175116 07/22/2009 CITY OF CARMEL, INDIANA VENDOR: 276575 Page 1 of 1
s ONE CIVIC SQUARE SAFETY SOLUTIONS, INC CHECK AMOUNT: $170.00
CARMEL, INDIANA 416032 PO BOX 8100
DUBLIN OH 46016-2100 CHECK NUMBER: 175116
CHECK DATE: 7122/2009
DEPA ACCOUNT PO NUMBER IN VOICE NUMB AMOUNT DESCRIPTION
651 5023990 01491284 170.00 OTHER EXPENSES
rArgy 6161 Shamrock GL Box 8100
1 K) 'TIC `gyp. 6uhlin, OH 43016 16 -2100
ln�otce
I N C O R P O R A T E D 800.232.7463 €ax)614.799.9901 s 01491284
Regional Offices Distribution Centers
PY s
s
Birmingham, AL Mobile, AL Columbus, OH Toledo, off
866.2419399 888.871.7463 800.2327463 419.360.9900
'...T g, bated 04/17 2009
Pittsburgh, PA Syracuse, NY Auburn, IN
800.562.0555 800.836.7463 260.927.1956 n, s h
Du e Date.; 05/02/2009
Sold �To 129700 Ship To: 1
City Of Carmel City of Carmel
Water Distribution Sewer Department
3450 W 131st ST 760 3rd Ave. SW, Suite 110
Westfield, IN 46074 Carmel, IN 46032
Customer PO Number °ReleaseNo a 8 Salesperson s WhseSiip Date Document
m' �.a ...wssu r,a �;o ,�,n n1'_�v.a�-..»a a'a�. .tn �s u� mod„
m f e r ar xa;»• i `�s 1 ZAP'
Jason Barzak 0 -1 041-1-7/2009-j-_ 01_407.088
t r ;,ix
Terms a Taxi r g Frht Shipllla�
e.a .a eig
��€al r
m e #M r'�a.aa @c.a
Net 15 IN15 Prepaid Fedex Ground Intl Economy
Item Number l �escnption I prcfered 8 �SMpped��� Ba
n ckorder UM Price,wPerExtension
0100000669680130 1 1 0 PR 122.00 PR 122.00
6696 ROCKY SZ: 13W
Bell, Darryl 1
Shipping warehouse: 90
01503012 1 1 0 PR 15 -00 PR 15.00
030 MEGACOMFORT INSOLE SZ: 12
MENS SZ:12, WOMENS SZ: 14
Shipping warehouse: 90
0151104 1 1 0 PR 9.00 PR 9.00
110 SOLETECH INSOLE
MENS. 13 -14
01503965 2 2 0 PR 12.00 PR 24.00
396 SPENCO INSOLE
MEN'S (12 -13)
Shipping warehouse: 58
Taxes: 11 90
INDIANA
C7� "va
n N g s
22 q.F;
Remit To: Safety Solutions Inc. Merchandise S H{, `Taxi Payments 4 Total�Due
PO Box 8100 ,�a dam
Dublin, OH 43016 -2100 170.00 0.00 1 0
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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
276575
SAFETY SOLUTIONS, INC Purchase Order No.
PO BOX 8100 Terms
DUBLIN, OH 46016 -2100 Due Date 7/13/2009
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/13/2009 01491284 $170.00
hereby certify that the attached invoice(s), or bill(s) is (are) true and
orrect and I have audited same in accordance with iC 5- 11- 10 -1.6
Date Officer
VOUCHER 096004 .WARRANT ALLOWED
276575 IN SUM OF
SAFETY SOLUTIONS, INC
PO BOX 8100
DUBLIN, OH 46016 -2100
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
01491284 01- 7200 -01 $170.00
Voucher Total $170.00
Cost distribution ledger classification if
claim under vehicle highway fund