205225 01/05/2012 CITY OF CARMEL, INDIANA VENDOR: 00351502 Page 1 of 1
ONE CIVIC SQUARE MACALLISTER MACHINERY
0 CHECK AMOUNT: $146.14
CARMEL, INDIANA 46032 P.o. BOX sso2oo
INDIANAPOLIS IN 46266 -0200 CHECK NUMBER: 205225
CHECK DATE: 1/5/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 040216243 77.94 OTHER EXPENSES
651 5023990 R6463621701 68.20 OTHER EXPENSES
MacAllister Engine Power
L 7575 E. 30th Street
PO Box 1941
Indianapolis, IN 46206
Ph: (317) 860 -4401
Please Remit All Payments to:
MacAllister Machinery Co. Inc.
PO Box 660200 Invoice Number PT040216243
Indianapolis, IN 46266 -0200
1175550
CITY OF CARMEL FRESH WATER CARMEL WATER UTILITY
PLANT 5 PLANT 5 ATTN DJ COWAN
760 3RD AVE SW 5484 E 126TH
CARMEL IN 46032 CARMEL IN 46033
Tiivoce; Date: PucYiase Order ;NLmi�er Doc Date S'Yip V Page
13DEC2011 JIM HAAG 13DEC2011•' CUST WAITING 1
Equ�.pment Number;:: Make Model 3er3 a1;; Number Meter Reading Machine ,;ID
!Quant Part ;;Number. N(R Descriptign UnY,t Price Extended ;Price:::.
PACKING SLIP NUMBER:04C287124
PARTS SALES PERSON: JAMES E. BARLOW
6 OIL SAMPLE WHITE CAP S 12.99 77.94
TOTAL PARTS 77.94 T
IND SALES TAX 5. T
TAX EXEMPTION LICENSE 00031201550010
NET 30 DUE 30 DAYS FROM INV DA
MacAllister Machinery's service labor is warranted to the customer for a period of 180 days from the date of work, to include defects in workmanship performed by MacAllister Machinery
employees. This warranty would include the replacement of parts and labor, damaged by that defect in workmanship.
Any failures caused by defect of parts, whether replaced new at the time of our work, or re -used, will be covered by the original manufacturer's warranties, if any.
Goods cannot be returned without our permission and are subject to restocking charge. All items marked with an asterisk have been declared non refundable by the manufacturer and
are not acceptable for credit.
Items not shown are backordered.
Claims for shortages must be made within 5 days.
TERMS: 1.5% PER MONTH (18 PER ANNUM) WILL BE CHARGED ON INVOICE PAST DUE Please Pay
THIRTY 130) DAYS. This Amount
CORPORATE OFFICE: 7515 E. 30th Street, PO Box 1941, Indianapolis, IN 46206 Ph: (317) 545 -2151 Fax: (317) 860 -3310
VOUCHER 113369 WARRANT ALLOWED
351502 IN SUM OF
Mac Allister Engine Power WA7ER
PO BOX 660200 OipERA710NS
INDIANAPOLIS, IN 46266 -0200
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
040216243 01- 6500 -05 $77.94
Voucher Total $77.94
Cost distribution ledger classification if
claim paid under vehicle highway fund
i
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
351502
Mac Allister Engine Power Purchase Order No.
PO BOX 660200 Terms
INDIANAPOLIS, IN 46266 -0200 Due Date 12/29/2011
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/29/201' 040216243 $77.94
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
MacAllister i E
Rental
Contract No. 636217-01
MacAllister Rental
Invoice No. R6463621701 Page 1
13450 BRITTON PARK ROAD
FISHERS, IN 46038
317 598 -9700
SALES INVOICE
Date 21DEC2011 2:10
1174600
CITY OF CARMEL
STREET DEPT =CARMEL 106TH ST
3400 W 131ST ST
WESTFIELD, IN 46074 106TH ST JEFF COOPER
WYNPHOEBE 00089
Qty %0 Item Number Bin Loc Unit Price Amount
4:'I C00LAN7.1?GAL(.ELC).. SHOWROOM EA 17 05 68.20
mspi
Sub -total 68.20
Total 68.20
IMPORTANT! Please note and acknowledge safety instruction by initialing here:
DECLARE DAMAGE WAIVER (Damage waiver is not available on crane rentals). Initial here:
"If declined current insurance certificate must be on file with MacAllister Machinery. By his/her Initial Customer will provide guard railing, planking, out riggers, and
other safety accessories a required, per safety instructions. Initial here:
PurchaserlLessee upon failure to pay balance when due shall be liable for all expenses incurred in collection of said balance including but not limited to attorney's
fees and court costs. It is agreed by the parties hereto that reasonable attorney's fees shall be one -third (113) of any amount owned by Purchaser /Lessee.
Net 10 days unless otherwise specified. A service charge will be applied to all past due accounts. This agreement shall include the above terms and conditions as
well as those set forth on the reverse hereof.
ACCEPTED BY CUSTOMER
WYNNSL511 ]Ju120111
:Please Remit.AII.P_ayments to: MacAllister Machinery Co. Inc., PO Box 660200, Indianapolis, IN 46266 -0200
MASTER RENTAL AGREEMENT TERMS AND PROVISIONS
1. MacAllister hereby agrees to lease to the named Lessee, meaning all lessees jointly and sever.]],, and Lessee hereby leases from MacAllister, under and subject to the terms and provisions hereof until the end of the term specified
the personal property described as "Equipnneni rented together with all present and future altaehmenis, replacement pans, repairs, and additions and all proceeds thereof.
2. It is understood belween the parties that MacAllister is ra l the mandacturer of the equipment herein rented, nor the agent of the manufacturer of said equipment and that no warranty against patent or latent defects in
material, workmanship, or capacity is given, nor that said equipment will meet the requirements of any law, rules, specifications or contract, which provide for specific machinery or apparatus or special methods, other than that
of the original manufacturer of said equipment and as set forth hithe manufacturer's catalog and representations wherein said machines' and equipment is listed and described. No representation or warranty is made as to the
year of manufacture of any equipment. NIACALLISTER HEREBY DISCLAIMS ANY AND ALL WARRANTY, IMPLIED OR E \PRESSED, OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.
3. MacAllister shall use reasonable care to see that the equipment is in proper working condition before shipment to lessee, MacAllister will not operate or rest the equipment unless such operation or lest is deemed necessary by MacAllister
or unless Lessee shall request such operation or test in waiting, in which event the Less" will he notified of the time and place of such operation and test, and shall be permitted to be present during said operation and test. If having requested
ii. Lessee fails to he present at the time of operation and test, Lessee agrees that said equipment as turned out is in proper operating condition.
4. The Lessee agrees to maintain the machinery and equipment in the same condition as when delivered to it by MacAllister, less normal wear and tear, and to pay all claims and damages to the equipment during the life of this contract, and to mf
return said property in as good condition as when received by MacAllister, and to pay freight demurrage, storage, switching, drayage, trackage, or other charges against said equipment from the time the same shall leave MacAllister up io and t
including the time of its return to MacAllister. MacAlf,tor reserves the right to charge Lass- for excessive undercarriage wear and tear.
5. For rubber tired equipment, Lessee acknowledges that repair and replacement of tires are not included in the rental rate and agrees to pay for the repair or replacement (with an allowance for reasonable depreciation) orally tires returned 16 Y
A1acA /lister in a damaged condition regardless of the cause of damage. Reasonable wear and tear is expected, however, it is agreed rubber abrasions (gouges, tears, cuts, grooving, and removal of rubber in pieces) or damage to castings is not'
reasonable wear and tear.
6. The receipt and acceptance by Lessee of said equipment will constitiue acknowledgement that said property has been accepted and found in good, safe and serviceable condition, and fit for use, unless Lessee makes claim io the contrar, to' AS
MacAllister by' registered mail wilh receipt demanded, addressed to MacAllister's home Office within (hire days after receipt of said equipment The complaint shall set forth specifically and in detail the complete nature and condition''
critic property received.
