170962 04/16/2009 1
CITY OF CARMEL, INDIANA VENDOR: 362779 Page 1 of 1
0 ONE CIVIC SQUARE LEACH RUSSELL CHECK AMOUNT: $6,109.51
CARMEL, INDIANA 46032 9151 FORD CIRCLE
FISHERS IN 46038 CHECK NUMBER: 170962
CHECK DATE: 4/16/2009
DEP ACCOUNT P O NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
902 4460807 14 6,109.51 PERFORMING ARTS CENTE
f:�
SL Subcontract Billing Report
For Work Invoiced From 03/24109 to 03/24109
5" .r Q �,a; was, m4'
010AMechanical, HVAC, Pfumbin5 .v„ sF W g. 3s.�
ubcontract i 2805
eY
Job: 2805- Energy Center -Carmel Vendor: 3923 LEACH RUSSELL MECHANICAL.
a A�w��� saae
Contract �ToYaDate �'Ttis
aka. wm L-a
Item Units UM Unit Cost Amount Units/% Amount Units/% Amount
1 Mechanical, HVAC, Plumbing LS 1,554,000.00 99.69% 1,549,219.51 0.02% 237.51
Total Contract Items 1,554,000.0 1,549,219.51 237.51
Change Orders
2 CCR 1007 HVAC Controls LS 107,000.00 100.00% 107,000.00 0.00% 0.00
4 CCR 2001 Boiler LS 12,319.0 100.00% 12,319,00 0.00% 0.00
Combustion Air Modification
5 CCR 2011 ASI #4 Revised LS 52,947.00 100.00% 52,947.00 0.00% 0.00
Water Treatment System
6 CCR #2013 Eliminate Future LS 25,941.0 100.00% 25,941.00 0,00% 0.00
HVAC Stubs
7 CCR #2013 Add Future LS 46,262.0 100.00% 46,262.00 0.00% 0.00
HVAC Stubs to South
8 CCR #2013 Sleeve for LS 989,00 100.00% 989.00 0.00% 0.00
Future HVAC Stubs to South
9 CCR 1008 Relocate Gas LS 5,587.00 100.00% 5,587.00 0.00% 0,00
Meter
10 ASI EC -008 LS 0.00 0.00% 5,872.00 000% 5,872.00
Total Change Order Items 174,525.00 180,397,00 5,872.00
Subcontract Totals: 1,728,525.00 1,729,616.51 6,109.51
Total Billings: 1,729,616.51 6,109.51
Unpaid Retainage: 50,652.90 0.00
Discounts: 0.00 0.00
Net Billings: 1,67 8,963.61 6,109.51
98 SSC CMa Projects Page 1 03/27/09 03:03:46 PM
Date Format MM /DD /YY SLSubBillingReport .rpt
`APPLICATION AND CERTIFICATE FOR PAYMENT CONSTRUCTION MANAGER ADVISER EDITION
AIA DOCUMENT G702 /CM2 (Instructions on reverse side) PAGE ONE OF PAGES
TO..OWNER: Carmel Redevelopment Commission PROJECT: Carmel City Ctr Energy Ctr APPLICATION NO.: 14 Distribution to:
One Civic Square 3rd Ave SW City Center Dr. PERIOD TO: 3 -31 -09 OWNER
Carmel, IN 46032 Carmel, IN 46032 PROJECT NOS.: SS #2805 CONSTRUCTION
MANAGER
FROM CONTRACTOR: Leach Russell Mechanical CONTRACT DATE: 6/27/07 ARCHITECT
9151 Ford Circle CONTRACTOR
Fishers, IN 46038 VIA CONSTRUCTION MANAGER: Shiel Sexton,
CONTRACT FOR: M echanical VIA ARCHITECT.. CSO Architects, Inc. INVOICE# 16842 (29
The undersigned Contractor certifies that to the best of the Contractor's knowledge, infor-
CONTRACTOR'S APPLICATION FOR PAYMENT mation and belief the Work covered by this Application for Payment has been completed
Application is made for payment, as shown below, in connection with the Contract. in accordance with the Contract Documents, that all amounts have been paid by the
Continuation Sheet, AIA Document G703, is attached. Contractor for Work for which previous Certificates for Payment were issued and pay-
I. ORIGINAL CONTRACT SUM Z 1 554, 000.00
ments received from the Owner, and that current payment shown herein is now due.
Leach ssell Mechanical
2. Net Change By Change Orders
180r397 C TRAC R:
3. CONTRACT SUM TO DATE Line I 2 1,73 st t Date:
S ate of: Indiana
4. TOTAL COMPLETED STORED TO DATE l r 729 r 616.51
County of: Hamilton
(Column G on G702) Subscribed and sworn to before
5. RETAINAGE: me this 23rd da of
50 652.90 y Marc 2009
a. of Completed Work
(Columns D E on G703)
Notary Pul
b. of Stored Material My Commission expire 0 9
(Column F on G703)
Total Retainage (Line 5a 5b or
Total in Column I of G703) 50 ,652 .90 CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAINAGE s _1 ,67& ,963 61 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 less Line 5 Total) comprising this application, the Construction Manager and Architect certify to the Owner
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT that to the best of their knowledge, information and belief the Work has progressed as
1,672,8 indicated, the duality of the Work is in accordance with the Contract Documents, and
(Line 6 from prior Certificate) the Contractor is entitled to payment of the AMOUNT CERTIFIED.
8. CURRENT PAYMENT DUE 6 109.51 G 1
AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE (Attach e if amount certified differs from the amount applied for Initial
(Line 3 less Line 6) 5S 433.39 \f Gl all figures on this Application and on the Continuation Sheet that changed to conform
to the amount certified.)
UC ER:
Z�r
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS CONS1'R 3 3 1 Total changes approved in By Date:
previous months by Owner 186, 844.00 12 31 9.00 ARCHITECT:
Total approved this Month 5 00 3 sr
TOTALS 192 716.00 B Date:
12 This Ce tficate ;e in, of negotiable. The AMOUNT CERTIFIED is payable my to the Con
NET CHANGES by Change Order 180 397.00 tracto named issuance, payment and acceptance of payment are without
prej slice any rights of the Owner or Contractor under this Contract.
MW AIA DOCUMENT G7021CMa APPLICATION AND CERTIFICATE FOR PAYRVIENT CONSTRUCTION MANAGER ADVISER EDITION
1992 EDITION AIA- 91992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVENUE, N.W, WASHINGI UN, Ex
D.C. 20006 -529? WARNING: Unlicensed photocopying violates U.s. copyright laws and will subject the violator to legal prosecution. G702/CMa-1992
CAUTION: You should use an original AIA document which has this caution printed in red. An original assures that chances will not be obscured as may occur when documents are reproduced.
CONTINUATION SHEET G703 Carmel Energy Center SS #2805 PAGE 2 OF 2 PAGE
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, Leach Russell APPLICATION NUMBER: 14
containing CONTRACTOR'S signed Certification is attached. APPLICATION DATE: Mar 31,2009
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO: Mar 31,2009
Use Co lumn I on Contracts where var retainage for line items may apply. ARCHITECT'S PROJECT NO:
A B C D I E F G H I
WORK COMPLETED TOTAL COMP.
STORED BALANCE TO
ITEM SCHEDULED AND STORED RETAINAGE
NO. DESCRIPTION OF WORK VALUE PREVIOUS THIS PERIOD MATERIALS (NOT FINISH
APPLICATIONS IN D OR E) TO DATE (G /C) C G) 3/0
D +E +F)
Bond 19,900.00 19,900.00 19,900.00 100% 581.20
Mobilization /Submittals 5,400.00 5,400.00 5,400.00 100% 157.71
Labor 8,000.00 8,000.00 8,000.00 100% 233.64
Allowance 10,000.00 4,982.00 237.51 5,219.51 52% 4,780.49 292.03
Sanitary/Storm Pipe, Material 11,722.00 11,722.00 11,722.00 100% 342.34
Labor 18,264.00 18,264.00 18,264.00 100% 533.40
Domestic Water Pipe 7,481.00 7,481.00 7,481.00 100% 218.48
Labor 10,556.00 10,556.00 10,556.00 100% 308.29
Buried Hydronic Pipe, Material 12,478.00 12,478.00 12,478.00 100% 364.42
Labor 6,114.00 6,114.00 6,114.00 100% 178.56
Above Grnd Hydronic Pipe, Mat 284,244.00 284,244.00 284,244.00 100% 8,301.32
Labor 191,080.00 191,080.00 191,080.00 100% 5,580.47
Plumbing Fixtures /Equipment 24,939.00 24,939.00 24,939.00 100% 728.34
Labor 7,553.00 7,553.00 7,553.00 100% 220.58
HVAC Equipment 762,839.00 762,839.00 762,839.00 100% 22,278.64
Labor 60,118.00 60,118.00 60,118.00 100% 1,755.74
Temporary Heat, Material 2,000.00 2,000.00 2,000.00 100% 58.41
Labor 1,840.00 1,840.00 1,840.00 100% 53.74
Sheet Metal, Material 5,300.00 5,300.00 5,300.00 100% 154.79
Labor 12,000.00 12,000.00 12,000.00 100% 350.46
Mechanical Insulation, Material 41,518.00 41,518.00 41,518.00 100% 1,212.53
Labor 32,470.00 32,470.00 32,470.00 100% 948.28
Balance 3,499.00 3,499.00 3,499.00 100% 102.19
Excavation, Material 3,885.00 3,885.00 3,885.00 100% 113.46
Labor 10,800.00 10,800.00 10,800.00 100% 315.41
CO #1 21,310.00 21,310.00 21,310.00 100% 622.36
CO #2 (12,319.00) (12,319.00) (12,319.00) 100% (359.78)
CO #3 5,587.00 5,587.00 5,587.00 100% 163.17
CO #4 52,947.00 52,947.00 52,947.00 100% 1,546.31
CO #5 107,000.00 107,000.00 107,000.00 100% 3,124.92
CO #6 5,872.00 5,872.00 5,872.00 100% 171.49
TOTAL 1,734,397.00 1,723,507.00 6,109.51 1,729,616.51 100% 4,780.49 50,652.90
AFFIDAVIT AND WAIVER OF LIEN
PARTIAL XXX FINAL PAYMENT TO FOLLOW XXX
State of Indiana, County of Hamilton, SS:
Michael S. Russell being duly sworn states that he is the CFO of Leach
Russell Mechanical Contractors, Inc. having contracted with CARMEL
REDEVLOPMENT COMMISSION to furnish certain material, supplies, equipment or
labor for mechanical services for the project known as CARMEL CITY CENTER,
ENERGY CTR. and does hereby further state on behalf of the aforementioned
contractor:
(PARTIAL) that there is due from the owner the sum of SIX THOUSAND, ONE
HUNDRED, NINE AND 51/100 DOLLARS ($6,109.51).
O receipt of which is hereby acknowledged or
(X) the payment of which has been promised as the sole consideration of this
Affidavit and Partial waiver of Lien which is given solely with respect
to said amount, and which waiver shall be effective only upon receipt of
payment thereof by the undersigned:
(FINAL) that the final balance due from the owner is the sum of
receipt of which is hereby acknowledged or
O the payment of which has been promised as the sole consideration of this
Affidavit and Final Waiver of Lien which shall be effective only upon
receipt of such payment
THEREFORE, the undersigned, waives and releases unto the Owner of said
premises, any and all lien or claim whatsoever on the above described property
and improvements thereon on account of labor or materials, or both, furnished
by the undersigned thereto, and further certifies that no other party has any
claim or rights to a lien on account of any work performed or material
furnished to the undersigned for said project, and within the scope of this
affidavit and waiver.
