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173247 06/10/2009CITY OF CARMEL, INDIANA ONE CIVIC SQUARE CARMEL, INDIANA 46032 VENDOR: 360614 BUREAU OF MOTOR VEHICLES REGISTRATION DIVISION- SPECIAL PLAT 100 N SENATE AVE N404 INDIANAPOLIS IN 46204 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION Page 1 of 1 CHECK AMOUNT: $15.00 CHECK NUMBER: 173247 CHECK DATE: 6/10/2009 1125 4351000 15.00 AUTO REPAIR MAINTEN Carmel e Clay Parks &Recreation Date: 6/4/2009 Check payable to: Name: Address: Indiana Bureau of Motor Vehicles 100 N. Senate Ave. City, State, Zip Indianapolis, IN 46204 Marl check to payee CHECK REQUEST Return check to requestor Check Amount: 15.00 Date Required: ASAP Check needed for: Transfer of title and purchase of municipal plates Requested by (print): Requested by (signature): Supporting documentation or receipt(s) MUST be attached. To be paid from: PO Budget account GL 101 -1125 4351000 Budget Line Description Auto repair and maintenance Approved by (signature of Division Manager): on this date Paula Schlemmer JUN 0 4 2009 Form revised 1 -21 -08 DATE'a MARCH '12,200;9 VEHICLE IDENTIFICATION NO IFTPF14VX9KC'05934 14.5 F150 REG CAB 4X4 SS HP(SAEj GV,WR 4Q 30 7200 LBS 'NOMINAL 'TONNAGE YEAR MAKEi 2'0.09 FORD: SHIPPIl'R WEIGHT.'.':,: 50.71 LBS CYLS SERIES OR MOOEL 8 F141 Ford Motor Credit: Co (SIGNATURE OF RUTH RI ED REPRESENTATIVE) r Dearborn MI DEARBORN, MICHIGAN: 4 8121 CITY STATE 1 111111 .111.111:1111111111.11111 l,thei:undersigrted autho ed re p r esentdfroe of the com.ppny firm or corporahori named below herby cer City that the .new vehicle described above is the property of the said coinpany,flrm or corpporatian'and Is transferred of the above date 'and N under the Invoice umber in icat to the fo'llowing Ji stril u tor or dealer.. NRME QF DISTRIBUTOR t3EALER C'; P O` NUMBER Ruxer Ford ';Lincoln Mrciiry, In 1.23 Place :Road Ja°spe.t IN 4 754 6 47E067 is further certified that this was the first transfer of such new motor vehicle in ordinary trade and'commerce Each undersigned seller certifieii to the best of his knowledge, information and belief under penalty of law that the vehicle is new and has not been registereii in this or any state at the time of delNeryitind the vehicle is,net .subject to any security interests other than'those s#is Posed heroin and yrdnant title to.the vehicle. EO13 VALUERECEIYED.I7RANSFERTHE VEHICLE.'TESCRIBED ON'.THE FACE OFTHISCERTIFICATE.TO NAME OF:':: rp' PURCHASEfi(S)_ ADDRESS I C ertl}yi o the best 01 myy kkhow(bdge.that the odometer reading is r N DTenths DEALEH!^'WC I iGf 6500 74 By ��qy r NAME OF DEALERSHIP i DEALFR'S'ENSE NUMBER Being duly sworn upon ath sae statements se State of t•O■rl forth are true awl correct._ Subscribe2nd sworn to �j �e ::'betora thie day 01 20 County of 2: USE NOTARIZATION ONLY IF HE uirrei IN TITLING JURISDICTION NAMEIOF.:. PURCHASERS) l A DDRE SS :I can fy to the best Of'iny:know dge that the odometer:reading`i No Te nths BY' DEALER NAME 0 D UEALERSHIY DEALER'S, LICENSE NUMBER Being du y..twain upon oath says that the statements set State of forth are -true anc cot recf StiBscribed and: sworn to me L beiorethis da 20 County of v NoteryPubild LSE NOTARIZATI0NONLY if REQUIRED IN TITLING JUPoSDICTtON NAME OF- E PLIRCHASER(S) ADDRESS I certify to the best of my knowledge that the odometer reaping is No Tenths DEALER NAME ,i0 EALESHIP DEALERS LICENSE NUMBER Belau duly BY•- Sworn upon oath says.tliat the staterents set State o1 OY ..forth tr and con.ect SubsCH bed and sworn to me ue tietore [his day of 20 County o[ Notary Public ci• 0 5 E NOTARIZATIUNLY ON IF REOUIHEP IN TITLING JURISDICTIp11 PURCHASERS) ADDRESS n I cerlily to ille best of my knowledge that the: odometer:, reading is Nd Tenths NAME O DEALERSHIP DEALER'S LICENSE. NUMBER Being.duly sworn- upon...oath Says that the`Statemenl$ set;: are true an correct. Subscribed and sworn to me belola this,' day ot;: 20 County 01 1. Y. Notary Public ,Federal Law requlreS.you to stethIKe odotneter rrsteage. N connection with ate transipr of oymeiship. Failure to complete,or provlding a false statement may r6sult in fines and/or Imprisonment FS I certify to the knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked Odometer anical limits. -p Tthe odometer reading'k5 not the act i Ipileage,. Reading No Tenths, ;O The Mileage stated is m excess at its mach WARNINCsODOtuIETEH S E ANCY pate 04 ltatement •A' Date of Sale D 4 G 1�7 Beung duly sworn upon ath says that the statementsset forth are true An d'. correct..Subscribedand sworn 'to �meC Stgnatyra(s) of PutChaser(s) bef thi daV of G 20 sPnnted•Narne(s) of Pirrchaser(s) CompanyNarne (ifA State :of Add ress ot.Purchaser(S) 1st lien in:tavor:of 'sivhpge atffflreSS is `2nd lien:in tavorot whose address is IfSE NOTARIZATION ONLY IF REOUIRED'IN '1TUNG`JURISDICTIUhI,- County. of USE NOTARIZATION ONLY IF REOUIFIED .N TITLING,0.1RISDICTIDN 708897 Sold to CARMEL CLAY PARKS-" RMB REC.. Address 1427' E 116TH STREET CARMEL, IP:46032 EfC MER RUXER Ford Lincoln 'Mercury_" 123 PLACE ROAD' JASPER, IN 47546 PHONE (812) 482 -1200 Web Site w•w.ruxercom. e- mail .into@ wxer com The Manufacturer's warranty constitutes all of the Warranties with respect to the "sale of this item. The seller; Ruxer'Ford= CASH Lincoln- Mercury; Inc., :hereby expressly. disclaims all warranties, either. expressed or implied including any implied warranty Of merchantability offitness for: a particular purpose f. and the seller neither assumes or authorizes other person to assumes for'it'any. liability in connection with the sale of this product 'TOTAL Date 'Salesman 2309 F 14' 1•2_OXFORD_WH I T FORD, E 1 SO 4X4 1•FTPF 14VX9KCO5934 ARR AT RA 1 TIAL SELLING PRICE 02 APR 2009. IPCIANA.,SALES TAX iA!PIAtA TIRE TAX s TI�RL IrI T R' U C K S Model V.I.N.N Description. Amount .EXTENDED SERVICE' CONTRACT P p# 07 6) .SELL f N#G. PRICE 43394 21710,75 1.26 21712.00 NAME OF DEALER RUXER FORD LINCOLN-MERCURY, INC. Dealer's RRMC 10118i73 (Registered 3TOO1 Retail i Merchant (I Certificate 1 1 Number) 1 1 1 u (10 digits) LOC# 3 digits) D ter:s FID,# t�g(feral Identification Number, 9digits) TID Dealer' U Address of Dealer 123 PLACE ROAD City J ASPER te It Zip.C_ode 4 /54b NAME OF PURCHASER(S) (PRINT OR TYPE) CARMEL. CLAY PARKS AND REC SSN FI D (Mandatory) Address of Purchaser 1427 E 11GTH STREET City C ARMEL tate I1 Zip Code 40.32 Vehicle Identification Number) Or HIN (Hull Identification Number) lf FPF141/X9KCOS34 Year (1 rd VIN e RD odell.Len Calcula tion Of Purchase Price Trade in' Information'. 1. Total Purchase Price 2. Trade Allowance (Like -kind exchanges only) 3. Net Purchase Price (Line 1 minus Line 2) 1. tr/1U /..5- VIN (Vehicle Identification Number) Or HIN #(HuRIdentitication 2. Year Make Model /Length 3. 21 10. 75 NEW RESIDENT STATEMENT Must Be Completed if Exemption 8 is claimed, see reverse side. certify that I became a resident of INDIANA on (month year) My previous State of Residence was I hereby. certify that the above statement is true and correct. Date Signature of Owner A SALES /USE TAX WORKSHEET To be completed if Sales and /or Use Tax was paid to a state other than Indiana, Exemption 15. See reverse side. Date of Purchase 1. Purchase price of property subject to sales /use tax 1. 2. Indiana sales /use tax due: Multiply Line 1 by sales /use tax percentage (6 2. 3. Credit for safes tax previously paid to another state 3. (Do not include flat fees, local, and /or excise taxes.) In what state was the tax paid? 4. Total amount due: Subtract Line 3 from Line 2. 4. (Line 3 can not exceed Line 2) DIRECT RELATIVE IDENTIFICATION EXEMPTION (Must Be Completed if Exemption 11 is claimed, see reverse side). Name(s) on original title Relationship of above parties Name(s) being added /deleted PUBLIC TRANSPORTATION EXEMPTION (Must be completed if exemption 4 6 is claimed and you are not a school bus operator.) USDOT (U.S. Department of Transportation Number) uric I certify that the above vehicle or watercraft is exempt from sales /use tax under exemption (see reverse side). I also certify that any sales tax credit shown as paid to an out of state dealer using exemption #15 wal actually collected by the dealer and the dealer has not provided the buyer with a check to be paid to the BMV. I understand that making a false statement on this form may constitute the r e .oliperjury. Date A i V Signature of Purchaser A A Form ST -108E State Form 48841 R3/ 5 -05 Indiana Department of Revenue Certificate of Gross Retail or Use Tax EXEMPTION for the Purchase of a Motor Vehicle or Watercraft CI DEMO.(:. YEAR COLOR. M VIiOR :SERIAL NO. -I TO BE DELIVERED:• U. ON OR ABOUT ODOMETER; DISCLOSURE STATEMENT' Federal law (and State law,'. if applicable) requires tha£you state the mileage' upon transfer of ownership. Failure to complete -or provid- ing a false statement may result !n fines andior`iniprisoninent (transferor's name, Print), state that the •odometer now' reads` s s (no:tenths).miles and to'the best oh* knowledge.that it reflects the> actual Jfniledge, of the vehicle described below unless one :of the followirig, state ,ments is checked: (1), ''I, hereby: certify that to :the best of my knowledge„ the odometer reading.: reflects: the amount of- mileage in,excess of :its' (2; I hereby certify, that theJ odometer, reading is,NOT the actual mileage WARMNG .ODOMETER DISCREPANCY (SELLER OR TRANSFEROR'S ADDRESS) (SELtEROR TRANSFEROR'S SIGNATURE) •DATE OF_THIS STATEMENT USED VEHICLE CREDITS YEAR MODEL' OR SERIES -MAKE BODY' TYPE' M.V.I. OR SERIAL NO "USED TRADE?IN ALLOWANCE BALANCE: OWED TO DEPOSISORCREDIT•BALANCE CASH'VVITH ORDER TO TAL' cREor TRANSFERTO RIGHT COLUMN ODOMETER DISCLOSURE•STATEMENT Federal Jaw (and State law, if applicable) requires that you state` the mileage upon transfer of ownership:., Failure to complete "or provid i a false statement may result in fines and/or'imprisonment, (transfeior'sname, Print) state that the odometer now reads (no tenths) miles and to the best of 'my knowledge that,itreflects the actual 'mileage 'of the vehicledescribe d;below,`unless one of the following statements'is Checked.. (1) 1 hereby .certify that AO the best of my knowledge the odometer` reading reflects the amount ,of milea9e'in, excess of kits `mechanical-limits. 't• (2) I hereby certify that the odometer reading Is NOT the actual INARNING'ODOMETER DISCREPANCY" (SELLER OR TRANSFERORS ADDRESS) SALESMAN TV STATE" RD� LINt:01'N� MfI1CiiRY,." STOCK'NO- :The only•warranties applying' to this 'vehicle are those offered. ;by' -the. manufacturer The selling, dealer hereby expressly disciaims all 'warranties, either express or irriplied;, including, any implied warranties of merchantability or• .fitness for a particular purpose, and assumes .noriauthori`zes any other person to assume for it`any Ilabili,ty'iri: connection` with >th -sale oi' ^this vehicle. Buyershall not -be entitled to recover-from the selling dealer any consequential, damages, .damage's 4o;property, damages,for Ions of .use; .loss:',.of •ti foss .,of• profits, or income,` or -1 any _other' ihcidental :damages NAME r r'•sri STREET'. STATE PHONE: t" OFFICEa, PHONE 'RES. DATE 'EXTRA`EQUIP.MENT; 'BASE PRICE L? l te) "9 7 .aIRTH'MONTH TRADE IN CERTIFICATION :THE C USTOMER CERTIFIES HIS TRADE IN.VEHIC HAS NEVER BEEN TITLED UNDER ASTATE`OR FEDERAL* BRAND" SUCH, AS 'DEFECTIVE "REBUILT', "SALVAGE ";'FLOOD", ETC RUST INHIBITOR/UNDERCOATING ,EXTENDED SERVICE AGREE. •:CASH PRICEOF�VEHIGLE &`ACC' cSTATE AND;LOCAL'TAXES. 'LICENSE AND TRANSFER ;PREPARATION AND,DELIVERY ;TOTAL SELLING PRICE TOTAL CREDIT OR ASH NET- SELLINGPRICE- AMOUNT OWED ON TRADE .;UNPAID -CASH BALANCE DUE,ON DELIVERY, ✓v ($ELLEROR TRANSFEROR'$S P TURF.: ..DATE OF THI$$TATEMENT Purchaser, agrees' that this includes` all' of` the terms and `conditions `on:.both the and reverse side hereof, that this` •Order- cancels,•"and supersedes any prior agreement and .as of this SIGNATURE date hereof comprises the 'complete •and 'exclusive t ,stateent :of 'the ;terms of the :4agreement relating to the subject matters covered hereby m and'that THIS :ORDER SHALL' BECOME .ACCEPTED BY BINDING UNTIL'ACCEPTEDBYDEALER OR HIS-AUTHORIZED REPRESENTATIVE,- Purchaser. by' execution' of this,Order certifies he is of majority, age and acknowledges that he has read ifs PE R •rat '3' j^'t �M r+ ;;r rs, terms and conditions and has 'received 'a`true copy of this "order. ';.f,. ;PURCHASER'S` Reynold. Aod'Rcy:wld, R09658 6/'(8,59) RUXER FORD LINCOLN `MERCURY INC.:.' 1'23 PLACE RDAD `JA SPE"k'INDIANA 47545 (812);482 -.1200 •F4X (812) 634 21.19t AND State APPLICATION LAW Form 53565 Bureau Complete application Attach additional license The application agreement. FOR NEW AND /OR TRANSFERRED ENFORCEMENT LICENSE PLATES 4 -08 of Motor Vehicles with all information in sections 1, 2, 3, sheets if necessary for information for each plate is requested. must be accompanied by a copy of each vehicle(s) MUNICIPAL and 4 as applicable. vehicle for which a municipal or law title, title application, or Internet: Please submit all Applications to: Indiana Bureau of Motor Vehicles Registration Division Special Plates 100 N. Senate Ave., N404 Indianapolis, IN 46204 Telephone: (317) 233 -3148 Fax number: (317) 233- 0053 http:llwww.mybmv.in.gov Indiana ',NSTRUCTiONS: 1. 2. enforcement 3. lease AM SEC T10N V APPUJCANTTtNFORMATION, r' Y. 0 Name of entiity that lie Cr& r j 1 or leases 2 the r v l e r hiic l n e(( s r a a', �i� 11115 Entity Telephone number (31 1) 1 J 2_ Entity's Executive Officer's name and title TeYry I�ly�.�s t7 x s Entity street address (r i 4 21 E• 1 toil& umber and street) cAve -2t City Coy Ake I County 4cLAML VI-13%n Indiana Zip Code 4 6 0 3 State Board of Accounts number Federal I.D. number ,55 1 Z tl (t;t they SECTION 2: "VFiitaE'1NEORmigION V b<; h nafiortfoceaofr ��(ar fri ,murtfcfpaf oriew errf nt ik erase tateds requested) '(1)zVEHICLE 4fi 4 {r q qty V1N (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) 1 Ftrni4U X 9 V.CO 513 Vehicle color laJ ha 1-r✓ Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, trailer, semi trailer, recreational vehicle) i"Yv r✓1— Vehicle Description (Make, model, Year) Fo lyd F'- I D i a -00 i Basis of Financial Responsibility (Source of self insurance; or Insurance Company Name and Policy number) lh C-C Z9 Description of official business for which the entity will use the vehicle 1'OlV'I i Yt' W 0Vie- Vehicle purchase or lease date (month, day, year) v© y The application is for X A new Municipal (check one): or Law Enforcement License Plate existing License Plate If a Transfer, VIN of Vehicle from which the License Plate is Transferred To transfer an (2) VEHICLE 1 VIN (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, trailer, semi trailer, recreational vehicle) Vehicle Description (Make, model, Year) Bas is of Financial Responsibility (.Source of self insurance; or Insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease date (month, day, year) The application is for A new Municipal (check one): or Law Enforcement License Plate existing License Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an ='(3» VEHICLE: f; VI (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, trailer, semi trailer, recreational vehicle) Vehicle Description (Make, model, Year) Basis of Financial Responsibility (Source of self insurance; or Insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease date (month, day, year) The application is for A new Municipal (check one): or Law Enforcement. License Plate existing License Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an (4r-VEHICLE, l!' VIN (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, frailer, semi frailer, recreational vehicle) Vehicle Description (Make, model, Year) Basis of Financial Responsibility (Source of self insurance; or Insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease date (month, day, year) The application is for (check one): A new Municipal or Law Enforcement License Plate Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an existing License (5) AVEHICLE ':4 f VIN (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g: Passenger, truck, motorcycle, school bus, city bus, trailer, semi- trailer, recreational vehicle) Vehicle Description (Make, model, Year) Basis of Financial Responsibility (Source of self insurance; or Insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease date (month, day, year) The application is for (check one): A new Municipal or Law Enforcement License Plate Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an existing License :(6 };VEHICLE"' rt VIN (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, trailer, semi trailer, recreational vehicle) Vehicle Description (Make, model, Year) Basis of Financial Responsibility (Source of self insurance; or Insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease data (month, day, year) The application is for (check one): A new Municipal or Law Enforcement License Plate Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an existing License '.(I• ,.VEHICLE "3' VIN (of New Vehicle or Vehicle that Municipal License Plate will be transferred to) Vehicle color Vehicle type (e.g. Passenger, truck, motorcycle, school bus, city bus, trailer, semi trailer, recreational vehicle) Vehicle Description (Make, model, Year) Basis of Financial Responsibility (Source of self insurance; or insurance Company Name and Policy number) Description of official business for which the entity will use the vehicle Vehicle purchase or lease date (month, day, year) The application is for (check one): A new Municipal or Law Enforcement License Plate Plate If a Transfer, VIN of Vehicle from which License Plate is Transferred To transfer an existing License CTION 3.ilwNTiTY CLrASSMFtCA ON The entity shall indicate which one (1) of the following classifications the entity belongs, thus entitling the entity to a permanent municipal license plate: The entity must also submit the following requested written documentation or meet the requirements that establish that the entity meets the classification for which it qualifies for a municipal or law enforcement license plate. Please check one (1): 1. The State of Indiana a) a state agency, b) a state university, or c) other state entity 2. A municipal corporation (as defined in IC 36- 1 -2 -10) "Municipal corporation" means any of the following: X a) a county, city, town, or township, b) school corporation (Must be listed as a school corporation with the Indiana Board of Education), c) library district (Must be Listed as a Library with the Indiana Stale Library), d) local housing authority (Must provide a certified copy of the ordinance(s) that establishes the authority), e) fire protection district (Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security), f) public transportation corporation (Must provide a certified copy of the ordinance(s) that establishes the corporation), g) local building authority (Must provide a certified copy of the resolution or ordinance(s) that establishes the authority), h) local hospital authority or corporation (Must provide a certified copy of the resolution or ordinance(s) that establishes the authority), i) local airport authority (Must provide a certified copy of the resolution or ordinance(s) that establishes the authority), j) special service district (Must provide a certified copy of the resolution or ordinance(s) that establishes the district), k) other separate local governmental entity that may sue and be sued (Must provide a certified copy of the statute, ordinance or resolution that establishes the entity) 3. A volunteer fire department (as defined in IC 36- 8 -12 -2) (Must be listed with the Indiana State Fire Marshall or Department of Homeland Security and provide a copy of the contract or resolution to provide firefighting services for a county, city, town, or township.) 4. A volunteer emergency ambulance service that meets the requirements of IC 16-31 and has only members that serve for no compensation or a nominal annual compensation of not more than $3,500.00. (Must be registered as a Volunteer Emergency Ambulance Service with the Indiana Emergency Medical Services and provide an official letter from the Indiana Emergency Medical Services Commission.) 5. A rehabilitation center funded under IC 12 -12 (Must be listed as a rehabilitation center with the Indiana Rehabilitation Bureau and provide a letter from the Indiana Rehabilitation Bureau of the FSSA.) 6. A community action agency (IC 12 -14-23) (Must be designated by the Governor or under Federal law as a community action agency.) 7. An area agency of aging and the aged (IC 12- 10 -1 -6) and a county council on aging that is funded through an area agency (Must provide a copy of the contract with the Bureau of Aging and In -Home Services.) 8. A community mental health center (IC 12 -29 -2) (Must provide a copy of the Division of Mental Health and Addiction's certificate to operate in Indiana as a community mental health center.) For Law Enforcement License Plate (only available to these entities pursuant to IC 9- 19 -3 -6): (Must provide official identification showing the representative is employed with the entity.) 9. The Indiana State Police Department 10. The Indiana Department of Natural Resources 11. A county police department 12. A city or town police department SECTION4 AFFRMAT1ONWAND`tlGNATURE The authorized representative submitting this application swears or affirms under the penalty of perjury that the answers and information contained in this application are true and correct, that the entity for which this application is made owns or leases the above listed vehicle(s) and uses it for official business pursuant to IC 9- 18 -3 -1. A municipal license plate issued to a vehicle shall be permanently attached to the vehicle listed in this application in accordance with IC 9- 18 -3-4. Date (month, day, year) 20o Typed or printed title of entity representative ParK Opent,} j1J l kt in RAW Signature of authoriz entity repres, ntgtive Typed or printed name of en ty representative Office telephone number of entity representative (31 7 s'7/ t// I/1/ FOR;BMV.OF FICE :USE ONL Application is: Approved Comments /Additional Information Needed: -For. Approved Applications: VIN (of Vehicle Receiving License Plate) Denied Additional Information Needed (see below) License Plate Number issued/Transferred Date Reviewed (month, day, year) MO License Plate Account Number APPLICATION FOR CERTIFICATE OF TITLE STATE OF INDIANA BUREAU OF MOTOR VEHICLES State Form 44049 (R4 3-02) Approved by State Board of Accounts 2002 TO BE COMPLETED BY A POLICE OFFICER, BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM INED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS. INVE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA- TION ENTERED ON THIS FORM IS CORRECT. 1 /WE UNDERSTAND THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI- TUTE THE CRIME OF PERJURY. FUTHERMORE, IIWE AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY LIABILITY ARISING FROM THIS TRANSACTION. X VEHICLE IDENTIFICATION NUMBER I 1 t I I 11 1 1 131 1 1 1 17 YR. MAKE MODEL TYPE DATE X r 1/1-01-4--- INSPECTOR'S PRINTED NAME 8 TITLE CITY 200 CI DATE: ju.„dyt 1? 1 The law regares that you apply for Certificate of Title within thirty -one days 1rom the date of purchase of a INSPECTOR'S SIGNATURE BADGE, BRANCH OR DEALER PLATE NO. motor vehicle. There is a dellnouent lee for failure to do so. Attach Certificate of Title assigned by seller. On en- domed Tdles. lien must be released. Supporting documents surrendered with this application cannot be returned to the eppli- cant. accordance with Federal Code 383. 1. 2, 4. 5. 6. 7. e. 9. 10. TITLE NUMBER BRANCH NO. INVOICE N0, BMV USE ONLY SOC. SEC. /FEDERAL LD.NO. APPLICANT'S NAME ��pA'4�� 1, u BMV USE ONLY STREET ADDRESS Loan E. }Iloll^ 1'. CITY CAVV STATE 1 K I ZIP CODE I .4 VEHICLE I.D. NUMBER 1 PI`14VX,WCOS 13 VEH,YEAR .2069 VEH. MAKE F,Yd VEH. MODEL NO. F 6 }D VEH TYPE TIZk ODOMETER I S 1 FORMER TITLE NUMBER PURCHASE DATE LIEN SPEED PICK UP MAIL DEALER NO. BMV USE ONLY FIRST LIEN'S NAME OR SPECIAL MAILING ADD ESS STREET ADDRESS CITY STATE ZIP CODE BMV USE ONLY SECOND LIEN'S NAME STREET ADDRESS CITY STATE ZIP CODE LICENSE NUMBER LICENSE YEAR FORMS USED BMV USE ONLY GROSS RETAIL USE TAX AFFtDAVIT INJE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW. SELLING PRICE LESS TRADE -IN AMOUNT SUBJECT TO TAX AMOUNT OF TAX DEALER BRANCH EXEMPT IF EXEMPT PLACE PARA.# Your Social Security number Federal I.D. number is being requested by this agency under IC 4- 1-8-1. Disclosure is manadalory 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 BUREAU TO BE MAILED WITH TITLE REPORT Transactions Bureau of Motor Vehicles Detailed Transaction Receipt State Form 51714 (4 -04) R 3a47 6 0 9 I il il JUL 0 7 2009 $15.00 tl Branch: VEHICLE SERVICES REGISTRATIONS Date: 06129/2009 Time: 9:28 EDT Visit ID: 1gg50081997 CSR: MS Visit Customer: CARMEL CLAY PARKS AND REC Trans IDTrans Tvoe Trans Subtype Amount 167243870 Title Initial Title Issuance New Title Fee Vehicle $15.00 Vehicle: 1 FTPF14VX9KCO5934 2009 FOR F15 PK Lien Holder: None Customer: CARMEL CLAY PARKS AND REC Purchase Date: 06/03/2009 Purchase Description P.O.* PorF G.L Budget Line Descr Purchaser Date Approval Date 7." 7-07 Charges to your credit card will appear as a line item charge not as a total transaction charge. Page 1 of 1 Invoice Date Invoice Number Description (or note attached invoice(s) or bill(s)) PO Amount 6/4/09 Ck request Title plates for new vehicle 1 15.00 Total 15.00 Payee Indiana Bureau of Motor Vehicles 100 N. Senate Ave. Indianapolis, IN 46204 ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice of 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. 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 Clerk- Treasurer Purchase Order No. Terms Voucher No. Warrant No. PO# or Dept 1125 MEtlii Bureau of Motor Vehicles Allowed 20 100 N. Senate Ave. Indianapolis, IN 46204 15.00 ON ACCOUNT OF APPROPRIATION FOR 101 General Fund INVOICE NO. Ck request ACCT #/TITLE 4351000 Cost distribution ledger classification if claim paid motor vehicle highway fund AMOUNT 15.00 15.00 In Sum of Board Members 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 4 -Jun 2009 p JG2ilirnowz) Signature Accounts Payable Coordinator Title