3, Should any of the machinery, equipment.or appurtenanees be received by Lessee from any drayman, railroad company or any other carrier transporting same in a damaged condition. or with any of the machinery, equipment. pans or
appurtenances missing -ail shall be the duty of Lessee to obtain From said drayman, railroad company or other carrier a written acknowledgement of the damage or shortage. The failure on the part of Lessee to obtain such statement or t
ackn6wled ement upon its receipt and acceptance ofsmcl machinery. equipment, parts and a nenances shall be heated as an acceptance of said machinery, equipment, ass and a appurtenances in good, safe, serviceable condition and fit for 4
P P P PP a P P PP B
tae, Any damage or loss which has Occurred and is not covered by a written acknowledgement or statement as'al'oresaid, or which occurs after acceptance of said property, shall be repaired and replaced at the expense of Lessee. If the
machinery. equipment, parts or appurtenances are damaged or lost in transportation and the lessee furnishes to MacAllister a written detailed acknowledgement and statement from the carrier setting forth the character of damage and loss,
MacAllister agrees to use reasonable diligence in having said damage repaired and loss replaced within a reasonable time, but the equipment shall be deemed to have been delivered on the date of acceptance thereof from the carrier.
8. In the event of notice to MacAllister by Lessee that the equipment is not in good, safe and serviceable condition and fit for use upon its accred. MacAllister shall have the right to put said equipment in good, side and serviceable condition
and fit for use, within a reasonable time, or cancel this rental.
9. MacAllister shall not be liable in any event to the Lessee for any loss, delay'. or damage of anv kind of characteriesulling front defects in or deficiency of the equipment hereby rented or accidental breakage thereof:
10. Lessee shall immediately notify MacAllister of om accident involving the equipment. MacAllister may repair said machinery for the Lessee. using reasonable diligence to make said repairs upon demand- In the event any work is done
outside of MacAllister's regular hours, by reason of which MacAllister shall be required to pay double time or other overtime charges to its employees, or to anyone doing the work for Lessee, all such charges will be paid by Lessee to
MacAllister. ht the event of accident or breakage of any Pan of the equipment, and upon receiving written approval from MacAllister. Lessee may have the saute repaired by anv competent person, firm or corporation at its own expense or,
upon notice to ,MacAllister as to such breakage or accident.
I I. In the event Lessee accepts the machinery and equipment, as herein provided, and thereafter the said machinery proves defective or unfit for use, or it for any reason Lessee desires to discontinue the use of said machinery or equipment,
the only remedy of Lessee shall be to return the machinery to MacAllister and terminate this contract as herein elsewhere provided_ by paying all rental charges and other charges herein provided for.
12, Lessec agrees to pa)' any and all charges for work or inspection by any labor union. MacAllister may. at its option, refuse to do any repair work on the equipment in time of strike, or any cause beyond its control, or in violation of any rule
affecting the equipment. MacAllister reserves the right to remove the equipment from the job .1 any lime when, in its opinion_ the equipment is in danger because of strike, war, civil disobedience, or anv otter condition which MacAllisier
determines may threaten the equipment.
13, Lessee agrees to comply with and conform to all municipal, state and federal laws relating to the operation of said machinery sad to pay all costs and expenses of every character occasioned or involving the use or operation of the
machinery or equipment, and to pay all legal assessments, taxes or public charges which may he levied upon said equipment while in the possession of the Lessee.
14. Lessee agrees to pay MacAllister for all loss and damages occasioned by fire, theft, flood, accident, explosion, wreck, and act of God or any other causes that may occur during the life of this rental, and until such machinery has been
returned to the possession o1 MacAllister and accepted by it. For the purpose of finding the valuation of said property in order to determine the loss, damage or injury thereto, it is agreed by the parties hereto that the value as herein before
slated shall be a true and fast value forming a basis for such adjustment. When equipment leased is deemed to be a total loss, Lessee agrees to pay MacAllister the manufacturer's suggested price of the equipment_ In making such adjustment
it is understood that po rentals theretofore paid or due apply to the payment of such loss, and it L further understood that MacAllister shall solely make the determination ofwhether the equipment is a total loss.
15, Lessee further agres to hold harmless and indemnify MacAllister from and against any and all loss, damage, expense, claim and /or penalty arising from any action on account army injury to person or property of any character whatsoever
occasioned by the operation, handling or transportation of any of the equipment during the rental period, and agrees to indemnify MacAllister from and against any and all such claims regardless of whether such loss was caused in pan by the
act. omission or negligence of MacA Ilister.
16. Lessee further agrees to insure all equipment rented from MacAllister with full insurance coverage as required herein, insuring the equipment against loss or damage arising front any cause whatsoever, including but not limited to
earthquake. Hood or mudslide_ MacAllister will provide Lessee at the commencement of the term of this Lease, and +vhe:h•shall be incorporated herein by reference, a separate document entitled "Equipment Rental Insurance Requirements
detailing the necessary coverages and terms thereof but which terms shall at least contain, but not by way of limitation, provision for I.) MacAllister as a lass payee' and 'additional insured' as applicable: 2.) waiver of subrogation against
MacAllister and its insurers on all claims: 3.) Lessee 's insurance shall be primary and non contributory; :rod, 4.) Providing said insurance to cover any and all damage arising from any or all perils, including but not limited to damage
occasioned by fire, theft, flood, explosion. accident, vandalism- electrocution. act of God, or anv other damage that may occur without limitation as to cause during the life of this rental. Lessee shall within one (I) day from the receipt Of the
equipment provide to MacAllister proof of insurance relative to the equipment from a carrier and in amounts acceptable to MacAllister. The proof of insurance shall contain at least (1) a cenificute of insurance (2) naming MacAllister as
additional insured and loss payee, (3) clearly describing coverage for the equipment, and (4) disclosing the name, address and phone number of the company providing the coverage.
17. The Ode to the properly herein rented and to all replacements thereof or substitution thereof is, and shall remain, with MacAllister, and said machinery and Nutriment shall not become a part of any building by being placed therein or by
being annexed thereto. Where the equipment is annexed to any properly the Lessee shall furnish MacAllister with a landlord's release, which shall permit MacAllister to remove the equipment from said property at any time during the life of
or after expiration of thi s contract.
18. The Lessee agrees, whenever requested bw MacAllister, to give MacAllister the exact location of all of the machinery and equipment covered by this contract and further agrees to give MacAllister immediate notice of any levy attempted'
upon said equipment, or if said equipment from any cause becomes liable to seizure, and to indenmify MacAllister against all loss and damages caused by any such action. MacAllister shall have the privilege at all times of entering any job, •'I
building or location where the above property is being used for the purpose of inspection and reserves the privilege of removing said machinery and equipment without notice if it is being overloaded or taxed beyond its capacity or in any
manner being abused or neg €eciA Lessee warrains that it has the express permission of all land owners upon whose land the equipment is used to so use the equipment. Lessee further warrants that it will not move the equipment from one
project to another without MacAllister's advance approval. which notice of movement shall be in writing.
19. This agreement cannot be assigned without the written consent or MacAllister. The equipment hereby rented shall not be sub -let without the written consent of foacAllister.
20. Should any of the provisions of this rental be violated by Lessee the rental for the entire period herein specified shall become forthwith due and payable and MacAllister, or its agents, may, without notice, enter the premises occupied by
Lessee without being a trespasser thereon, and lake possession of and remove said equipment with or without process of lave. In the event of any action as bereinbefore set forth becomes necessary the Lessee agrees to pay. in addition to other
charges herein specified, all costs of removal of said machinery from the possession of the Lessee and all freight, demurrage, storage, labor or other charge on or against said property incurred during the removal, shipping and return to the
Possession Of MacAllister at its home office or equivulent porn( designated by illacAllister.
21. Lessee agrees to pay MacAllister all sums due hereunder when the) become due.
22. Lessee agrees that if any of these provisiurls are breached and MacAllister demands the return of the equipment this rental agreement shall constitute authority to the watchmen or other persons responsible for fire equipment h) deliver all
or any pmt of the equipment to MacAllister or us agents.
23. In case any matter is written ar typed into this printed contract other than such as is necessary to fill in blanks provided herein, such matters shall be deemed an addition to the contract and it is specifically understood and agreed that such
added mater is not in any manner, whatsoever intended to alter the meaning or intention of the printed clauses of the contract and in case of conflict and inconsistency between the printed portions and the written or typed additions, the printed
portions shall control arry written or typed clause in conflict there,, iih and the loner shall be treated as void.
24. bush MacAllister and Lessee agree that no modifications of this agreement shall be binding upon ylacAllister unless such modification, cancellation. addition thereto or notation shall be in writing duly signed by MacAllister and duly
approved by an officer of MacAllister at the home office of MacAllisier. „u
25. This rental before becoming effective most be approved by an Officer or other authorized representative of MaCA l l aster.
26. MacAllister may execute, Ili, and sign Lessee's name to a financing statement or file a financing statement signed only by MacAllister covering equipment nr goods dvlivcrcd or In be deli d to Lessee under this agreement for
"informalOn purposes" or otherwise and also covering proceed and lance advances. This agreement constitutes a reservation of title or Security Agreement with reference to such transactions.
27. This agreement and acceptance of this agreement is subieci to corrections for arithmetic errors in computation-
28. MacAllister reserves the right to replace a rental unit with a like rental unit.�;i
29. Lessee agrees to maintain the rented equipment per factory recommended lubrication and maintenance imervals and keep seheduled oil sample records, MacAllister reserves the right to ask for maintenance records for the rental period.
Should said maintenance records not he available and factory recommended service maintenance is required, MacAllister will perform the appropriate service work al the Lessee's expense.
30. MacAllister's rental machines will be full of fuel when they leave MacAllister's premises. Lessee agrees to return said rental equipment fill of fuel or be charged with appropriate fuel backcharge.
3t. RATES. Rues are based on one shift operation 8 hour/day, 5 day /week or 40 hour /week. 160 hour14 week rental month. Unlcss quoted otherwise, ]tours used in excess of "one" shift (i.e. in excess of 8 hours per day or 40 hodis per•
week or 160 hours per month) will result in an additional shift rate being charged. and hours used in excess of a two shift operation (i.e. greater than 16 bours)day. 80 hours /week or 320 houm/mouth) shall result in yet an additional one shift
rate being charged.
32. Aggregation Clause The terms and conditions of this Master Rental Agreement shall cover all equipment, machinery and appuncnences leased by Lessee from MacAllister both presently and in the future. It is the intent of 1laeAllister
and Lessee that this Master Rental Agreement shall be construed as, and shall be, the Only rental agreement between file parties, even though Lessee may herealler execute additional Master Rental Agreements. For instance, if Lessee leases
one piece of equipment from MacAllister under this agreement in January, then another in May, both pieces ofequipment shall be construed as having been leased under one agreement: this Master Rental Agreement.
33. Damage Waiver Lessee specifically acknowledges that the payment of a fire, thcN, or vandalism damage waiver with respect to any equipment leased Crum MacAllister does not satisfy Lessee's obligation to insure the equipment nor
absolve Lessee of damage to the equipment caused by the negligence or carelessness of Lessee The damage waiver does not insure Lessee from damage to the equipment caused by Lessee, its agents, or others acting under Lessee's control or
operation of the equipment with Lessee's active or constructive permission.
34. Jurisdiction The parries agree that any disputes arising hereunder shall be resolved in the courts of Marion County, Indiana, and Lessee specifically subjects itself to the jurisdiction thereof. Further, Lessee agrees that in the event
MaeA Ilister is required to employee an attorney for the Po"SC of on forcing the terms and conditions hereof, or with respect to the collection of any amount due hereunder, MacAllister shall he enticed to recover its attorneys fees, cost of
collection, and all other reasonable expenses associated with such proceeding. m .j'.r
35: Accidents Without demand Lessee shall notify, Lessor immediately {and in any event, within twenty four 24) hours (hereafter) of each accident involving any equipment covered by this Master Rental Agreement Lessee shall include'
such information as is known, including, but not limited to the time, place. and nature of the accident or damage, the names and addresses of parties involved in the accidcnt(s), including but nor limited to persons injured, witnesses, and 14
owners of property dama Lessee shall promptly, advise Lessor of all correspondence, papers, notices, or documents whatsoever. received by Lessee in connection wilh'mmy claim or demand involving Or relating to anv equipment or its
operation and, together wish Lessee's employees aid in the investigation and defense craft such claims and demands, and in the recovery of damages from third parties liable therefore.
36. Rental. Protection Plan This paragraph is in force provided Lessee a) accepts the "Rental Protection Plan" through the proper indication thereof on the front of this contract, and pays at the time of equipment rental, or any extension of
said equipment rental, an additional sum equal 10 14 percent of the gross equipment rental charges: b) Lessee takes reasonable precautions to protect equipment and does not intentionally damage said equipment; c) Lessee does not cause any
loss or damage by negligence, including but not limited to negligent use or operation of the equipment in a reckless or abusive manner. Notwithstanding the purchase of a Rental Prgieetion Plan. Lessee shall it remain liable for a) 25
percent of the manufacturer's list price not to exceed $25.000 for sttileii equipment and b) 50 percent of the cost of repairs of any damaged equipment. Nothing herein to the comtrarv, the foll6wing iisks are expressly assumed by Lessee as its
exdusivc respocs,bilii): a) Damages caused by use or eperalion. of.the :equipment in a manner inconsistent with the manufacturer's instructions, or contrary to this contract; b) Loss or damage of accessory equipment such as welding leads,
electric cords, bits, batteries, hoses, rives, tubes or harnesses. etc:: c) Loss due to operation of the equipment by a person other than an aphorized operator per the contract or a ny'dishonest act by Lessee or by persons) entrusted by Lessee with r
the equipment, including Lessce s employees, subcontractors or agents: d) Loss of dam d m
age ue to flood, stor, earthqua ke or other external causes: c) loss cr mage da due to exceeding rated capacity, inisuse, abuse, negligence, or improper
servicing of equipment: f) Seizure or destruction of equipment by order of governmental authority, g) All loss or damage caused by vandalism, malicious mischief, disappearance. theft or wrongful conversion of equipment not reported by
Lessee prompt, (within 24 hours) to the police and Lessor by filing a formal written theft. wandithe an or conversion repon: h) All loss or damage to equipment resulting from nuclear reaction or radiation, or radioactive contamination from any
other cause; i) f.oss or damage as a result of the striking of overhead objects with equipment; J) Loss or damage to equipment occurring during the loading, unloading or transportation by Lessee; k) Loss due to the equipment being upset or
rolling over: m) loss or damage to equipment due to the exposure and contamination from hazardous material. This rental protection plan will not he effective unless at the time of such loss or damage the Lessees account with Lessor is
curtest In any event, accrued rental charges cannot be applied against the purchase. Or the cost of repair, of damaged, stolen or lost equipment. In the event of any loss, damage or destruction to equipment. Lessor will be subrogated to any
rights of Lessee to reani tr against any person, firm or corporation. Lessee will execute and deliver to Lessor whatever instruments and papers are required, and lake all other necessary steps to secure In Lessor such rights. Lessee will
cooperate fully with Lessor artdlor its insureds) in the prosecution of those rights and will neither take nor permit nor suffer any action to prejudice Lessors or its insurer's rights with respect thereto. The rental orotecton plan is not insurance
and does not protect lessee from its neplipenee nor from lability to others arisine out of possession use or operation oCeguip
09109
VOUCHER 116527 WARRANT ALLOWED
351502 IN SUM OF
MACALLISTER MACHINE CO., INC.
PO BOX 660200
Indianapolis, IN 46266
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
R6463621701 01-7502-06
Voucher Total $68.20
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
351502
MACALLISTER MACHINE CO., INC. Purchase Order No.
PO BOX 660200 Terms
Indianapolis, IN 46266 Due Date 12/30/2011
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/30/201" R646362170 $68.20
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