201333 09/13/2011 CITY OF CARMEL, INDIANA VENDOR: 365657 Page 1 of 1
ONE CIVIC SQUARE MOLD DIAGNOSTICS
CHECK AMOUNT: $300.00
CARMEL, INDIANA 46032 206 E MAIN, SUITE D
MONROVIA IN 46157 CHECK NUMBER: 201333
CHECK DATE: 9/13/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1120 4350900 2765 300.00 OTHER CONT SERVICES
Mold Diagnostics, LLC Phone: 317 996 -4414
Fax: 317-996-4420
Email:
dcatt @molddiagnostics.net
Invoice 2765
Customer: SDto
Carmel Fire Station 42
3610 W 106`h M Carmel, IN 2M57
C ontact:
Captain Ernie Maroon
emaroonPcarmel.in.gov
Date Our Order Terms
8-26-11 2765 Date of
service
Quantity Item Units Description Sample location Unit Price Total
I On -site Air Includes I indoor and 1 Outside control $200.00 200.00
sample outdoor control sample; Over ceiling at
collection microscopic analysis and smokers table'
report
Additional Includes sampling, microscopic Over ceiling in $50.00 $100.00
samples analysis and detailed report Day room
Over ceiling in
Pepsi hallway
Subtotal $300.00
Thank you for your business! Balance Due $300.00
Form 111 9 Request for Taxpayer Give Form to the
(Rev. January 2011) Identification Number and Certification requester. Do not
Department of the Treasury send to the IRS.
Internal Revenue Service
Name (as shown on your income tax return)
I lY v�Gl Ifi
N Business name /disregarded entity name, if different from above
Ca
mo P ict os c c ;5
fl Check appropriate bA for federal tax
c
classification (required): Z Individual /sole proprietor C Corporation S Corporation Partnership Trust/estate
N
C O
v Limited liability company. Enter the tax classification C =C corporation, S =S corporation, P= partnership) 11- El Exempt payee
Y P Y P P P P)
C
N
C
CL c Other (see instructions)
Address (number, street, and apt. or suite no.) Requester's name and address (optional)
U
C ZoCa
m City, state, and ZIP code
List account number(s) here (optional)
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Social security number
to avoid backup withholding. For individuals, this is your social security number However, fora m
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on n page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3. 1 am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 4.
Sign Signature of
Here U.S. person Date 0, d!
General Instructions Note. If a requester gives you a form other than Form W -9 to request
your TIN, you must use the requester's form if it is substantially similar
Section references are to the Internal Revenue Code unless otherwise to this Form W -9.
noted. Definition of a U.S. person. For federal tax purposes, you are
Purpose of Form considered a U.S. person if you are:
A person who is required to file an information return with the IRS must An individual who is a U.S. citizen or U.S. resident alien,
obtain your correct taxpayer identification number (TIN) to report, for A partnership, corporation, company, or association created or
example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States,
you paid, acquisition or abandonment of secured property, cancellation An estate (other than a foreign estate), or
of debt, or contributions you made to an IRA.
A domestic trust (as defined in Regulations section 301.7701 -7).
Use Form W -9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN to the person requesting it (the Special rules for partnerships. Partnerships that conduct a trade or
requester) and, when applicable, to: business in the United States are generally required to pay a withholding
tax on any foreign partners' share of income from such business.
1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W -9 has not been received, a
number to be issued), partnership is required to presume that a partner is a foreign person,
2. Certify that you are not subject to backup withholding, or and pay the withholding tax. Therefore, if you are a U.S. person that is a
3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United
payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W -9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S. trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners' share of
effectively connected income.
Cat. No. 10231X Form W -9 (Rev. 1 -2011)
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))
2765 Sta. 42 $300.00
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
Mold Diagnostics
IN SUM OF
206 E. Main Street
Monrovia, IN 46157
$300.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT #/TITLE AMOUNT Board Members
1120 I 2765 I 43- 509.00 I $300.00 1 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
CEP 12 2n19
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund