167772 01/20/2009 sa. CITY OF CARMEL, INDIANA VENDOR: 360614 Page I of 1
ONE CIVIC SQUARE BUREAU OF MOTOR VEHICLES
0
CARMEL, INDIANA 46032 REGISTRATION DIVISION- SPECIAL PLAT CHECK AMOUNT: $15.00
o w Eo 100 N SENATE AVE N404 CHECK NUMBER: 167772
INDIANAPOLIS IN 46204
CHECK DATE: 1/20/2009
DEPARTMENT ACCOUNT PO NUM IN VOICE NUMBER A DESCRIPTION
601 502399.0 15.00 PLATE FEE
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DATE INVOICE NO.
APRIL 22, 2008 II 55878 w
1 I YEAR
MAKE
0 1 1111VEHICLE IDENTIFICATION NO. IIIII 1,
III 2008 CORN PRO
4MJFB162X8E049416
BODY TYPE I II SHIPPING WEIGHT
p' ;ItI,• 5800 LBS 9,
FLAT <�.k
H.P. (S.A.E) G.i
200 R. NO. CYLS.IiI SERIES OR MODEL
00 ((LBS yl 16 1 OK (B) cr_"
1
Iii 9 _s II#�� !ill, i liil `i(s`'E°F
�fi: I {ItI' 1111 i'�i; ''4•^=����
I, the undersigned authorized representative oflthe company, firm or corporation named below, hereby certify that the,,; x
s the'property of said company, firm or corporation and is transferred on the above
new vehicle described above i
4t:=.,a date and underthe Invoice Number indicated to Elie following distributor or dealer.' s
NAME OF DISTRIBUTOR, DEALER. ETC. �I,. r1 "✓i6 s
IIIIlI 11 s•
l�Illl NORTHSIDE T LLC IIII,
II {il 11411 IIIII
969 RANGELINE ROAD
AREL IN
C M
Y¢�� 114111 46032 ►i�!� I !I 4 f�
1111.. 11411. ►IIII
It is further certified that this was the first transfd'r of such new vehicle in ordinary; trade and commerce. ii:
t:• ill ;I'I iiil�`��I
IIII CORNELIUS MANUFACTURING INC.,,•
IDII ct,► u a
W:
(SIGNATURE N.
BY: l r•
r (SIGNATURE OF AUTHORIZED REPRESENTATIVE) (AGENT) �r \t
a 4 Illll 0'0285 11111 IIIIi
I nil 5344E 1250 N
ELNORA, IN 47529
CITY STATE
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Each undersigned seller certifies to the best of his knowledge, information and belie) under penalty of law that the vehcle Is new and ha not boon rag?ytered
state or any state at the time of delivery and the vehicle is not subject to any security interests other than those disclosed herein and warrant titre to the ,h`. ta C 1
FOR VALUE RECEIVED I TRANSFER THE VEHICLE DESCRIBED ON THE FACE OF THIS CERTIFICATE TO:
NAME OF
PURCHASER(S), CAPKEL_WATZR_U-T -I-L -I T -I -E-S
w m ADDRESS 0_J_V 1 C It5gUCve )ill Q1�2
w
o Z I certify to th� best of my knowled a that the odometer reading is 4 v 7 ry
DEALER {u�R- ,kD- A- I- L— �'d NUM6"#Tl T
Z NAME OFD AL R HI EA LICEN E
w INDIANA Being duly sworn upon oath says that the statements set
M State of
m Z forth are true correct. Subscrib -d and sworn t e p
m before this TH —.day of_ U
County of HA
o Notary Public
USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION
NAME OF i
w¢ PURCHASER(S) 1
W
m ADDRESS
o 1 certify to the best of my knowledge that the odometer reading is No Tenths
Z
O Z DEALER NAME OF DEALERSHIP DEALER'S LICENSE NUMBER BY I
w Being duly sworn upon oath says that the statements set
m Z State of forth are true and correct. Subscribed and sworn to me
H 2 before this day of
In
a Co of Notary Public
USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION
NAME OF
w PURCHASER(S)
m ADDRESS
M I certify to the best of my knowledge that the odometer reading is No Tenths
Z Z DEALER BY
Z NAME OF DEALERSHIP DEALER'S LICENSE NUMBER
Being duly sworn upon oath says that the statements set
m Z State of forth are true and correct. Subscribed and sworn to me
a before this day of
o County of Notary Public
USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION
NAME OF
v
w¢ PURCHASER(S)
Q w ADDRESS
to
yy O I certify to the best of my knowledge that the odometer reading is No Tenths I
Z DEALER BY I
wr; O Z NAME OF 15EALERSHIP DEALER'S LICENSE NUMBER I
w Being duly sworn upon oath says that the statements set
2 State of
m_ forth are true and correct. Subscribed and sworn to me
before this day of l
U) v) fie ry of Notary Public
a a p Q
USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION
Federal Law requires you to state the odometer mileage in connection with the transfer of ownership. Failure to complete or providing a false statement
W may result in fines and/or imprisonment.
r I certify to the best of my knowledge that the odometer reading is the actual mileage unless one of the following statements is checked. Odometer
to Lu reading,_ No tenths []The mileage stated is in excess of its mechanical limits. ❑The odometer reading is not the actual mileage.
Signature of Seller(s) WARNING ODOMETER DISCREPANCY
cn
U) Date of statement Date of Sale
g Printed Name(e) of Seller(s) Dealer's No.
Ci Being duly sworn upon oath says that the statements set
W Signaturo of Purchaser(s) forth are true and correct. Subscribed and sworn to me
w Printed Name(s) of Purchaser(s) before this day of
qq Notary Public
u Company Name (It Applicable). State of
y Address of Pu+chaser(s)__� County of
E j U SE NOTAR17AT10N ONLV tF R UI
EQRED IN TITLING JURISDICTION
w 1&i lint) in favor of
^si c� j whose uddressi la'...
x
Y 2nd I" in fa+or of
Form Indiana Department of Revenue
STA 08E
Certificate of Gross Retail or Use Tax
State Form 49841 EXEMPTION for the Purchase of a
R3( 5-05
Motor Vehicl or W atercra ft
NAME OF DEALER f I Dealer's RRMC It (Raglsterea Retail WarchantCena3cate Number)
01.1974.1474 001
Northside Trailer LLC
TtD# (to digits) Lo 3 aig;
Dealer's FID (Federal Identification Number, a digits) Dealer's Plate Number
202061596 1796M
Address of Dealer City State Zip Code
969 North Rangeline Road Carmel IN 46032
NAME OF PURCHASER(S) (PRINTORTYPE) SSN, TID, OR FID (Mandatory)
CARMEL WATER UTILITIES
Address of Purchaser v City Slate Zip Code
C IViC
VIN (vehfdetdenttllCation Number) or HIN (Hutlldentnkaton Number) I Year Make Model/Length
4NiJFB162X8E049416 2008 CORN PRO 16 10K (B)
Ealculaiitin �f PurchaseP i Trade in Information:
1. Total Purchase Price 1. 7 37 5 00 VIN (vehlcleltlentAiraton Number)Or HIN (HWlldenttcetion Number)
2. Trade Allowance
(Like -kind exchanges only) 2� 0 Year Make Model /Length
3. Nei Purchase Price I I j
(Line f minus Line 2) ......................1., 3.1 7 ,375-00
I
NEW RESIDENT STATEMENT Must Be Completed if Exemption 8 is claimed, see reverse side
I certify that i became a resident of INDIANA on (month year)
My previous State of Residence was 1 hereby certify that the above statement is true and correct.
Date Signature of Owner oD
ISALES/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 sales 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. S
(Line 3 can not exceed Line 2)
DIRECT RELATIVE IDENTIFICATION EXEMPTION (Must Be Completed if Exemption It 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 6 is claimed and you are not a school bus operator.)
USDOT (U.S. Department of Transportation Number)
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 was 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 crime of perjury.
Date Signature of Purchaser
12/09/2008 14:46 FAX 3172330053 BMV Z003
Please subIIii all
t Applications t07
APPLICATION FOR NEW AND /OR TRANSFERRED MUNICIPAL
a AND LAW ENFORCEMENT LICENSE PLATES Indiana Bureau of Motor
V
p Slate Form 53565 (4.09) ivisi
D
Registraton Division-Special Indiana Bureau of Motor Vehicles iorrSpecial
Plates
INSTRUC77ONS. 1. Complete application with all information in sections 1, 2, 3, and 4 as applicable. 100 N. Senate Ave., N404
2. Attach additional sheets if necessary for Information for each vehicle for which a municipal or law Indianapolis, IN 46204
enforcement license plate is requested. Telephone; (317) 233 -3146
3. The application must be accompanied by a copy of each vehicle(s) title, (It/e application, or Fax number. (317) 233.0053 f'
lease agreement. Internet htt :l/www.m bmv,i OV
Official Name of enthy that owns or leases the vehlcle(s) (3 t t Telephone number Entity's Executive Officer's ndm4'arid t
C a/=
County Zip Code
Entity street address (number and street) City Indiana 1J1�
1.
A 00-re- CcLr� �Q.i'►�il
Stale Board of Accounts number redaral I.D. number
i 4 r,Y'Rbrw�i�
VIN Vehicle color Vehicle type Vehicle Description
(of New Vehicle or Vehicle that (e.g. Passenger, truck, motorcycle, school bus, (Make, model, Year)
Municipal License Plate will be city bus, trailer, seml4railer, recreational vehicle) V A/
transferred (b) n/Q c Z od
N T u der 0 4 7 B/4Ck
Basis of Financial Responsibility Description of official business for which the entity will use the vehicle Vehicle p urchase
month clay` year) date
(Source of self- insurance; or
insurance Company Name and i
Policy number)
O r Cum., LIP
The application is for (check One): rt a Transfer, VIN of Vehicle from which the License Plate is
Transferred
V A new Municipal or Law Enforcement License Plate
To transfer an existing License Plato
.M Vehicle a Pfi
VIN Vahlcle color) type
Vehicle Description
(of New Vehicle or Vehicle that (e.g. Passenger, truck, motorcycle, school bus, (Make, model, Year)
Municipal License Plate will be city bus, trailer, semi trailer, recreational vehicle)
transferred to)
Basis of Financial Responslblllty Description of official business for which the entity will use the vehicle Vehicle purchase or lease date
(Source of self-insurance; or (month, day, year)
Insurance Company Name and i
Policy number)
i
I
The application is for (check one) i If a Transfer, VIN of Vehicle from which License Plate is Transferred
A new Municipal or Law Enforcement License Plate
i
To transfer an existing License Plate
VIN Vehicle color, Vehicle type Vehicle Description
(of New Vehicle or Vehicle that (e.g. Passenger, truck, molarcycle, school bus, (Make, model, Year)
Municipal License Plate will be city bus, trailer, seml4railer, recreational vehicle)
transferred to)
Basis of Financial Responsibility Description of official business for which the entity will use the vehicle Vehicle purchase or lease date
(Source of self insurance; or (month, day, year)
Insurance Company Name and
Policy number)
The application is for (check one): If a Transfer, VIN of Vehicle from which License Plate Is Transferred
A new Municipal or Law Enforcement License Platt-
To transfer an existing License Plate
12/09/2008 14:46 FAX 3172330053 BMV 16 005
The entity shafi indicate which one (1) of the following classifications the entity belongs, thus entitling the entity to a permanent municipal license plate. 1he
entity must also submit the tollowing wrfften documentation or meet the requirements that establish that the entity meets the classification for which it
qualities fora 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 corporation (as defined in IC 36.1 -2.10) "Municipal corporation" means any of the following:
y 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 State Library),
d) local housing authority (Must provide a certified copy of the ordinances) that establishes rho authority),
e) fire protection district (Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security).
public transportation corporation (Must provide a certified copy of the ordinence(s) that establishes the corporation),
g) local building authority (Must provide a certifled copy of the resolution or oniinance(s) that establishes the authority),
h) local hospital authority or corporation (Must provide a certified copy of the resolution orordinence(s) that establishes the authority),
i) local airport authority (Must provide a certified copy of the resolution or ordinances) that establishes the authority),
J) special service district (Must provide a certified copy of the resolution or ordinances) that establishes the distrio.
X) other separate local governmental entity that may sue and be sued p(ovI the entity)
copy of the statute, ordinance or resolution that
3. A volunteer fl-.e department (as defined in IC 36- 8.12 -2)
(Must be listed with the Indiana State Fire Marshall or Department of Homeland Security end provide a copy of the contract or resolution to provide firefighting
services for a county, city, town, or township.)
A. 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 33,500.00.
(Must be registered as a Volunteer Emergency Ambulance Service vrlth 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 fisted as a rehabilitation center with the Indiana Rehabilitation Bureau and provide a latter from the Indiana Rehabilitation Bureau of the FSSA.)
5. A community action agency (IC 12 -14-23)
(Must be designated by the Governor or under Federal few 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 fn -Home Services.)
S. 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 919.3.6):
(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
J N .N
The authorized representative submitting this application swears or affirms under the ponalty of perjury that the answers and intionnatlon 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
1C 9.18
Date (month, day, yead Signature of authorized entity representative
Typed or printed title of entity representative Typed or printed name of entity representative Office telephone number of entity representative
PlgNr u� RGb -��r
12/08/2008 14.47 FAX 3172330059 BMV x]008
APPLICATION FOR CERTIFICATE OF TITLE STATE OF INDIANA a BUREAU OF MOTOR VEHICLES
Wto Form 44040 (R4 13 -021 Approved by Stale Board of Aacou 007
J TO SE COMPLETED BmwPfhiCG OFFICER BMV OFFlCW.OR BMV Cl RTTWEO DEALER BIONEE VINE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA-
FOfk OUT NEDTIKE FOLLOWeNGVEHICLEANDIFINDTNE 0FNnFI LOWS. THAT MAKI A FALSE CNTHIS FORM MAY CONSTI
VEHICLE IDENTIFICATION NUMOER TUTS THE CRIME 4F PERJURY, FUTHERMORE. UWE AGREE TO
INDEMNIFY ANC HOLD HARMLESS THE INDIANA BMV FROM ANY
LIABILITY ARISING FROM THIS TRANSACTION. ��[J
YR MAKE I MODEL TYPE DATE f,.4 +r' 7
x .l�n
INSPECTOR'S PRINTED NAME 6 SIT LE CITY
TI,. I.r nWl•w No +yw aoplY7 V_0c. VTwvd'w ^Ihlnka day tram me Cow of pvichwa ors
pVBPEGTOR'6
St BADGE. BRANCH OR rwrc• +.hlu.. TTfye u a d411n044"I rr. 1a (,iota m de ae. Alaeh C8011ML010 of 7100 ea OPW bT wh.r. 01 .n
DEALER PLATE N0. ewxa 7xwr. was mw1 a. Aaa.d. euonaNao aeoumahu ourranaerod.hh dW .ndbrJw. r+m.1 e. nwrndd la M dPO
camL 11 acs_6. 0 .irh Fod" coda 3E7.
TITLE NUM @ER $RANCH NO. INVOICE NO. BMV USE ONLY
500.SECIFCDERAL LD,NQ- APPLICANT'S NAME 9MV UBE ONLY
X 2 C T O F
STREFf ACDRE55 CITY STATE ZIP COOS
L l uare Larrv�:1 1 [v0
VEHICLE 1.0, NUMBER VEFI.YCJIR vEH. MAKE VEH. MODEL NO. VEH TYPE ODOMETER
fl T 461 E 9y �v� Id CB Jar
oy d P T '/tom
FORMER TITLE NUMBER PL!RC zu D LIEN SPEED PICKUP MAIL DEALER N0. IDWVVBFDNL.Y
S.
FlRSTUCOS NAME OR SPECIAL MAILING ADDRESS STREET ADRREES
a fi.
GTY STATE ZIP CODE 0MV USE ONLY
7.
SECOND LIEN'S NAME STR EET ADDRESS
e.
Oily 5TATE PT CODE I LICENSENUMBER LICENSE FORMS 8MV USE ONLY
B YEAR USED
GROSS RETAIL RUSE TAKAFF10AVIT IM1E HEREBY CERTIFY THAT RALE5 OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATFO BELOW.
SELLING FRICE LE99 TRADE`IN AMOUNT SUBJECT TO TAJ4 J AMOUNT OF TAX 99 ALGR BRANCH EXEMPT JIFEXIEMPT Ep APAs
10 3 3
lour Sodal 59LVxiry mrmbcr i Federal I.D. PumDer b being mquoslaci by [hie agency undor IG4 -1$T- Dlaabeur'e It menadaiory and this document aannal to pro0l800 wlpqu10.
APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION
APPLICATION FOR CERTIFICATE OF TITLE a STATE OF INDIANA s BUREAU OF MOTOR VEHICLES
BUREAU -TO BE MAILED WITH TITLE REPORT
12/09/2008 14:46 FAX 3172330053 BMV Z002
STATE OF INDIANA
Ronald L Stiver, Commissioner
Mitchell E. Daniels, Jr., Governor Bureau of Motor Vehicles
100 North Senate Avenue
Indianapolis, Indiana 46204
(317) 233 -6000
SPECIAL PATES
TITLF-
X/ Ori inal- Certificate of Ori In, Bill of Sale, or Statement of Manufacture
State Form- ST146E Certificate of Gross Retail or Use Tax Paid EXEMPTION
Odometer Statement- For All Vehicles, Except for Trailers
Contact Informatio Name, Phone Number, and Fax Number
For School Buses- Please Provide a School Bus Inspection Form
`State Form 44049 Application for Certificate of Title- For All Vehicles
1. Fill out Lines 2, 3 4 and Sign and Date
Check Mone Order, or Credit Card Slip- pa able to the BMV of 15.00
REGISTER
Application For New And /Or Transferred Municipal And Law Enforcement License
Plates State Form (53565)
1, Please indicate The Color of the Vehicle
2. Gross Weight Of the Vehicle
3. insurance Name and Policy Number
Copy of the Title OR Application For Certificate Of Title- 44048
If you need any help while filling out the form(s) Please contact
1. Allsha Blinker 317 233 -3148
2. Kim Cannon -Bell 317- 234 -5581
3. Sylvia Lines 317 234 -3922
q, Marquette Stewart 317 -233 -1797
Supervisor Shan'non Dickson 317- 233 -6213
An Equal Opportunity Employer
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF C:ARMEL
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.
G
Payee
79627
BUREAU OF MOTOR VECHILES Purchase Order No.
1009 W MAIN ST Terms
CARMEL, IN 46032 Due Date 12/31/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
12/31/20M 1/06/09 $15.00
l
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
/J'/ y� t,
Date Officer
VOUCHER 084031 WARRANT ALLOWED
79627- rt4 uf ec (Yl IN SUM OF
0b9=4%VtN::ST PC
f nU N SCrVXf- k-JE- tr 4_
Carmel Water Utility G
ON ACCOUNT OF APPROPRIATICO
Board members
PO INV ACCT AMOUNT Audit Trail Code
1/06/09 01- 6500 -04 $15.00
Voucher Total $15.00
Cost distribution ledger classification if
claim paid under vehicle highway fund