173331 06/10/2009 F CITY OF CARMEL, INDIANA VENDOR: 248970 Page 1 of 1
ONE CIVIC SQUARE ANN GALLAGHER CHECK AMOUNT: $110.93
CARMEL, INDIANA 46032 171 PARKVIEW COURT
CARMEL IN 46032 CHECK NUMBER: 173331
CHECK DATE: 6/10/2009
DEPA RTMENT ACC OU-NT PO NUM INV NU MBER AM DESC RIPTIO N
851 5023990 69.99 OTHER EXPENSES
900 4359005 40.94 CAR SEAT GRANT FOR CP
REMIT TSC BUSINESS ACCOUNT
j 'f
PAYMENTS TO:
i ilfiilV�� TRACTOR SUPPLY COMPANY
Su"LYC2 P.O. Box 9020 Tractor Supply Company
Des Moines, IA 50368 -9020 18160 U.S, 31 North
TSC TEAM MEMBER TO COMPLETE Please include 16 Digit Account Number Westf ield, IN 46074
6035 301 317) 867 -3505
NAME CARMEL POLICE
3 CIVIC SO
ADDRESS CARMEL IN 460322584
(317) 571-2428
CITY STATE ZIP PHONE 431 786000104 2 933466
05/22/2009 11:23am
CUSTOMER TO COMPLETE 2177201 TANK ROUND 2FTX2FTX4
1,00 69,99 69.99 NT
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT. Government Asencies
The undersigned certifies The undersigned party certifies their exemption from
compliance with the agricultural Subtotal 69.99
payment of sales and use tax on tangible personal
sales tax exemption law of the state property as indicated below and /or purchaser is 7.00: Tax 0.00
indicated below and understands Total 69.99
and agrees with the General engaged in the business of agricultural production of Visa 69.99
Exemption Statement a right and food or fiber, horticulture, aquaculture of floriculture for Accts E i E i E E i:: i E E9937
resale and /or uses the farm machinery, equipment or
the applicable statement of the Auth *:002307 Refo:900015166238
respective state printed on the other agricultural production items purchased free of Chance 0.00
reverse side of this form. tax, as defined by state law, and as indicated below. Cash tack
PRODUCT IS TO BE USED IN THE FOLLOWING The undersigned party further certifies they
STATE: understand they may be liable for payment of all taxes
(REQUIRED) due on the purchase price for the goods as allowed by I asree to pay above total amount
(Exceptions: Georgia, New York Kentucky state law should such goods be used or consumed In
COMPLETE REVERSE SIDE) a taxable manner as defined by state laws. accordins to card issuer asreement
PURCHASER IS ENGAGED IN: (REQUIRED) (merchant asreement if credit voucher).
Resale Under penalty of perjury, signee swears the EiEiiiEiEiEE :EEiiEEEYEitEEEtEEiiiEiii
Government information on this statement is true and correct in
Exempt organization every material manner. A willfully false representation
Agricultural Production of exemption will cause the purchaser to be subject to Call 800 -968 -0734 within 7 days to
Dairy Production penalty and /or other provisions as allowed under state complete a survey and be entered in a
Livestock Production monthly drawins for a chance to win a
Floriculture /AcluacultureProduction law $2500 shoppins spree.
Other: (Awarded as Gift Card) NO PURCHASE
OR SURVEY NECESSARY, Ends 9/30/09,
ITEMS PURCHASED WILL BE USED FOR: (REQUIRED) 2EitEiEfiEEEEYEEEEE2EfEiYitEEEtEilEEi
Farm Machinery/Repair Parts Government Agency (Entity
Livestock Injestibles or Injectibles Exempt Organization (Entity Enter Store 0431
r NC: only DOT and US Government are exempt
Fertilizer /A g ichemicals For complete details so to:
Consumed in Production (KS) Resale (Sales Tax Permit# Tractoy
EEEEEE1EEEiitEYEEE2EEEEiiEEEEi3EEiEiE
Ingredient or Component Parts (KS) EfEii2EEEiiiEEfiiEEEEEEEEEEEiii2EEEiE
Other: For Customer Service comments
Call 877 -872 -7721 or so to
CUS MER GNATUR UI ED) MGR. APPROVAL tractorsupply.com
And click On Customer Service tab
USE SHADED AREA X
ONLY
CASH CHECK VISA TSC CHARGE ACCOUNT NO. CHG: EXCH. DATE
L] ITEM NUMBER D ESCRIPTI O N
Form No. 99 -00401 (12/05) CUSTOMER ORIGINAL
ARKANSAS: The customer as indicated by thew signature on the reverse, certifies 11,11 he:she is c- ngaged in the business of farming and the farm machinery and equipment purchased
will be used exclusively and directly in the agricultural production of food or fiber as a business. the reverse signed is aware that any false representation made by them in an attempt to
Purchase farm machinery and equipment free frnrr'+ Arkansas Sales Tax is a misdemeanor,
GEORGIA: The reverse signed hereby certilies that all tangible personal property purchased or leased after the reverse indicated date will he purchased or leased for the purpose
indicated below, unless otherwise specified on a particular order, and that the purchases are used as a pan of a pursuit engaged in for profit. This certificate shall remain in effect until
revoked in writing. Any tangible personal property obtained under this certificate of exemption is subject to the sales and use tax if it is used or consumed by the purchaser in any manner
other than indicated on this certificate, (Check proper box.)
-FARM MACHINERY AND EQUIPMENT-
1. Rubber-tired farm tractors and attachments which will be used exclusively in tilling, planting, cultivating or harvesting farm crops for sale. Such crops will he planted and harvested
within a twelve -month period O.C_G "A. 48 -8- 3(29)(1)
j 2. Machinery anti /or equipment which will be used on the farm directly in the production of poultry cr eggs for sale. O.C.G.A" 48- 8- 3(29)(A)
3. Machinery and /or equipment which will be used on the farm directly in the production, processing or storage of fluid milk for sale. O- C "G.A- 48- 8- 3(29)(C)
4. Machinery and /or equipment which will be used on the farm directly in the production of livestock for sale, O.C.G,A- 48- 8- 3(29)(D)
5, Machinery and'cr equipment -hich will be used on the farm directly in harvesting farm crops grown and Used on the farm as teed for poultry or livestock by a producer falling
under the cau 2, 3. c: abcvc- O- C -G.A. 48- 8- 3(29)(E)
j 6. Machinery and/or equipment which will be used in the hatching and breeding of poultry and livestock for salo_ O.C.G "A. 48- 8- 3(29)(B)
7. Machinery andior equipment which will be used in tilling the soil or in animal husbandry. O.0 "G "A" 48- 8- 3(29)(F).(G) (H)
8. Machinery and/or equipment which will be used exclusively for irrigation of farm crops grown for sale including, but not limited to fruit, vegetable and nut crops.
O- C.G.A.§ 48 -8 -3(26)
j 9. Pecan sprayers, pecan shakers and /or other equipment used in harvesting pecans. O.0 "G.A. 48- 8- 3(29)(J)
1 10. Equipment which will be used on the farm exclusively in processing onions. O.C.G.A" 48 -8- 3(29)(1)
TIMBER EQUIPMENT AND RELATED ATTACHMENTS-
11. Off -road equipment and related attachments which will be used exclusively in the site preparation. planting, cultivation, or harvesting of timber. This shall include all off -road
equipment and related attachments used in every forestry procedure starting with the severing of a tree front the ground until and including the point at which the tree or its
parts in any form ties been loaded in the field in or on a truck or other vef+icie for transport to the place of use. O.C.G.A- 48- 8- 3(29).9)
LIVESTOCK, SEED, FERTILIZER, FEED, PACKAGING, ETC.-
12. Cattle, hogs, sheep, horses, poultry, and bees when sold for breeding purposes. O- C.G "A. 48 -8 -3(28)
13. Seed, seedlings. fertilizers, insecticides, fungicides, rodenticides, herbicides, defoliants, soil fumigants, plant growth regulating chemicals. desiccants (including shavings and
sawdust (turn wood, peanut hulls, fuller's earth, straw and hay) and feed for livestock, fish or poultry when used either directly in tilling the soil or in animal, fish or poultry
husbandry: and /or, nonreturnable materials used fo; packing farm products for shipment or safe. O "C "G.A. 48 -8 -3(25) (35) (A) (iii)
-FUELS USED IN POULTRY STRUCTURES ELECTRICITY USED IN IRRIGATION OF FARM CROPS-
j 14. The sale of electricity for the operation of an irrigation system which is used on a farm exclusively for irrigation of farm crops when separately metered. O- C -G.A. 48 -8 -3(64)
j 15. Liquefied petroleum gas or other fuel used in a structure in which broilers. pullets, or other poultry are raised when separately metered. O.0 "G,A- 48 -8 -3(49)
ILLINOIS: The reverse signed hereby ce,tities that the property purchased will be used primarily in production agriculture or in State or Federal agriculture programs. Any farm chemicals
purchased as exempt are such pursuant to Section 130- 195.5.
KENTUCKY: The reverse signed hereby certifies that they are a farmer regularly engaged in the occupation of: (farmer must initial appropriate line(s))
tilling and cultivating the soil for the p.'oduction of crops;
raising and feeding livestock or poultry the i:,ror.:ucts of which ordinarily constitute food for hurnan consumption; or ;r; t +r r i .i f1, i,
raising and feeding flotillas, alpacas, ratites, buffalo, or aquatic organisrs.
The reverse signed also certifies that the tangible personal property purchased as indicated below will be used for the exempt purpose(.) provided 'ifir uncle r'KF1S 132 X480.
Farmer must INITIAL appropriate line(s)-
r 1 t,�
Baling twine and wire I'
_.____Farm chemicals r %.t.- Ili :C. rn;lil)I! „i'
Farm machinery, attachments and repair /replacement parts therefor
Farm work stock i.•.t$t'Ss'iftBb$tts: 1 "tY$14 itifb2't,EL:
Feed and feed additives
Gasoline, special fuels, natural gas or liquefied petroleum gas d t t t f T I t t t i t fi S E
Livestock or poultry the products of which ordinarily constitute food for human consumption
Ratites, llamas, alpacas, buffalo, or aquatic organisms
Machinery, equipment, attachments and repair /replacement parts therefor to be incorporated into an existing on -farm grain /soybeaii:facil'ityj and 1poultrtyt Avestock,fiatlte, (lama,
alpaca, or aquaculture facilities`
Seed or fertilizer
Materials to be incorporated into the renovation or repair of an existing on -farm grain /soybean facilities and poultry. livestock, ratite, llama, alpaca: .,,aquaculture facility,
Water used in the production of crops as a business or in the raising of livestock /poultry, ratites, llamas, alpacas, buffalo. aquatic organisms antl dairy cattle.
SFF REVERSE SIDE SEE REVFRSE SIDE
Signature Date
MICHIGAN: The reverse signed hereby certifies that all items, except as indicated, are purchased for use or consumption in connection with the production of honjcu[turai.or,�•$$gricuitural
products as a business enterprise, and agrees to reimburse the seller the sales tax if used or consumed otherwise. Unlawful use of this certificata 'subjects `Persons to the piln�ities of the
sales tax act. (`JI"!' R•r (fif i'r LEa �,[iYr7,��✓r�
NORTH DAKOTA, SOUTH DAKOTA: The purchases made herein are subject to the reduced rate of sales tax and are not exempt from sych tax.
NEBRASKA: The reverse sig ned certifies the intended use of the items :L f 1+ .l L Si
9 purchased renders it exempt under Rag- I -060. 1 -061 or I -063. Q 1
TEXAS CERTIFICATION OF EXEMPTION n '7 t. r lit r j -11 fel
Purchaser's name SE F_ REVERSE SIDE
Street Address SEE REVERSE SIDE
City, state, zip code SEE REVERSE SIDE
I claim an exemption from payment of sale s and use taxes for the purchase of taxable items described below or on the attached order invoice:
SEE REVERSE SIDE t)t!L4e'f Lt 9? f lwt l of i't tt.t l t$ rS t 9 i L2
Description of items (or an attached order or invoice) to be purchased: t I t
S E E REVERSE- SIDE_ t$t2!tttf.t3 t 9' t it t t t t.tt it tf t t; t•d
I claim this exemption for the following reason:
SEE REVERSE SIDE
I understand that I will be liable for payment of sales tax which may become due for failure to comply with the provisions of'1he Use. T. Vtii,Act.
Municipal Sales and Use lax Act, Sales and Use Taxes for Special Purpose Taxing Authorities. County Sales and Use Tax Act, County Health Services Sales and Use,kax and the
Texas Health and Safety Code: Special Provisions Relating to Hospital Districts, Emergency Services Districts, and Erergency Services bfstricts in cou "a pop"i!'6d6rl of 1 000
or less. Liability for the tax will be determined by the price paid for the taxable items purchased or the fair market rental value for,,the period_ of used.., r r, I t 7;!i +I
I understand that it is a criminal offense to give an exemption certificate to the 'seller for taxable items which I know, at the time of purchase, wlit be used in a manner other than that
expressed in this certificate.
Seller: SEE REVERSE SIDE
Street address: SEE REVERSE SIDE
City, state, zip code: SEE REVERSE SIDE
Purchaser's signature: SEE REVERSE SIDE Date: Phone:
Title: SEE REVERSE. SIDE t� r?If t•1h
This certificate does riot require a number to be valid.
Sales and use tax exemption numbers or tax exempt numbers do not exist. -I 15 it d6 `!I
This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts,
Effective Date: September 10, 1991 i�(1. j1 �t /I t' j.. ,liglf �y' 3.287
NEW YORK STATE DEPARTMENT OF TAXATION AND FINANCE NEW YORK STATE AND LOCAL SALES USE d SAX
FARMER'S EXEMPTION CERTIFICATE s i r. nr}.i
To purchasers and setters: To be completed by the farmer, given to and retained by the seller. To have a valid certificate, all entries must be completed.
Read all instructions carefully before completing or accepting this certificate.
'io sellers: You may net accept this certificate as the basis for selling exempt from tax the property or services listed below. Taxl rriu'st be collected on such sales.
This certificate may not be used to claim exemption for the following:
1, utilities, fuel oil, motor fuel or diesel fuel; a
l; 2. labor charges in connection with repair, maintenance of or service to real properly: 3!'ngil lc personal property incorporated into �a building,
structure, silo foundation or other capital improvements to real property (excluding grape trellises and the remaining portions al a;silo)r 1t, motor vehicles; or 5, property listed s taxable.
Name of seller TRAC SUPPL CO MPANY AF FILIA TES Attn: Tax Name of Farmer SEE REV ERSE SIDE
Street address 200 Powell Place
.Street address SEE REVERSE SIDE
City Br entwood __State TN ZIP Code 37027 City,_. SEE_ REVERSE SIDE State ZIP Code
rSr lfir I'v :n
Check applicable box: =x Single Purchase Certificate El Blanket Certificate i,-
i, the reverse signed hereby certify that I am exempt from payment of the sales and use tax an tangible personal property purchassd f you because the property is to be used for
an exempt purpose and that certain services are also exempt when performed on an exempt property. (Check applicable box or boxes) `t 1
17 (a) Tangible personal property, except property incorporated into a building or structure, for use or consumption directly and predominately in;the production of tangible
personal property for sale by farming, including stock, dairy, poultry, fruit, fur bearing animal, and truck farming The t term farmfng'also includes ranching, operating
.Nurseries, greenhouses or other similar structures used primarily for the raising of agricultural, horticultural or floricultural commodities, and operating orchards or
vineyards.
F (b) Tangible personal property for use in erecting, adding to, altering or improving a silo used in farming to make 'and'atore'siiage ,pri farm, provided such tangible
personal property is to become an integral component part of such silo. (This exemption does not apply to to ngibiegpr, gal property used in constructing a silo
foundation.) t;S
C! (c) Posts and wire for use in constructing or maintaining vineyard trellises used in growing grapes for sale-
L (d),-Services of installing, repairing, maintaining and servicing exempt tangible personal property" (This exemption is provided for both state and local sales and use tax
with the exception of the tax Imposed by or for New York City 1 r
l "hose statements are made with the knowledge that willfully issuing a false or fraudulent certificate with the intent to evade tax is aryi isdemeanor under section 1617(m) of the New
York State Tax Law and section 210.45 of the penal law punishable by a fine of not more than $1,000, or imprisonment for not more than 'B year or both {'1
Signature of farmer or farmer's re p) SEE REVERSE SIDE I i ,r •(i
gn presentative (State title and relationship) Date
Seller The tax exemption for farmers is limited to the purchases of (1) tangible personal property used directly and predomina tly inthe production phase of farming and (2) the services
described in (d) related to that property- Purchases for use in administration, storage_ or marketing or purchases of tangible personal property used indirectly in farming would not qualify.
(See Publication 844, Sales Tax Information for Farruers, for a complete explanation of the tax treatment of farmers purchases and sales.)
For your protection, a farmer must give you this certificate not later than 90 days after delivery of the property sold or services rendered- If you not received this ce within 90
days of the date of sale, the sale will be deerned to have been taxable at the time the transaction took place and the burden of proving it was nut; shall be upon bbilr you`•and the purchaser.
part of n order received from the i Z, 1n1
If the blanket certificate box is checked, you rnay consider this certificate
p� any purchaser. A blanket certificate Tema ns n force ntilW purchaser gives
You written notice of revocation, or until the Tax Department notifies you that the purchaser may riot make exempt purchases- j;'_ !if t 1, 1
Purchaser You pay tax on utilities (telephone, telegraph, electricity or gas service) heating oil, motor fuel and diesel motor fuel at the time of purchase and claim a refund for any
exempt'usA(If you are purchasing diesel motor fuel for exclusive consumption in farm machinery used to produce tangible personal property for sale, you may use Form FT -1004,
Farmers Examption Crvrfificate for Purchases of Diesel Motor Fuel to purchase that fuel exempt.)
If the blanket certific;aie box is checked, you may consider this certificate part of any order received from the purchaser_ A blanket certificate remains in force until the purchaser gives
You written notice of revocation, or until the Tax Department notifies you that the purchaser may not make exempt purchases.
-"arc.. r• .t -4.:.
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))
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
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. A T #!TITLE A UNT
DEPT. I 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
JUN
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
F res` i by State Board of Accounts City Form No. 201 (Rev. 1995)
V 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
Ann Gallagher Purchase Order No.
1 71 Parkview Court Terms
Car IN 46032 Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s).or bill(s))
5/28/09 reimbursement for noodles for car seats 29.94
6/2/09 reimbursement for noodles and liner for car seats 11.77
Total 41.71
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
'HER NO. WARRANT NO.
r
ALLOWED 20
Ln Gallagher
IN SUM OF
171 Parkview Court
Carmel, IN 46032
ON ACCOUNT OF APPROPRIATION FOR
police grant fund
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
900 590 =05 29.94 bill(s) is (are) true and correct and that the
900 590 -05 44-7 materials or services itemized thereon for
`l which charge is made were ordered and
received except
June 3 20 09
&�A 'C 1)
Signature
Chief of POlice
Cost distribution ledger classification if
Title
claim paid motor vehicle highway fund
v �qr�
the Meijer Team appreciates your business
05/28/09
Your fast and friendly checkout was
provided by FASTLANE
GENERAL MERC'1
81541700096 FUNN00DLE
6 4.99 29.94 CT
1 01' A L
TOTAL TAX .06
TOTAL 29.
PA'v:MEN f S
VISA Payment TENDE=R 29.94
Acct:XXXXXX)(XXXXX9937
NUMBER OF ITEMS 6
Ti ITEM VALUE EXEMPTED 29.94
T1 TAX EXEMPTED 2.10
T2 ITEM VALUE EXEMPTED .00
T2 TAX EXEMPTED .00
T4 ITEM VALUE EXEMPTED .00
1'4 TAX EXEMPTED .00
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A0130007Z94DJS
Tx:85 Op:564 Tm:113 St:130 14:07:21,
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Meijer donors General Merchandise retums within 90 d}ys
from date of purchase and when accompanied with receipt.
After 90 days, manufacture? wafranty applies. For computer
and electronic items returns must be made within 30 days.
We cannot refund opened music, movies, collectibles, video
games and video games systems. However, damaged and
defective items will be exchanged for an identical item.
Ammunition must be returned�,within 24 hours of purchase.
n f tj
We accept returned food Items,;wIth or without
a receipt, including meals, p44 deli, produce,
grocery, dairy and frozen"
We will only accept returns on State approved WIC
items and formula with a receipt.
0 0
We stand behind ,our name, any product with the Mejjer"
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T x W
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Return Exchange Policy
Meijer honors General Merchandise-retums within 90 days
from date of purchase and when accompanied with receipt.
After 90 days, manufacturer's warranty applies. For computer
and electronic items returns must be made within 30 days.
We cannot refund opened music, movies, collectibles, video
games and video games systems. However, damaged and
defective items will be ech�anged, for an identical item.
Ammunition must }be returned> fthm124 hours of purchase.
We accept returned foo I ems with or without
a receipt, including meat, seafood, deli, produce,
grocery, dairy and frozen.**
We will only accept returns on State approved WIC
items and formula with a receipt.
We stand behind -our name any product with the "Meijer"
brand may be returned with or without a receipt.**
"Returns without receipt are subject to lowest sale price
Return AIExchanget
WO 41 U tt ns
Meijer honors General Merchandise returns within 90 days
from date of purchase and when accompanied with receipt.
After 90 days, manufacturer's warranty applies. For computer
and electronic items returns must be made within 30 days.
We cannot refund opened music movies, collectibles, video
games and video games system vHowever, damaged and
defective items will`tie exchanged for an Identical item.
Ammunition must be returned within 24 ours of purchase.
We accept returned food items with or without
a receipt, including meat, seafood, deli, produce,
grocery, dairy and frozen.**
CJ Cie
We will only accept retums oh State.. approved WIC
items °and formulawith a receipt.
We stand behind our name, any product with the "Meijer"
brand may be returned with or without a receipt.—
GC
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W I m,*ok,'
Save money. Live better.
WE SELL FOR LESS
MANAGER MIKE SMITH
317 844 0096
ST# 1601 OP# 00005488 TE# 19 TR# 06529
POOL NOODLE 08'1541700051 4,00 X
POOL NOODLE 081541700051 4.00 X
SELECT LINER 007535326880 3.00 T
SUBTOTAL 11.00
TAX 1 7,000 0.77
TOTAL 11,77
VISA TEND 11,77
ACCOUNT 49937
APPROVAL 4085700
TRANS ID 0289153502200415
VALIDATION -5761J
PAYMENT.SERVICE E
CHANGE DUE 0.00
ITEMS SOLD 3
TC# 3897 5744 9299 3050 3992
I IIIIIII 1111I IIIIIIII II IIIIIIIiIIIII IIII I111 1 I111111111111
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