HomeMy WebLinkAbout173106 05/28/2009 CITY OF CARMEL, INDIANA VENDOR: 00351564 Page 1 of 1
ONE CIVIC SQUARE GARY CARTER CHECK AMOUNT: $15.00
CARMEL, INDIANA 46032 4748 BISHOPSGATE DR
CARMEL IN 46032
CHECK NUMBER: 173106
CHECK DATE: 5/28/2009
APARTM ENT ACCOUNT PO NUM BER INVOICE NUMBER AMOUNT DESCRIPTIO
1120 4358300 15.00 OTHER FEES LICENSES
Bureau of Motor Vehicles III IIIIIII IIIIIIIII III IIIIIIIIII III
Detailed Transaction Receipt
BMV State Form 51714 (4 -04)
Branch: VEHICLE SERVICES REGISTRATIONS Date: 05/18/2009 Time: 10:34 EDT
Visit ID: '19048553 CSR: MS
Visit Customer: CITY OF CARMEL FIRE DEPT
Transactions
Trans IDTrans Type Trans Subtype Amount
165587886 Title Initial Title Issuance New
Title Fee Vehicle $15.00
Vehicle: 1 FTSX21579EA85476 2009 FOR F2S 4C
Lien Holder: None
Customer: CITY OF CARMEL FIRE DEPT
Purchase Date: 05/05/2009
$15.00
Charges to your credit card will appear as a line item charge not as a total transaction charge. Page 1 of 1
APPLICATION FOR CERTIFICATE OF TITLE STATE OF INDIANA BUREAU OF MOTOR VEHICLES
State Form 205 (R7 6 -04) Approved by State Board of Account 1997
TO BE COMPLETED BY A POLICE OFFICER, BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE 1/WE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA-
FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAMINED THE FOLLOWING TION ENTERED ON THIS FORM IS CORRECT. I/WE UNDERSTAND
VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS. THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI-
VEHICLE IDENTIFICATION NUMBER TUTE THE CRIME OF PERJURY. FUTHERMORE, I/WE AGREE TO
INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY
R MAKE MODEL TYPE DATE LIABILITY ARISING FROM THIS TRANSACTION.
X
X
INSPECTOR'S PRINTED NAME TITLE CITY
DATE:
BADGE, BRANCH OR The law requires that you apply for Certificate of Title within thirty -one days from the date of purchase of a
INSPECTOR'S SIGNATURE motor vehicle. There is a delinquent fee of 821.00 for failure to do so. Attach Certificate of Title assigned by seller. On en
DEALER PLATE NO. domed Titles, liens must be released. Supporting documents surrendered with this application cannot be returned to the apply
cant. State fee for applying for Title is81s.00. *In accordance with Federal Code 080.
TITLE NUMBER BRANCH NO INVOICE NO BMV USE ONLY
1. 05180980300006 803 MV- GOVERNMENT CERTIFICATE OF ORIGIN
'SOC. SEC. /FEDERAL I.D. NO APPLICANT'S NAME BMV USE ONLY D
2. CITY O F CARMEL FIRE DEPT O
STREET ADDRESS CITY STATE ZIP CODE N
3. 2 CIVIC SO CARMEL IN 46032 0
VEHICLE I.D. NUMBER VIER YEAR VEH. MAKE VEH MODEL NO. VEH. TYPE ACTUAL
ODOMETER T
4. 1 FTSX21579EA85476 2009 FOR F2S TK 10 M T
FORMER TITLE NUMBER PURCHASE DATE LIEN SPEED PICK UP MAIL DEALER NO. BMV USE ONLY Y
P
5. C OF O 05/05/2009 0 No No Yes E
FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS STREET ADDRESS
6. I
N
CITY STATE ZIP CODE BMV USE ONLY
7. T
H
SECOND LIEN'S NAME STREET ADDRESS
8 S
CITY STATE ZIP CODE LICENSE NUMBER LIYEARE FORMS BMV USE ONLY A
9 USED Ms R
E
GROSS RETAIL USE TAX AFFIDAVIT I/WE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PA ID AS INDICATED BELOW A
SELLING PRICE LESS TRADE -IN DISCOUNT AMOUNT SUBJECT TO T AMOUNT OF TAX DEALER BRANCH EXEMPT IF EXEMPT
PLACE PARA.#
10. 0.00 0.00 0.001s 0.00 X 1
'Your Social Security number/ Federal I.D. number is being requested by this agency under IC 4- 1 -8 -1. Disclosure is mandatory and this document cannot be processed without it.
APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION
APPLICATION FOR CERTIFICATE OF TITLE STATE OF INDIANA BUREAU OF MOTOR VEHICLES
IIIIIIIIIIIIIII II VIII VIII VIII IIII I II VIII IIII VIII III
2 0 5 1 6 5 5 8 7 8 8 6
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))
Title Fee New Pickup $15.00
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
Gary Carter
IN SUM OF
$15.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Fire Department
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1120 43- 583.00 $15.00 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
MAY 22 2ana
a
Fire Chief
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund