HomeMy WebLinkAbout171883 04/29/2009 CITY OF CARMEL, INDIANA VENDOR: 361251 Page 1 of 1
ONE CIVIC SQUARE IN.GOV
CARMEL:, INDIANA 46032 PO BOX 6047 CHECK AMOUNT: $50.00
INDIANAPOLIS IN 46206 -6047 CHECK NUMBER: 171883
CHECK DATE: 4/29/2009
D EPARTMENT AC COUNT PO NUMBER IN VOICE NUMBER AMOUNT DESC RIPTION
1201 4355300 50.00 ORGANIZATION MEMBER
IN ,90V Account Agreement
INSTRUCTIONS:
Upon`Completion'of this form please sign and send your annual .account -fee of $50.00 to:
IN.gov, 10 West Market Street, Suite 600, Indianapolis, IN 46204 or Fax.to: 317- 233 -2011
Note: The $50.00 annual account fee payrnent is required prior to activation of the INl.gov Monthly-
i
t
New Agreement XUpdating Existing If existing provide current account S a. b'7 4
CUSTOMER CONTACT INFORMATION
Businesses and Indiv iduals (Only businesses and individuals need to complete this section. if you are applying on behalf of a
governmental entit-
y, please continue to the next section)
Company Name (Required for businesses) or Full Name of Individual Customer
Mailing Address (Required) City /State /Zip (Required)
Phone No. (Required) Fax No. Driver's License Number and State of Issuance
(Only non- business accounts)
Customer Contact Name (Required) Customer Contact E -mail Address (Required)
BUSINESS ACCOUNTS ARE REQUIRED TO PROVIDE THE FOLLOWING ADDITIONAL INFORMATION:
Name of President /General Manager /Officer
Federal Tax ID Number: Web Site Address:
Government Entities (Only government entities need to complete this section)
Annual account fees and transaction fees (including enhanced access to BMV records) are waived for Indiana state agencies, county prosecutors,
county /city/town courts, and law enforcement agencies (as defined in IC 10- 13- 3 -10). However, non law- enforcement agencies must pay the $7.00 fee required
by IC 10- 13- 3 -30(a) (3) for each search ofthe Indiana State Police Online Limited History database.
All other governmental entities applying for online access to Bureau of Motor Vehicle Records must pay the $50.00 annual fee and pay actual transaction fees
consistent with this agreement. However, certain governmental entities qualify for the reduced charge of $1.00 per transaction record for BMV searches made
in furtherance of the governmental entity's business. The government entities qualifying for the reduced per transaction fee are: Indiana counties and
municipalities (and their duly authorized officers, divisions and agencies), Indiana state universities, and the United States federal government and its agencies.
Name of G vernment Entity
Mailing Address (Required) City/State/Zip (Required)
o.�� f�^/ o.� l� 1 c�..v�l� C�.�C'`.Y Y1�A� l Yom-- V
Customer Contact Name (Required) Customer Contact E -Mail Address (Required)
F.;> t, a O
Type of Governme t Entity State Board of Accounts number (if Applicable)
o,yr e_ C. �J c� l .'Y Cl 3 S G() C) p 9 7 a
Name of elected official or head authority of entity Federal State Local (Please indicate by writing in above)
v� w w' c, C 3► S q aLi n C3 C? 5l
Entity's Web site Phone No. (Required) Fax No.
Account No. Page 2 of 10
Prescribed ;q 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
v4 Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total f L7
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. t4 IR -1 19 VARRANT NO.
ALLOWED 20
IN SUM OF
t o 1D -0
L+
co�
ON ACCOUNT F APPROPRIATION FOR
�3 L.VO
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I hereby certify that the attached invoice(s), or
D 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
20
Signatur
o� i�
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund