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173865 06/24/2009 CITY OF CARMEL, INDIANA VENDOR: 357304 Page 1 of 1 0 ONE CIVIC SQUARE JAMES HOBBS 1, CARMEL. INDIANA 46032 11180 E. 111TH STREET CHECK AMOUNT: $8.98 FISHERS IN 46038 CHECK NUMBER: 173865 CHECK DATE: 6/24/2009 DEP ARTMENT AC COUNT PO NUMBER IN VOIC E N UMBE R AMOU DESCRIP 2201 4238900 8.98 OTHER MAINT SUPPLIES REMIT TSC BUSINESS ACCOUNT TRAiC�R® PAYMENTS TO: TRACTOR SUPPLY COMPANY 101 "I' ,YCO P.O. BOX 9020 Tractor Supply Company Des Moines, IA 50368 -9020 18160 U.S. 31 North Westf ield. IN 46074 TSC TEAM MEMBER TO COMPLETE Please include 16 Digit Account Number (317) 867 -3505 6035 301 NAME CARMEL STREET DEPT 3400 W 131ST ST WESTFIELD IN 460748267 ADDRESS (317) 733 2001 CITY STATE ZIP PHONE 431 431000172 2 938972 06/10/2009 10:34am CUSTOMER TO COMPLETE 3516547 VK.A825 1/2 UTL LK KY 1.00 4.49 4.49 NT CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT- Government Asencies The undersigned certifies 3516547 VKA825 112 UTL LK KY g The undersigned party certifies their exemption from compliance with the agricultural payment of sales and use tax on tangible personal 1.00 4.49 4.49 NT sales tax exemption law of the state property as indicated below and /or purchaser is Government Asencies indicated below and understands engaged in the business of agricultural production of Subtotal 8,98 and agrees with the General food or fiber, horticulture, aquaculture of floriculture for 7.00% Tax 0.00 Exemption Statement at right and resale and /or uses the farm machine equipment or the applicable statement of the machinery, Total 8.98 respective state printed on the other agricultural production items purchased free of Cast, 10.00 reverse side of this form. tax, as defined by state law, and as indicated below. Chanse 1 02 Th art further certifies they Cash Back PRODUCT IS TO BE USED IN THE FOLLOWING e under P Y STATE: understand they may be liable for payment of all taxes (REQUIRED) due on the purchase price for the goods as allowed by Signature: (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. PURCHASER IS.ENGAGED IN: (REQUIRED) Resale Under penalty of perjury, signee swears the Government information on this statement is true and correct in Exempt organization every material manner. A willfully false representation i# E #YYSiiiiEi #iY#YEt32t Agricultural Production of exemption will cause the purchaser to be subject to Call 800 968 -0734 within 7 days to Dairy Production p enalty and /or other p rovisions as allowed under state F1 Livestock Production P Y P complete a survey and be entered in a Floriculture /AquacultureProduction law. monthl drawins -for a chance to win a Other: $2500 shoppins spree. (Awarded as Gift Card) NO PURCHASE ITEMS PURCHASED WILL BE USED FOR: (REQUIRED) OR SURVEY NECESSARY. Ends 9/30/09. Farm Machinery/Repair Parts Government Agency (Entity EE22tiY #SiiEY ##2 ###ii##Yitiii3i2E# Livestock Injestibles or Injectibles Exempt Organization (Entity F1 Fertilizer /Agrichemicals NC: only DOT and US Government are exempt Enter Store 0431 Consumed in Production (KS) Resale (Sales Tax Permit For complete details so to: Ingredient or Component Parts (KS) Tractor Supply .con)/cttstomersLlrvey i3EiEEiEiEtiiEiii #Eif#i#ii#ifiii #2Y2 Other: iEEiYiiYEYii #iiii#i##2iiiEiiE#EY2222E For Customer Service comments CUSTOMERS UR (R IRED tractorsupPly.com MGR. APPROVAL Call 877 -872 -7721 Or s0 to a X IN USE SHADED AREA ONLY WHEN REGISTER IS ASH CHECK 7V A M/C DISCOVER TSC CHARGE ACCOUNT NO. CHG. EXCH. DATE ITEM NUMBER DESCRIPTIO Form No. 99 -00401 (12/05) CUSTOMER ORIGINAL ARKANSAS' The customer, as indicated by their signature on the reverse, certifies that he:sho is engaged in the business of farming and the farm machiri —y and equipment purchased will be used exclusively and directly in Ilse 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 purchases far in machinery and equipment free fro ,n Arkansas Sales Tax is a misdemeanor. GEORGIA: The reverse signed hereby certifies that all tangible personal property purchased or leased after the reverse indicated date will be purchased or leased lot the purpose indicated below. unless otherwise specified o a particular order, and that the purchases are used as a part 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 prooer 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) 2. Machinery and /or equipment which will be used on the farm di racily in the production of poultry or eggs for sale. O.C.G.A. 48- 8- 3(29)(A) 3. Machinery and /or equipmen; which v�ill be used on the farm directly in the production, orocessino or storage of fluid milk for sale. O.C.G.A. 48- 8- 3(29)(C) j 4. Machinery and!or equipment whiolt will be used on the farm directly in the production of livestock for sale. O.C.G.A. 48- 8- 3(29)(0) 5, Machinery andror equipment which will be used on the farm directly in harvesting tarn crops grown and used on the farm as feed for poultry or livestock by a producer falling under the categories 2, 3. or 4 above O.C.G.A. 48- 8- 3(29)(E) 6. Machinery and. %or equipmen) which will be used in the hatching and breeding of poultry and livestock for sale. O.C.G.A. be used in tilling the soil or in animal husbandry. O.C.G.A. 48- 8- 3(29)(F).(G) (H) 48 -8- 3(29)(8) 7. Machinery and /or equipment which will j S3 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.C.G.A. 48- 8- 3(29)(J) J 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 from the ground until and including the point at which the free or its parts in any form has been loaded in the field in or on a truck or other vehicle for transport to the place of use. O.C.G.A. 48 -8- 3(29).1) 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, farlilizers, insecticides, fungicides, rodentici6cs, herbicides, defoliants. soil fumigants, plant growth regulating chemicals. desiccants (including shavings and sawdust from wood, peanut hulls, fuller's earth, straw and ha;) 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 for packing farm products for shipment or sale. O.C.G.A. 48 -8 -3(25) (35) (A) (iii) -FUELS USED IN POULTRY STRUCTURES ELECTRICITY USED IN IRRIGATION OF FARM CROPS- 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.C.G.A. 48 -8 -3(49) ILLINOIS:.The reverse signed hereby certifies 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 130.1955. 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 production of crops; raising and feeding livestock or poultry the products of which ordinarily constitute food for human consumption; or raising and feeding llamas, alpacas, ratites, buffalo, or aquatic organisms. The reverse signed also certifies that the tangible personal property purchased as indicated below will be used for the exempt purpose(s) provided for under KRS 139.480. Farmer must /N /T /AL appropriate line(s)- Baling twine and wire Farm chemicals Farm machinery, attachments and repair /replacement parts therefor Farm work stock a f Feed Feed and feed additives Gasoline, special fuels, natural gas or liquefied petroleum gas t r l 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 /soybean facility and poultry, livestock, ratite, llama, alpaca, or aquaculture facilities` Seed or fertilizer r Materials to be incorporated into the renovation or repair of an existing on -farm grain /soybean facilities and poultry, livestock, ratite, llama, alpaca. or 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 and dairy cattle. SEE_. REVERSE SIDE SF_F_ REVERSE SIDE I 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 horticullu rat or agricultural products as a business enterprise, and agrees to reimburse the seller the sales tax if used or consumed otherwise. Unlawful use of this certificate subjects persons to the penalties of the sales tax act. NORTH DAKOTA, SOUTH DAKOTA: The purchases made herein are subject to the reduced rate of sales tax and are not exempt from such tax. NEBRASKA: The reverse signed certifies the intended use of the items purchased renders it exempt under Reg. 1 -060. 1 -061 or 1 -063. I TEXAS CERTIFICATION OF EXEMPTION Purchaser's name SEE REVERSE SIDE_ Street Address SEE REVERSE SIDE City, state, zip code SEE REVERSE SIDE I claim an exemption from payment of sales and use taxes for the purchase of taxable items described below or on the attached order or invoice: SEE REVERSE SIDE Description of items (or an attached order or invoice) to be purchased: SEE REVERSE SIDE I claim this exemption for the following reason; SEE REVERSE_ SIDE I understand that I will be liable or F_ payment of sales tax which may become due for failure to comply with the provisions of the Tax Code: Limited Sales. Excise. and Use Tax Act, Municipal- Sales and Use T f Fax Act, Sales and Use Taxes for Special Purpose Taxing Authorities. County Sales and Use Tax Act, County Health Services Sales and Use Tax and the Texas Health and Safety Code: Special Provisions Relating to Hospital Districts, Emergency Services Districts, and Emergency Services Districts in counties with a population of 125, 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 time used. I understand that it is a criminal offense to give an exemption certificate to the seller for taxable items which 1 know, at the time of purchase, will be used in a manner other than that expressed in this certificate. Seller: SEE REVERSE SIDE Street address: SEE REVERSE SIDE City, slate. zip code: SEE REVERSE SIDE Purchaser's signature: SEE REVERSE SIDE Date: Phone: Ttle: SEE_ REVERSE SIDE This certificate does not require a number to be valid. Sales and use tax exemption numbers or tax exempt numbers do not exist. 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 Rule 3.287 NEW YORK STATE DEPARTMENT OF TAXATION AND FINANCE NEW YORK STATE AND LOCAL SALES AND USE TAX FARMER'S EXEMPTION CERTIFICATE I "o purchasers and sellers: To be completed by the farmer, given to and retairied'by the seller. To have a valid certificate, all entries must be completed. Read all instructions carefully before completing or accepting this certificate. To sellers: You may not accept this certificate as the basis for selling exempt from tax the property or services listed below. Tax must 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; 2. labor charges in connection with repair, maintenance of or service to real property: 3- tangible personal property incorporated into a building, structure, silo foundation or other capital improvements to real property (excluding grape' trellises and the remaining portions of a silo): 4. motor vehicles; or .5. property listed as taxable. Name of seller TRACTOR SUPPLY COMPANY AFFILIATES Attn: Tax Name of Farmer SEE REVERSE SIDE Street address 200 Powell Place Street address SEE REVERSE SIDE C lty Brentwood State TN ZIP Code 37027 City SEE REVERSE SIDE State ZIP Code Check applicable box: 0x Single Purchase Certificate Blanket Certificate I I, the reverse signed hereby certify that I am exempt from payment of the sales and use tax on tangible personal property purchased from you because the property is to be used for l an exempt purpose and that certain services are also exempt when performed on a exempt property. (Check applicable box or boxes.) p (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 term farming 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. 0 (b) Tangible personal property for use in erecting, adding to, altering or improving a silo used in farming to make and store silage on a farm, provided such tangible personal property is to become an integral component part of such silo. (This exemption does not apply to tangible personal property used in constructing a silo foundation.) I-1 (c) Posts and wire for use in constructing or maintaining vineyard trellises used in growing grapes for sale. I7 (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.) These statements are made with the knowledge that willfully issuing a false or fraudulent certificate with the intent to evade tax is a misdemeanor under section 1817(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 a year or both. Signature of farmer or farmer's representative (state title and relationship) SEE REVERSE SIDE Date Seller The tax exemption for farmers is limited to the purchases of (1) tangible personal property used directly and predominantly in'the 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 Farmers, 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 properly sold or services rendered. If you have not receivod this certificate within 90 days of the date of sale, the sale will be deemed to have been taxable at the time the transaction took place and the burden of proving it was not, shall be upon both you and the purchaser. If the blanket certificate 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. Purchaser You must 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 use (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, Farme s Exemption Carfificafn for Purchases of Diesel Motor F[,re/ to purchia se that fuel exempt.) If the blanket certificate 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 re ,,cation. or until the Tax Department notifies you that the purchaser may not make exempt purchases. 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)) 06/10/09 $8.98 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. Jim Hobbs ALLOWED 20 IN SUM OF c/o Carmel Street Department $8 .98 ON ACCOUNT OF APPROPRIATION FOR Carmel Street Department 1`09 Dept. INVOICE NO. I ACCT /TITLE AMOUNT Board Members 2201 42- 389.00 $8.98 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 Thursday, June 18, 2009 e -'1 '09treet C Ian er Title Cost distribution ledger classification if claim paid motor vehicle highway fund