207102 03/13/2012 CITY OF CARMEL, INDIANA VENDOR: 229400 Page 1 of 1
4 ONE CIVIC SQUARE INDIANA DEPT OF HOMELAND SECURI
CARMEL, INDIANA 46032 DIV OF ELEVATOR SAFETY- FISCAL OFFI HECK AMOUNT: $360.00
302 W WASHINGTON ST, RM E221
CHECK NUMBER: 207102
INDIANAPOLIS IN 46204
CHECK DATE: 3/13/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1110 4350100 120.00 7675 03012012 -1
1205 4351501 120.00 7675 02292012 -1
1205 4351501 120.00 7675 03012012 -1
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CARMEL PUBLIC WORKS SAFETY ONE CIVIC SQ CARMEL IN 46032
1.If Code An annual test report is due before a permit is issued.
2.If Code A 5 year Test report is due before a germit is issued.
3.0ver due fees must be paid before a permit is issued.
If elevator(s) are not in service please request an "ELEVATOR OUT OF SERVICE
AFFIRMATION" form.
State No Due Over Due Location Address
45583 $120.00 0.00 1 CIVIC SQ, CARMEL IN 46032
CBy---
Reference Number Invoice Date Please submit ENTIRE document with payment
7675 02292012 -1 02/29/2012 Unit(s) 1 Total Due upon receipt
of 1 120.00 of 120.00
Owner Id 7675
Ref.Num.:7675- 02292012 -1 $120 of 120.00 Invoice Date 02/29/2012
If Paying by check, include a check made payable to the Department of Homeland security. You can pay all your
payments online at IDRS web site httpo: /myoracle .in.gov /dfbs /idhsFeesFines /start.do with Visa /Master
Card /Discover cards. Use Owner Id on this letter or State Number on the invoice to pull up information when
paying the dues online.OR complete the following information and return by mail :Indiana Department of
Homeland Security, Fiscal Department, 302 W.Washington St., Rm E221,Indianapolis, IN 46204 or fax to
(317)233 -0401. Questions? call(317)232 -6427 or E- mail :elevator invoice @dhs.in.gov 2.25% convenience fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address: Street
City State Zip Code
CC type:Am.Express /Discover /Master Card ONLY (circle one) (VISA payment online only)
Acct. Number Exp.Date (mm /yy)
CVV2 Number Contact Phone Number Signature
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
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CARMEL PUBLIC WORKS SAFETY ONE CIVIC SQ CARMEL IN 46032
1.If Code An annual test report is due before a permit is issued.
2.If Code A 5 year Test report is due before a 2ermit is issued.
3.0ver due fees must be paid before a permit is issued.
If elevator(s) are not in service please request an "ELEVATOR OUT OF SERVICE
AFFIRMATION" form.
State No Due Over Due Location Address
45581 $120.00 0.00 3 CIVIC SQ, CARMEL IN 46032 1110
45582 $120.00 0.00 1 CIVIC SQ, CARMEL IN 46032
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D Q
MAR 12 2012
By
Reference Number Invoice Date Please submit ENTIRE document with payment
7675 03012012 -1 03/01/2012 Unit(s) 2 Total Due upon receipt
of 2 240.00 of 240.00
Owner Id 7675
Ref.Num.:7675 03012012 1 $240 of 240.00 Invoice Date 03/01/2012
If Paying by check, include a check made payable to the Department of Homeland security. You can pay all youx
payments online at IDHS web site https: myoracle. in. gov /dfbs /idhsFeesFines /start.do with visa /Master
Card /Discover cards. Use Owner Id on this letter or State Number on the invoice to pull up information when
paying the dues online.OR complete the following information and return by mail :Indiana Department of
Homeland Security, Fiscal Department, 302 W.Washington St., Rm E221,Indianapolis, IN 46204 or fax to
(317)233 -0401. Questions? call(317)232 -6427 or E -mail :elevator invoice @dhs.in.gov 2.25% convenience fee
charged on all credit card payments.
Full Name on Credit Card
Billing Address: Street
City State Zip Code
CC type:Am.Express /Discover /Master Card ONLY (circle one) (VISA payment online only)
Acct. Number Exp.Date (mm /yy)
CVV2 Number Contact Phone Number Signature
By signing, cardmember agrees to the obligations set forth by the Cardmember's
Agreement with the issuer.
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VOUCHER NO. WARRANT NO.
ALLOWED 20
IN Department of Homeland Security
Fiscal Department IN SUM OF
302 W. Washington St., Rm E221
Indianapolis, IN 46204
$360.00
ON ACCOUNT OF APPROPRIATION FOR
Administration Department
PO# Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Members
1205 7675- 02292012 -1 43- 515.01 $120.00 I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
l 1 0 7675- 03012012 -1 43- 501.00 $120.00
materials or services itemized thereon for
1205 7675- 03012012 -1 43- 515.01 1 $120.00
which charge is made were ordered and
received except
Monday, March 12, 2012
r
Director, Administratio
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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))
02/29112 7675 02292012 -1 ADMIN 45583 $120.00
03/01/12 7675- 03012012 -1 POLICE 45581 $120.00
03/01/12 1 7675 03012012 -1 ADMIN 45582 $120.00
1 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