171727 04/29/2009 CITY OF CARMEL, INDIANA VENDOR: 00350837 Page 1 of 1
ONE CIVIC SQUARE ATLAS RESTAURANT SUPPLY
CARMEL, INDIANA 46032 PO Box 4076 CHECK AMOUNT: $17,144.97
SOUTH BEND IN 46634 -4075
CHECK NUMBER: 171727
CHECK DATE: 4/29/2009
DEPART ACCOUNT PO NUMBER INVOI NUMBER AMOU DESCRI
1207 4350100 719006 4,530.73 BUILDING REPAIRS MA
1207 4350100 719007 3,617.60 BUILDING REPAIRS MA
1207 4350100 719008 4,566.91 BUILDING REPAIRS MA
1207 4350100 719009 317.18 BUILDING REPAIRS MA
1207 4350100 719580 191.26 BUILDING REPAIRS MA
:1207 4350100 720170 1,570.30 BUILDING REPAIRS MA
1207 4350100 721789 1,814.09 BUILDING REPAIRS MA
1207 4238000 721790 290.90 SMALL TOOLS MINOR E
=1207 4238000 725328 246.00 SMALL TOOLS MINOR E
52245 STATE RD. 933 NORTH 2244 S. DIVISION
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 7`5,x`8
(574) 272 -3343 1- 800 -552 -ATLAS (616) 248 -2888 1 -800- 492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY P.O. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 4075 1
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -11 11 1 -800- 333 -2001 (260) 467 -1788 I -866- 467 -1788
03/20/09
206230 01
CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
CARMEL, IN 46032
REFERENCE NUMBER 1:111 17—All! SALESPERSON
11 1101111111 SHIP VIA
.EN 3/20/09 1 21 STEVE PEAT NET 30 IG 367137 02 PREPAID ROUTE DEL;2=4 ERY
740180 WORKTABLE_ 30 "x48" SS W /GALV 1.000 1.000 .000 EA 246.00 EA 6.00
LEGS R ADJ UNDERSHELF NSF
Ser 6 1.000
MERCHANDISE MISCELLANEOUS TAX FREIGHT TOTAL DUE
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document. .00 .00 0 00 x 1 46. 00
DATE Company:
By:_ ORIGINAL INVOICE
Signature Title
EXCLUSION OF WARRANTIES. THE PUllV1C1t.11ASER AND SELL ,R AG .1l THAT THE IMPLIED
WARRANTIES
I �I r �1 I }ry I�I[IES OF MERCHANTABILITY AND FITNE IF SS If�� }£''O R, E T B II�AII� II a Q ttN I U I f I, �illf �i�{�}f([\,rn \ry A I �11D�
A L L OTIH E R OWARRA -NTI E S EXPRES OR IMPLI ARE EXCLUD FROM THIS 11 RA� AC
TII® N AMID I�\ g T ll�IA L1L 1 0T APPLY `I O. TIE S4� D, IPROV IID ED lr-IIO WIE THAIF TIHII S
E X`1�LU p S I 7 lYlV OIL WARRANTIES (7�'�p�7� (�/��T V.�J MAY Tll T GOODS SC�[ lD.'
PURSUANT TO THIS TRANSACTION ARE OR Mll. BE SUBJECT r Il SLY THE WARRANTIES,.
EXPRESS OR IMPLIED, GIVEN BY TIME MANUFACTURER THEREOF.
F.
Purc=haser. agrees, to purchase the above described goods and to-pay Atlas Restaurant Supply, .Inc. (Seller) the
total price stated herein for the above described goods, including sales tax, in accordance with,the Sale Terms.
Sale Terms b are net cash seven (7) days after delivery, with interest thereon at the rate of one and one half per-,
cent (l 4- month on the unpaid totap price, commencing seven (7) days delivery 'of the .described goods
for each month or portion thereof during which an outstanding balance of the total price ,remains. Purchaser
assumes all. risk of damages or destruction to the goods upon delivery. Purchaser agrees to pay Seller's`r'ea=
sonable attorney's fees and costs of collection of any amount not paid when due; Purchaser agrees that no
return of th& goods sold hereunder may be made to Seller without express writ=ten approval of Seller and that
Seller may charoe a reasonable stocking fee for all goods so returned.
SIECUR17 Y AGREEMENT. Purchaser hereby grants and conveys to Seller a .security interest in and to the
described goods, and in and to the proceeds thereon, to secure the payment of Purchaser for the goods sold
hereunder. Purchaser authorizes Seller to execute on its behalf and file any financing statements deemed nec-
essary by Seller to perfect its security interest in said goods. Purchaser warrants that the goods will be main-
tained in good condition and repair. The failure to pay when due of any amount payable here under shall con-
stitute a default under this agreement. Upon default, Seller have and may exercise all the rights and remedies
of a secured party under the Uniform Commercial Code or any other applicable law.
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASE R EMIT TO
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 5
0 (574) 272 -3343 I- 800-552 -ATLAS (616) 248 -2888 1- 800 492 -8527 ATLAS RESTAURANT SUPPLY 721790
RESTAURANT SUPPLY P.O. BOX 4075
3329.N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 4075
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805 1
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 800 333 -2001 (260) 467 1788. 1 866 467 1788
02/23/09
1I ARM EL, 2 06230 01
ITY OF CARMEL dba BROOKSHIRE GOLF CLUB
ROOKSHIRE GOLF CLUB .12120 BROOKSHIRE PARKWAY
CIVIC SQUARE CARMEL IN 46033
IN 46032
SALESPERS REFERENCE NUMBER I SHIP DATE DOC NO
2/23/09 21 STEVE BEAT NET 30 IG 364834 02 PREPAID ROUTE DELIVERY
660090 B44. 44" S/S REPL FLEX HOSE 1.000 1.000 .000 EA 40.00 EA 40.00
FOR PRE- -RINSE UNITS 25 /CS
660050 B107 SPRAY VALVE FOR PRERINSE 1.000 1.000 .000 EA 59.00 EA 59.00
UNITS B113/B133 12 /CS
740230 WORKTABLE CASTERS (84" /UNDER) 1.000 1.000 .000 ST 94.00 ST 94.00
5 "DIA SWIVEL 4 /SET 2 —W /LOCKS
790110 RANGE CASTERS HD SET OF 4 EACH 1.000 1.000 .000 ST 97.90 ST 97.90
5 "DIA. 2— LOCKING #S. B. RANGE ONLY
MISCELLANE MERCHANDISE
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document.
DATE Compan 290.90 .00 .00 .00 2 290.90
By.— ORIGINAL INVOICE
Signature Title
r
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASE REMIT TO
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507
(574) 272 -3343 1- 800-552 -ATLAS (616) 248 -2888 1 -800- 492 -8527 ATLAS RESTAURANT SUPPLY 71 9006
RESTAURANT SUPPLY P.O. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 -4075
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805 1
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 800 333 2001 (260) 467 1788. 1 866 467 1788
02/10/09
206230 01
CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
ICARMEL, IN 46032
REFERENCE NUMBER I SHIP N TERMS TAX CODE DOC NO
.EN 2/10/09 21 STEVE BEAT NET 30 IG D13577 02 PREPAID ROUTE DELIVERY
ITEM DESCRIPTION BACK ORDER U/M PRICE
795110 636MD 36" GRIDDLE MANUAL CTLS 1.000 1.000 .000 EA 970.4 EA 970.34
STAR —MAX NAT GAS 60M BTU
Ser# GM636DO608EO084 1.000
795170 602HD 2— BURNER N/G HOT PLATE 1.000 1.000 .000 EA 514.62 EA 514.62
STAR MAX 12- 3/16 "x28 -7/8" DEEP
Ser# 62009751 1.000
8050=0 T -49 SOLID 2 DOOR REFRIG 54" 1.000 1.000 .000 EA 2625.90 EA 2625.90
SS FRONT,ALUM SIDES INT 115V
Ser# 6600794 1.000
740178 WORKTABLE 24 "x30" SS W /GALV 1.000 1.000 .000 EA 201.76 EA 201.76
LEGS ADJ UNDERSHELF NSF
Ser# 71114 -3 1.000
740175 WORKTABLE 24 "x48" SS W /GALV 1.000 1.000 .000 EA 218.11 EA 218.11
LEGS UNDERSHELF NSF
Ser# 0809231822 1.000
MISCELLANE RPHANDISE
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document.
DATE Company: 4530.73 .00 .00 .00 4530.73
By:_ ORIGINAL INVOICE
Signature Title
tr N
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASE REMIT TO 719007
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507
(574) 272 -3343 1- 800 -552 -ATLAS (616) 248 -2888 1- 800 -492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY
3329 N. SHADELAND A VE. 929 N. COLISEUM P.O. BOX 4075 1
SOUTH BEND, IN 46634 -4075
INDIANAPOLIS, IN 462222 6 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1- 866 -467 -1788
x`/10/09
206230 01
o CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHI RE GOLF CLUB l,,.. 12120 BROOKSH I RE PARKWAY
It
1 CIVIC SQUARE CARMEL IN 46033
CARMEL, IN 46032
REFERENCE NUMBER SHIP DATE oe DOC NO
r
L J .:1.J L
ITEM DESCRIPTION o•e e 1 11=24111 o•e
740150 E3S8- 1620 -12T18 3 —C P'. II
BOWLS= 1GX20X12" 2 -18" DB'S
SETUP' SET IN PLACE OF EQUIPMENT 1.000 1.000 .000 EA 550.00 EA 550.00
DONE BY ATLAS
805040 T -23F SOLID 1 DOOR FREEZER 27" 1.000 1.000 .000 EA 2466.35 EA 2466.35
SS FRONT,ALUM SIDES INT 115V
Ser 4809663 1.000
MERCHAN US TAX FREIGHY TOTAL D UE
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document. 3617. 60 .00 00 00 3617. 60
DATE Company:
B ORIGINAL INVOICE
Signature Title
0
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASEREMITTO
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 7 19008
(574) 272 -3343 1- 800 -552 -ATLAS (616) 248 -2888 1 -800- 492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY
3329 N. SHADAVE- 929 N. COLISEUM SOUTH P.O. BOX 4075 BEND, IN 46634 -4075 1
INDIANAPOLIS. S. IN IN 4 462222 6 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1 -866- 467 -1788
DATE 0 2/10/07
206230 01
CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
CARMEL, IN 46032
SALESPERSON TIT
REFERENCE NUMBER SHIO VIA
2/10/07 21 STEVE BEAT NET 30 IG D13583 02 PREPAID ROUTE DELIVERY
ITEM DESCRIPTION
hi-
755135 AVENGER HT 2 08/1 UNDERCOUNTER 1.000 1.000 .000 EA 4566.91 EA 4566.71
DISHWASHER 70DEG RISE HI -TEMP
S/N 086245142
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a FR IGHT TOTAL DUE
TAX
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document. 7!45F, 91 00 00 00 4566.71
DATE Company:
By: ORIGINAL INVOICE
Signature Title
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASE REMIT TO
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 71 9009
(574) 272 -3343 1- 800 -552 -ATLAS (616) 248 -2888 1 -800- 492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY P.O. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 -4075 1
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1 -866- 467 -1788
e 02/10/09
206230 01
ICARMEL, CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 1`120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
IN 46032
REFERENCE NUMBER SHIP DA e• FREIGHT SHIP VIA
.EN MILLER 2/10/09 21 STEVE BEAT NET 30 IG 362332 02 PREPAIDI ROUTE DELIVERY
'ITEM DESCRIPTION
BACK ORDER U/M PRICE
T -24 -GC MUG FROSTER 24" BLK 1.000 .000 1.000 EA 1570.30 EA .00
WB2- -18 EAGLE UNDERBAR WORLBOARD 24" 1.000 .000 1.000 EA 313.96 EA .00
DRAINBOARD 24 "L X 18 "D
24STND -18 JACKSON 18 "H STAND FOR UNDER- 1.000 1.000 .000 EA 317.18 EA 317.18
COUNTER MACHINE
606297 EAGLE RACK SHELF 4c "KD 1.000 .000 1.000 EA 379.13 EA .00
TUBULAR DESIGN /KNOCK DOWN
CUSTOM EAGLE CLEAN DISHTABLE 43 "L 1.000 .000 1.000 EA 913.45 EA .00
APPROVAL DRAWING NEEDED
EAGLE CUSTOM QUOTE# H06941 A ITEM 2 1.000 .000 1.000 EA .00 EA .00
MEMO LINE FOR ABOVE ITEM
EAGLE #T3048SGS EQUIP.STAND 30X48 1.000 .000 1.000 EA 521.51 EA .00
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a MERCHANDISE DUE
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document. .18 00 00 .00 317. 18
DATE Company:
B y ORIGINAL INVOICE
Signature Title
52245 STATE RD. 933 NORTH 2244 S. DIVISION PLEASE REMIT TO
SOUTH BEND, IN 46637 GRAND RAPIDS, Ml 49507 1 INVOICE MMI �1 9580
(574) 272 -3343 1 -800 -552 -ATLAS (616) 248 -2888 1 -800- 492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY P.O. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 -4075 1
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1 -866- 467 -1788
206230 01
CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
ra BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
CARMEL, IN 46032
REFERENCE NUMIER SHIP DATE SALESPERSON TERMS 1 v SHIP VIA
,EN 2/03/09 21 STEVE BEAT NET 30 IG 364231 02 7PREP-A1IDR0
DELIVERY
ITEM DESCRIPTION BACK
660250 B -1230 WATER STATION COMPLETE 2.000 1.000 1.000 EA 191.26 EA 191.26
W /SS DRP PAN& B1210 GLS FILLER
STEVE TO DELIVER
MERCHANDISE MISCELLANEOUS 'TAX FREIGH1 TOTAL DUE
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document. 191. i 6 00 00 00 1 1 22G
DATE Company:
By:_ ORIGINAL INVOICE
Signature Title
+r
52245 STATE RD. 933 NORTH 2244 S. DIVISION
PLEASE R EMIT
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 INVOIC 72 1 789
(574) 272 -3343 1- 800-552 -ATLAS (616) 248 -2888 1 -800- 492 -85 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY RO. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 -4075 1
INDIANAPOLIS. IN 46226 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1 -866- 467 -1788
02/23/09
206230 y 1
CITY OF CARMEL_ dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 121 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
CARMEL, IN 46032
REFERENCE NUM13ER SHIP TE SALESPE R'SON TERMS TAX CODE DOC NO
.EN MILLER 2/23/09 21 STEVE BEAT NET 30 1 362332 02 P'REP'AID ROUTE DELIVERY
ITEM DESCRIPTION
006297 EAGLE RACK. SHELF 42 "KD 1.000 1.000 .000 EA 379.13 EA 379. 13
TUBULAR DESIGN /K.NOCK DOWN
CUSTOM EAGLE CLEAN DISHTABLE 43 "L 1.000 1.000 .000 EA 913.45 EA 913.45
AP'P'ROVAL DRAWING NEEDED
EAGLE CUSTOM QUOTE## H06941 A ITEM 2 1.000 1.000 .000 EA .00 EA .00
MEMO LINE FOR ABOVE ITEM
EAGLE #T3048SGS EQUIP. STAND 30X48 1.000 1.000 .000 EA 521.51 EA 521.51
MUG FROSTER S/N6652799
T MERCHANDISE MISCELLANEOUS TAX FREIGHT
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document.
DATE Compan 1814.09 00 .00 00 1814. 09
By ORIGINAL INVOICE
Signature Title
52245 STATE RD, 933 NORTH 2244 S. DIVISION PLEASE REMIT TO a
SOUTH BEND, IN 46637 GRAND RAPIDS, MI 49507 INVOICE ;—,0170
(574) 272 -3343 1- 800 -552 -ATLAS (616) 248 -2888. 1 -800 -492 -8527 ATLAS RESTAURANT SUPPLY
RESTAURANT SUPPLY P.O. BOX 4075
3329 N. SHADELAND AVE. 929 N. COLISEUM SOUTH BEND, IN 46634 -4075 1
INDIANAPOLIS, IN 46226 FORT WAYNE, IN 46805
FOOD SERVICE EQUIPMENT SUPPLIES (317) 541 -1111 1 -800- 333 -2001 (260) 467 -1788. 1 -866- 467 -1788
02-:/09/09
`06`30 01
CITY OF CARMEL dba BROOKSHIRE GOLF CLUB
BROOKSHIRE GOLF CLUB 12120 BROOKSHIRE PARKWAY
1 CIVIC SQUARE CARMEL IN 46033
ICARMEL. IN 46032
REFERENCE NUMBER SH16 VIA
.EN MILLER 2/09/09 2-1 STEVE BEAT NET 30 IG .6t 0 P'REP'AID ROUTE DELIVERY
ITEM DESCRIPTION BACKORDER U/M PRICE
T-2'4—GC MUG FROSTER E4" BLF'. 1.000 1.000 .000 EA 1570. 30 EA 1570.30
606297 EAGLE RACK SHELF 42 "KD 1.000 .000 1.000 EA 379. 13, EA .00
TUBULAR DESIGN /KNOCK DOWN
CUSTOM EAGLE CLEAN DISHTABLE 43 "L 1.000 .000 1.000 EA 913.45 EA .00
APPROVAL DRAWING NEEDED
EAGLE CUSTOM QUOTE# H06941 A ITEM c 1.000 .000 1.000 EA .00 EA .00
MEMO LINE_ FOR ABOVE ITEM
EAGLE #T3048SGS EIDUIP. STAND 30X48 1.000 .000 1.000 EA 521.51 EA .00
MUG FROSTER S/NG652799
SECURITY AGREEMENT. Purchaser hereby grants and conveys to Seller a MERCHANDISE MISCELLANEOUS TAX FREIGHT TOTAL DUE
security interest in the goods described above and their proceeds pursuant to the
terms and conditions contained on the reverse side of this document.
DATE Compan 30 00 00 00 1570. 30
By ORIGINAL INVOICE
Signature Title
Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
CITY OF CARMEL
r
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
�qS �f S7i4c Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
3 a
96 s o. 96
66 (v r de, s Ll Sao, 3
a 16 J g '7
a 6 6k D
D Oq g oo 6?
a L3 6g `7/9 sf1G
23 4 `J 3 o
g o '76 U_ f2o 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
9'7
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. A T #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
av
5 o bill(s) is (are) true and correct and that the
/aG 6. 9, materials or services itemized thereon for
G64, U CR) which charge is made were ordered and
1,2 ol received except
/a0'7
a0 '7 '7201 D 01 cv 15 36
20
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund