST COLOR 12PK 1 PK 1 10.76 10 -76 8 487908 TAPE STAPLES 314X1296 12PK 1 DZ 1 5.65 5.65 9 409562 STAPLER VALUE PACK 5 EA 5 4.34 21.70 10 519018 STAPLES CORRECTION TAPE 10PK 2 PK 2 9.51 19.02 re.1 ax: L a e Total: 516_ =18` Purchase Description T-IC-E ¢U I:;>p LI e< G. L. q Z Z{� P ore BY: [budget Line Descr Q :7 F Purcflaser C� Approval Date [)nte, Customer Service inquiries 800- 693 8080 Invoice Payment Inquiries 888 753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DET PO Box 83689, Chicago IL 60696 3689 0011157 0043110 0000004 11V:VQICE:'DA7E Ci1.5TOMER SUMMARY :jNVtOkCEi' 7/16/11 DET 1061088 8019118579 w s 8/15/11 Net 30 Oa s 744.91 INVOICE DETAIL Staples Advantage federal ID #:04- 3390816 CARMEL CLAY PARKS AND RECREATION CITY OF CARMEL PAULA SCHLEMMER ATTN: SERRA GARSKE 1411 E 116TH ST 1411 E 116TH ST CARMEL, IN 46032 CARMEL, IN 46032 Bill to Account: 1030597 Ship to Account: 1411 E 116TH ST Budget Ctr: 1125 100 010 4230200 ADMINISTRATION Invoice Number: 3157791590 P 0 Number: Release: Order: 7075525326 000 001 Ordered by: SERRA GARSKE Job: Order Date: 7/13/11 r r m 1p n1 x e Line Iterirkj ber. Description =Qt Qt Meal',, '`Qt Price Price-« 1 513598 TRAY ALUM STORAGE QUARTER OG 3 EA 3 5.62 16.86 2 187013 ENV COMM 24LB #10 WE 1 BX 1 5.78 5.78 3 492072 SPLS 8.5X11 30% REC COPY CS 2 CT 2 39.05 76.10 re,i ght::­ o a Total: 98:74 Purchase I SUP(�LIS Description O P.O.# Pore J U L a I G.L. l a5-1 0� -L 1230 Lin B udget Gce c-Q- a'Lp �-u� Line Descr Purchaser Date Approval Date Customer Service inquiries 800 -693 -8080 Invoice Payment Inquiries 888 753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DET PO Box 83689, Chicago IL 60696 -3689 0011158- 0043110- 0000005 INVOICE :DATE CUSTOMER Sl1MMARY: 111IVt310E 771677 DET 1061088 8019118579 8/15/11 Net 30 Oa s 744 -91 INVOI DETAIL Staples Advantage Federal ID #:04- 3390816 CARMEL CLAY PARKS AND RECREATION CITY OF CARMEL PAULA SCHLEMMER ATTN: SERRA GARSKE 1411 E 116TH ST 1235 CENTRAL PARK DR E CARMEL, IN 46032 DLV BEFORE 4PM CARMEL, IN 46032 Bill to Account: 1030597 Ship to Account: 1235 CNTRL PK E Budget Ctr: 1125 -100 -010- 4230200 ADMINISTRATION Invoice Number: 3157791591 P 0 Number: 1125 -2 -01- 4230200 MKTN Release: Order: 7075381255 -000 -001 Ordered by: SERRA GARSKE Job: Order Date: 7/08/11 r. r r' m tip m x L i o ne Item. Number Descr i t i on 0th p# Meas' Qt Price Pir i'ce 1 915787 FLIP ULTRA III HD CAMCORDER 1 BX 1 129.99 129.99 rel ax p a Total Backorder of 7075381255 7 MT Purchase Description l l�J l l I P.O. P or F G. L. I yi nC) �y�- y: 3udcet Line Descr 0FC_ Su l� PL I sS Purchaser Date Approval Data Customer Service inquiries 800 693 -8080 Invoice Payment Inquiries 888-753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 -3689 0011159 0043110 0000006 INV0[M: DATE: ;'s CU STOME#i ..S:UIVIMARY< INVOIGE> 7/23/11 DE 1061088 8019175743 8/22/11 Net 30 Days 169.77 1. ®�CFi DETAIL Staples Advantage Federal ID #:04- 3390816 CARMEL CLAY PARKS AND RECREATION CITY OF CARMEL PAULA SCHLEMMER ATTN: SERRA GARSKE 1411 E 116TH ST 1411 E 116TH ST CARMEL, IN 46032 CARMEL, IN 46032 Bill to Account: 1030597 Ship to Account: 1411 E 116TH ST Budget Ctr: 1125 100 010 4230200 ADMINISTRATION Invoice Number: 3158070560 P 0 Number: Release: Order: 7075754840 -000 -001 Ordered by: SERRA GARSKE Job: Order Date: 7/20/11 r, Order na ,p. Um x e, Line "Item Number 4' .ilpiion Qty- -Qt _Metes x.' l?t Price Price: 1 581672 DURACELL COPPERTOP AA16 DBLW 1 PK 1 14.78 14.78 2 612997 SHEET PROT STPLS HEAVYWT 20OCT 1 BX 1 21.86 21.86 3 764134 INKJET SHIP 3 113 25PK 6UP 1 PK 1 10.02 10.02 4 492072 SPLS 8.5X11 30% REC COPY CS 2 CT 2 38.05 76.10 5 452828 100% RECYCLED 115 MANILA LTR 2 BX 2 11.30 22.60 6 516564 FOLDR 100% RECY PCW 113 LTR NIL 1 BX 1 24.41 24.41 .F'e,l .'afX O a Total.: 169.77 Purchase Description FICL SljppLkE �D P.O.# PorF Q G.L.# G1 I -01-- 4 23 0202 A JUL 18]la I Line D OrWe PU MILO Line Descr P urchaser Date r ..,..e o.a Approval Date Customer Service inquiries 800 -693 -8080 Invoice Payment Inquiries 888 753 -4104 Page: 1 Make checks payable to Staples Advantage, Dept DET PO Box 83689, Chicago IL 60696 -3689 0016515 0014161 0000004 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of 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. 361528 Staples Business Advantage Terms Dept DET 2368 P.O. Box 83689 Chicago, IL 60696 -3689 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) PO Amount 719111 3157516220 Office supplies MCC 28788 492.82 7/16/11 3157791589 Office supplies MCC 28782 516.18 7/13111 3157791590 Office supplies AO 98.74 7/16/11 3157791591 Camcorder 129.99 7123/11 3158070560 Office supplies AO 169.77 Total 1,407.50 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, 361528 Staples Business Advantage Allowed 20 Dept DIET 2368 P.O. Box 83689 Chicago, IL 60696 -3689 In Sum of 1,407.50 ON ACCOUNT OF APPROPRIATION FOR 101-General/109 Monon Center PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members Dept 1091 3157516220 4230200 492.82 1 hereby certify that the attached invoice(s), or 1091 3157791589 4230200 516.18 bill(s) is (are) true and correct and that the 1125 3157791590 4230200 98.74 materials or services itemized thereon for 1125 3157791591 4230200 129.99 which charge is made were ordered and 1125 3158070560 4230200 169.77 received except 9 -Aug 2011 Signature 1 7 407.50 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund INVOICE<'DATE USTQMER SUMMARY INVOICE: 7723/11 DET 1061088 8019175742 B 8/22/11 Net 30 Days 293.85 I1W 01 C DETAIL Staples Advantage Federal ID #:04- 3390816 CITY OF CARMEL -NJPA CITY OF CARMEL JIM SPELBRING ATTN: MICHELLE BREEDLOVE 1 CIVIC SQUARE 3450.W 131ST ST. CARMEL, IN 46032 DELIVER BY 4PM CARMEL, IN 46074 Bill to Account: 1030382 Ship to Account: 3450 W.131ST ST Budget Ctr: 601 WATER DEPARTMENT Invoice Number: 3158070559 P 0 Number: Release: Order: 7075837869 000 001 Ordered by: MICHELLE BREEDLOVE Job: Order Date: 7/22/11 r r order... mt ,p x e Line` tern Nmiber Description Qt Qt Meas' qt" Price Price 1 BRTTN460 BROTHER TN -460 BLACK TONER 1 EA 1 61.72 61.72 2 490340 MARKER PENSTYLE LIO ACCENT PNK 1 DZ 1 21.05 21.05 3 920258 SELF INKING DATE STAMP 920258 1 EA 1 6.53 6.53 4 787051 Pen retract fine Softfeel Bk 2 DZ 2 5.71 11.42 5 450852 W1TE OUT SHAKE SOUZE COR PEN 3 EA 3 1.84 5.52 6 612919 PEN BALLPINT BLUE BARREL INK 2 DZ 2 4.58 9.16 Frei ax o a Total.: 115 �40'' Customer Service inquiries 800 693 8080 Invoice Payment Inquiries 888 753 4104 Page: 1 Make checks payable to Staples Advantage, Dept DIET PO Box 83689, Chicago IL 60696 -3689 0019584- 0933278- 0000005 VOUCHER 111976 WARRANT ALLOWED 361528 IN SUM OF STAPLES BUSINESS ADVANTAGE DEPT DET ,tea PO BOX 83689 CHICAGO, IL 60696 i Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO INV ACCT AMOUNT Audit Trail Code 8019175742 01- 6200 -06 $115.40 Voucher Total $115.40 Cost distribution ledger classification if claim paid under 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 of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 361528 STAPLES BUSINESS ADVANTAGE Purchase Order No. DEPT DET Terms PO BOX 83689 Due Date 8/8/2011 CHICAGO, IL 60696 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 8/8/2011 8019175742 $115.40 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 Date Officer