CLAIMANT: Leach Russell Mechanical By:
9151 Ford Circle Aichael S. ussell
Fishers, IN 46038 CFO
SWORN to and subscribed before me this 23rd day of March, 2009.
V Pin ted: Karen C. Brown
My Commission Expires 03/05/17 Seal:
Residing in Hamilton County.
Date 02/22/2009 (4) That:
Michael S. Russell, CFO (a) Where fringe benefits are paid to approved plans, funds, or programs
1,
1, hereby slate: In addition to the basic hourly wage rates paid to each laborer or mechanic
do listed in the above referenced payroll, payments of fringe benefits as
listed in the contract have been or will be made to appropriate programs
for the benefit of such employees, except as noted in Section 4(c) below.
(1) That I pay or supervise the payment of the persons employed by
Leach Russell Mechanic on the Carmel City Ctr- Energy (b} Where fringe benefits are paid in Cash
that during the payroll period commencing on the 16 day of February 2009 Each laborer or mechanic listed in the above referenced payroll has been
paid, as indicated on the payroll, an amount not less than the sum
and ending the 22 day of February 2009 all persons employed
of the applicable basic hourly wage rate plus the amount of the
on said project have been paid the full weekly wages earned, that no rebates have been required fringe benefits as listed in the contract, except as noted in
or will be made either directly or indirectly to or on behalf of said Section 4(c) below.
I-each Russell Mechanic from the full weekly wages earned (c) Exceptions
by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Exception (Craft) Explanation
Regulations, Part 3 (29 CFR Subtitle A) issued by the Secretary of labor under the Copeland
Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and None
described below:
Taxes authorized union deductions for all employees
involved in off -site work on any item to be used on this
project have been included in this payroll
Remarks
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete; that the wage rates for laborers
or mechanics contained therein are not less than the applicab!e wage rates
contained in any wage determination incorporated into the contract that the
classifications set forth therein for each laborer or mechanic conform with the work he
performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a State apprenticeship agency recognized
by the Bureau of Apprenticeship and Training, United States Department of
Labor, or if no such recognized agency exists in a State, are registered with the
Bureau of Apprenticeship and Training, United States Department of Labor. Leach Russell Mechanical Contractors, Inc.
Michael S. Russell, CFO
(Name and Title)
The willful falsification of any of the above statements may subject the contractor or subcontractor to civ;l or criminal prosecution. See Section 1001 of Title 18 and Section 231
of Title 31 of the United States Code.
Subcontractor Leach Russell Mechanic Proiect and Location Payroll 84
Address 9151 Ford Circle Carmel City Ctr- Energy Week Ending 02/22/2009
Fishers, IN 46038 -3000 3rd Av SW City Ctr Page 1
Day and Date
Employee Information Mon Tue Wed Thu Fri Sat Sun Total Pay
2/16 2/17 2/18 2/19 2/20 2/21 2/22 Hours Rate Work Classification
Carter, Tommy
8651 Pleasant Creek Cour
Indianapolis, IN 46227
312 -80 -3384 M 0 2.00 2.00 33.780 Plumbers Steamfitters
Job Earn: 67.56 FICA: 103.36 FIT: 184.27 State: 43.98 Local /SDI: 22.29 Oth Deds: 1,020.95 Adj Net: 23.65
Tot Earn: 1,351.20 Tot Deds: 1,374.85 Un Vac: 0.00 Benefits: 548.00 Un Misc: 20.00 Un Dues: 27.02 Net Pay: 0.00
Drt Dpst 973.93
Emp. Count fob Hours Job Gross FICA Taxes FIT Statc Taxes Total Deduct Total Gross Adjustments Net
1 2.00 67.56 103.36 184.27 43.98 1,374.85
1,351.20 23.65 0.00
Date 03/08/2009 (4) That:
Michael S. Russell, CFO (a) Where fringe benefits are paid to approved plans, funds, or programs
In addition to the basic hourly wage rates paid to each laborer or mechanic
do hereby state:
listed in the above referenced payroll, payments of fringe benefits as
listed in the contract have been or will be made to appropriate programs
for the benefit of such employees, except as noted in Section 4(c) below.
(1) That 1 pay or supervise the payment of the persons employed by (b) Where fringe benefits are paid in Cash
Leach Russell Mechanic on the Carmel City Ctr- Energy
that during the payroll period commencing on the 2 day of March 2009 Each laborer or mechanic listed in the above referenced payroll has been
paid, as indicated on the payroll, an amount not less than the sum
and ending the 8 day of March 2009 all persons emploved of the applicable basic hourly wage rate plus the amount of the
on said project have been paid the full weekly wages earned, that no rebates have been required fringe benefits as listed in the contract, except as noted in
or will be made either directly or indirectly to or on behalf of said Section 4(c) below.
Leach Russell Mechanic from the full weekly wages earned (c) Exceptions
by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Exception (Craft) Explanation
Regulations, Part 3 (29 CFR Subtitle A) issued by the Secretary of Labor under the Copeland
Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357: 40 U.S.C. 276c), and NONE
described below:
Taxes authorized union deductions for all employees
involved in off -site work on any item to be used on this
project have been included in this payroll
Remarks
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete, that the wage rates for laborers
or mechanics contained therein are not less than the applicable wage rates
contained in any wage determination incorporated into the contract; that the
classifications set forth therein for each laborer or mechanic conform with the work he
performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a State apprenticeship agency recognized
by the Bureau of Apprenticeship and Training, United States Department of
Labor, or if no such recognized agency exists in a State, are registered with the
Bureau of Apprenticeship and Training, United States Department of Labor. Leach Russell Mechanical Contractors, Inc.
1
Michael S. Russell, CFO
The willful falsification of anv of the above statements may subject the contractor or subcontractor to civil or criminal prosecution. See Section 1001 of Title 18 and Section 231
of Title 31 of the United States Code.
Subcontractor Leach Russell Mechanic Project and Location Payroll 86
Address 9151 Ford Circle Carmel City Ctr- Energy Week Ending 03/08/2009
Fishers, IN 46038 -3000 3rd Av SW City Ctr Page 1
Day and Date
Employee Information Mon Tue Wed Thu Fri Sat Sun Total Pay
3/2 3/3 3/4 3/5 3/6 3/7 3/8 Hours Rate Work Classification
Smith, Andrew
238 Heartwood Hill
Greenfield, IN 46140
305 -90 -8426 M 8 8.00 8.00 46.830 Project Manager
Job Earn: 374.64 FICA: 143.30 FIT: 154.59 State: 58.92 Local /SDI: 21.25 Oth Deds: 1,531.94 Adj Net: 36.80
Tot Earn: 1,873.20 Tot Deds: 1,910.00 Un Vac: 0.00 Benefits: 0.00 Un Misc: 0.00 Un Dues: 0.00 Net Pay: 0.00
401(k) 25.00 Drt Dpst 1,506.94
Carter, Tommy
8651 Pleasant Creek Cour t
Indianapolis, IN 46227
312 -80 -3384 M 0 1.50 1.50 33.780 Plumbers Steamfitters
Job Earn: 50.67 FICA: 102.08 FIT: 181.73 State: 43.41 Local /SDI: 22.02 Oth Deds: 1,074.20 Adj Net: 89.13
Tot Earn: 1,334.31 "Cot Deds: 1,423.44 Un Vac: 0.00 Benefits: 527.45 Un Misc: 19.25 Un Dues: 26.68 Net Pay: 0.00
Drt Dpst 1,028.27
Emp. Count Jf)b 1 -lours Job Gross FICA Taxes FIT State Taxes Total Deduct Total Gross Adjustments Net
2 9.50 425.31 245.38 336.32 102.33 3,333.44 3,207.51 125.93 0.00
Date 03/15/2009 (4) That:
1, Michael S. Russell, CFO (a) Where fringe benefits are paid to approved plans, funds, or programs
do hereby state: In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as
listed in the contract have been or will be made to appropriate programs
for the benefit of such employees, except as noted in Section 4(c) below.
(1) That I pay or supervise the payment of the persons employed by
Leach &Russell Mechanic on the Carmel City Ctr- Energy (b) Where fringe benefits are paid in Cash
that during the payroll period commencing on the 9 day of March 2009 Each laborer or mechanic listed in the above referenced payroll has been
paid, as indicated on the payroll, an amount not less than the sum
and ending the 15 day of March 2009 all Persons employed
of the applicable basic hourly wage rate plus the amount of the
on said project have been paid the full weekly wages earned, that no rebates have been required fringe benefits as listed in the contract, except as noted in
or will be made either directly or indirectly to or on behalf of said Section 4(c) below.
Leach Russell Mechanic from the full weekly wages earned (c) Exceptions
by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Exception (Craft) Explanation
Regulations, Part 3 (29 CFR Subtitle A) issued by the Secretary of Labor under the Copeland
Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and None
described below:
Taxes authorized union deductions for all employees
involved in off -site work on any item to be used on this
project have been included in this payroll
Remarks
(2) That any payrolls otherwise under this contract required to be submitted for the
above period are correct and complete; that the wage rates for laborers
or mechanics contained therein are not less than the applicable wage rates
contained in any wage determination incorporated into the contract; that the
classifications set forth therein for each laborer or mechanic conform with the work he
performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a State apprenticeship agency recognized
by the Bureau of Apprenticeship and Training, United States Department of
Labor, or if no such recognized agency exists in a State, are registered with the
Bureau of Apprenticeship and Training, United States Department of labor. Leach Russell Mechanical Contractors, Inc.
ichael S. Russell, FO
The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution. See Section 1001 of Title 18 and Section 231
of Title 31 of the United States Code.
Subcontractor Leach Russell Mechanic Project and :Location Payroll 87
A ddress 91.51 Ford Circle Carmel City Ctr- Energy Week Ending 03/15/2009
Fishers, IN 46038 -3000 3rd Av SW City Ctr Page 1
Day and Date
Employee Information Mon Tue Wed Thu Fri Sat Sun Total Pay
3/9 3/10 3/1.1 3/12 3/13 3/14 3/15 Hours Rate Work Classification
Carter, Tommy
8651 Pleasant Creek Cour
Indianapolis, IN 46227
312 -80 -3384 M 0 8.00 8.00 16.00 33.780 Plumbers Steamfitters
Job Earn: 540.48 FICA: 103.36 FIT: 184.27 State: 4198 Local /SDI: 2129 Oth Deds: 1,069.64 Adj Net: 72.34
Tot Earn: 1,351.20 Tot Deds: 1,423.54 Un Vac: 0.00 Benefits: 548.00 Un Misc: 20.00 Un Dues: 27.02 Net Pay: 0.00
Drt Dpst 1,022.62
Emp. Count Job Hours Job Gross PICA Taxes FIT State Taxes Total Deduct Total Gross Adjustments Net
1 16.00 540.48 103.36 184.27 43.98 1,423.54 1,351.20 72.34 0.00
PrescribedXy 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))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accoraance
with IC 5- 11- 10 -1.6.
e
20 a,
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
aj/5
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or INVOICE NO. ACCT #/TITLE AMOUNT
DEPT. I 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
•CJ
J
Signatore
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund