HomeMy WebLinkAbout179086 11/10/2009 CITY OF CARMEL, INDIANA VENDOR: 356934 Page 1 of 1
ONE CIVIC SQUARE SIGNATURE CONSTRUCTION LLC
CHECK AMOUNT: $152,026.32
CARMEL, INDIANA 46032 720 3RD AVE SW
CARMEL IN 46032 CHECK NUMBER: 179086
CHECK DATE: 11/10/2009
DEPARTMENT ACCOUNT PO NUMBER INVOIC NUMBE AMOUNT DESCRIPTION
902 4460805 15 143,246.80 RETAIL SITE #5
Y 2 4460873 2 7,719.77 PARCEL 5 STREETSCAPE
902 4460805 6 1,059.75 RETAIL SITE #5
APPLICATION AND CERTIFICATION FOR PAYMENT A IA DOCUMENT G 702 PAGE ONE OF 2 PAGES
TO OWNER Cannel Redevelopment Cotmnissic PROJECT: Parcel 5B APPLICATION NO Draw Number 15 Distribution to:
One Civic Square Phase I Carmel City Center Signature costs =OWNER
Carmel, Indiana 46032 Motor Court =ARCHITECT
PERIOD TO: 09/22/09 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction LLC
720 3rd Avenue S.W. PROJECT NOS: CSO Project 21010
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE 09/07/07
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 2,841,863.00
2. Net change by Change Orders 23,073.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line I t 2) 2,864,936.00
4. TOTAL COMPLETED STORED TO 2,864,936.00
By: Date: 9 Z O
5. RETAINAGE: Thomas oontz President
a. 0 of Completed Work ubscribed an worn to before me this 774ay of September, 2009
(Column D E on G703)
b. %of Stored Material e� LINDA BUCHANAN
(Column F on G703) nOTAar'. "'c Hancock County
Total Retainage (Lines Sa 56 or My Commission Expires
Total in Column I ofG703) 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT i_ w August 2o, 2011
6. TOTAL EARNED LESS RETAINAGE 2,864,936.00 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) 2,721,689.20 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE S 143,246.80 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 0.00 J 0
(Line 3 less Line 6) AMOUNT CERTIFIED jo 64 .9 0
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanatio aunt certified differs from the amount applied. Initial all figures on this
Total changes approved Application (an nth Continuation Sheet that are changed m conform with the amount certified)
in previous months by Owner ARCHITE
Total approved this Month By: Dale: f eu e G •wr
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006 -5292
Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
G703 CONTINUATION SHEET Page 2of2
To: From: Project: Application No.: 15.
Carmel Redevelopment Commission Signature Construction LLC Parcel 5B Application Date: 9/22109
One Civic Square 720 3rd Avenue S.W. Phase I Carmel city center Period To: 9122109
Carmel, Indiana 46032 Carmel, Indiana 46032 motor Court Engineer's Project No.
A B C D E F G H I
Work Co leted Materials Total
Presently Completed Balance Retainage
Item Scheduled From Previous Stored and Stored To If
Description of Work Value Application This Period (Not in To Date (G /C) Finish Variable
D or E) (D +E +F) (C -G)
101 General Requirement 132,109.09 126,824.73 5,284.36 0.00 132,109.09 100% 0.00 6,605.45
Bonding 113,675.00 113,675.00 0.00 0.00 113,675.00 100% 0.00 5,683.75
Insurance 25,000.00 25,000.00 0.00 0.00 25,000.00 100% 0.00 1,250.00
102 Existing Conditions 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
103 Concrete 2,170,090.00 2,170,090.00 0.00 0.00 2,170,090.00 100% 0.00 108,504.50.
104 Masonry 50,000.00 0.00 50,000.00 0.00 50,000.00 100% 0.00 2,500.00
105 Metals 19,368.00 0.00 19,368.00 0.00 19,368.00 100% 0.00 968.40
106 Wood, Plastics and Composites 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
107 Thermal and Moisture Protection 68,430.00 50,660.00 17,770.00 0.00 68,430.00 100% 0.00 3,421.50
108 Openings 6,100.00 0.00 6,100.00 0.00 6,100.00 100% 0.00 305.00
109 Finishes 26,360.00 26,360.00 0.00 0.00 26,360.00 100% 0.00 1,318.00
110 Specialties 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
ill Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
112 Furnishings 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
113 Special Construction 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
114 Conveying Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
121 Fire Suppression 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
122 Plumbing 31,000.00 31,000.00 0.00 0.00 31,000.00 100% 0.00 1,550.00
123 Heating, Ventilation AC 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
125 Integrated Automation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
126 Electrical 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
127 Communications 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
128 Electronic Safety Security 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
131 Earthwork 89,640.00 80,000.00 9,640.00 0.00 89,640.00 100% 0.00 4,482.00
132 Exterior Improvements 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
133 Utilities 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
134 Transportation 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
140 Process Integration 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
141 Material Processing Handling Equip. 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
144 Pollution Control Equipment 0.00 0.00 0.00 0.00 0.00 0% 0.00 0.00
Change Orders: 0.00 0.00
CCC.P100MC -CRCO2 49,400.00 49,400.00 0.00 0.00 49,400.00 100% 0.00 2,470.00
CCC.P100MC -CRCO3 46,989.00 46,989.00 0.00 0.00 46,989.00 100% 0.00 2,349.45
CCC.P100MC -CRC04 39,250.00 39,250.00 0.00 0.00 39,250.00 100% 0.00 1,962.50
CCC.P100MC -CRCO5 (112,566.00) 0.00 (112,566.00) 0.00 (112,566.00) 100% 0.00 (5,628.30)
Construction Fee 110,090.91 105,687.27 4,403.64 0.00 110,090.91 100% 0.00 5,504.55
2,864,936.00 2,864,936.00 (0.00) 0. 00 2,864,936.00 100% 0.00 143,246.80
CONDITIONAL FINAL
Payment to Follow
AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA
SS:
COUNTY OF HAMILTON
Tom Koontz being duly sworn states that he is the President of SIGNATURE
CONSTRUCTION, LLC having contracted to furnish certain materials and /or labor as
follows: Site Development for a project known as Parcel 5B Phase I Carmel City
Center Motor Court located at CARMEL, IN and owned by Carmel Redevelopment
Commission and does further state:
CONDITIONAL FINAL WAIVER:
that the balance due from the owner is the sum of one hundred forty -three
thousand two hundred forty -six dollars and eighty cents ($143,246.80) the
payment of which has been promised as the sole consideration for this Affidavit and
Conditional Final Waiver of Lien which is given to and for said amount, effective
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 material or both, furnished by the undersigned thereto, and
further certifies that no other party has a any claim or right 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.
SIGNATURE CONSTRUCTION, LLC
Thomas E. Koontz
President
Sub cribed and sworn to before me this:
Notary Public:
LINDA BUCHANAN
Hancock County
a� y Commission Expires
August 20, 2011
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENTG702 PAGE ONE OF 2 PAGES
TO OWNER CRC at City of Carmel PROJECT: Carmel City Parcel 73 APPLICATION NO, Invoice 2 1 Distribution to:
One Civic Square Signature costs =OWNER
Carmel Indiana 46032 =ARCHITECT
PERIOD TO: 09/22/09 CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction Services LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
1. ORIGINAL CONTRACT SUM 20,515.18
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line 1 t 2) 20,515.18
4. TOTAL COMPLETED STORED TO 13,740.23 j
By: Date: fl
5. RETAINAGE: 7omas E. 1 o htz, President
a. 0 of Completed Work 0 Sub cribed and st rn to before me this a day of September, 2009.
(Column D E on G703)
L of Stored Material e4e LINDA BU County
Hancock County
(Column F on G703) -T c
Total Retainage (Lines 5a+ 5b or ,9., sEx ,P My commission Expires
Total in Column I of G703) S 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT August20,.2011
6. TOTAL EARNED LESS RETAINAGE 13,74023 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) 6,020.46 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 7,719.77 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 6,774.95
(Line 3 less Line 6) AMOUNT CERTIFIED
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation amount certified differs from the amount applied. Initial all figures on this
Total changes approved Application and e Contmu on Sheet that are changed to conform with the amount certified.)
in previous months by Owner ARCHITECT L e
Total approved this Month By: Date: V i/
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the
Uontractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., N.W., WASHINGTON, DC 20006 -5292
Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice 2
9/22/09
Carmel City Parcel 73
Carmel, Indiana
Total Work RETAINAGE BALANCE
Scheduled Completed WITHHELD PREVIOUS TOTAL COMPLETED TO
DESCRIPTION Value This period THIS PERIOD APPLICATIONS TO DATE FINISH
General Requirement:
Testing 352.75 352.75 0.00 0.00 352.75 0% 0.00
Project Management 4,975.80 3 454.39 0.00 1,521.41 4 975.80 0% 0.00
Site Supervision 5,006.99 3,912.63 0.00 1,094.36 5,006.99 0% 0.00
Site Safety Director 0.00 0.00 0.00 0.00 0.00 0% 0.00
Design Drawings 269.69 0.00 0.00 269.69 269.69 0% 0.00
Sanitary Facilities 0.00 0.00 0.00 0.00 0.00 0% 0.00
Final Clean 0.00 0.00 0.00 0.00 0.00 0% 0.00
Constructin Management Fee 9,909.95 0.00 0.00 3,135.00 3,135.00 32% 6,774.95
20,515.18 7,719.77 0.00 6,020.46 13,740.23 67% 6,774.95
n
Date: 09/23/09 Signature Construction, LLC Page: 16
Time: 12:24:42PM
JOB COST TO DATE
Through Period 9 Year 2009
REVISED ESTIMATE
Job Number 12024
CCC P110 TOPPING SLAB
PARCEL 513 P110 (ROADWAY CONSTRUCTION)
Cost Cost Estimate Cost To Date-----------
Phase Code Type Description Revised Change Orders Current Month Year Job Variance
101 -2119 -S Testing Inspecting 3,000.00 10,000.00 13,000.00 3,515.83 3,515.83 9,484.17-
101 -3113 -L Project Management 3,005.24 3,005.24 3,005.24
101 -3113 -S Project Management 6,000.00 6,000.00 6,000.00-
101 -3114 -L Supervision 18,061.90 18,061.90 18,061.90
101 -3114 -S Site Supervision 16,153.85 16,153.85 16,153.85-
101 -3115 -S Site Safety Director 1,333.33 1,333.33 1,333.33-
101 -3316 -M Design Data Drawings 24.00 668.13 668.13 668.13
101 -3316 -S Design Drawings 5,000.00 5,000.00 594.80 594.80 4,405.20-
101 -5137 -S Sanitary Facilities 1,248.00 1,248.00 1,248.00-
101 5213.0 -S Field Office 1,512.00 1,512.00 1,512.00-
101 5213.1 -S Temporary Electric 225.00 225.00 225.00-
101 5213.2 -S Office Supplies 225.00 225.00 225.00-
101 5213.3 -S Temp. Telecommunicat 225.00 225.00 225.00-
101 5213.4 -S Tempory Water 225.00 225.00 225.00-
101 -5427 -S Tools Equipment 600.00 600.00 600.00-
101 -5813 -S Project Signage 100.00 100.00 100.00-
101 -7123 -M Surveying 1,835.00 1,835.00 1,835.00
101 -7123 -S Field Eng Survey 5,000.00 5,000.00 5,000.00-
101 -7319 -S Health Safety 1,000.00 1,000.00 1,000.00-
101 -7413 -S Waste Disposal 1,083.75 1,083.75 1,083.75-
101 -7423 -S Final Clean 1,000.00 1,000.00 1,000.00
Phase Total 43,930.93 10,000.00 53,930.93 24.00 27,680.90 27,680.90 26,250.03
Job Total 43,930.93 10,000.00 53,930.93 24.00 27,680.90 27,680.90 26,250.03-
L
APPLICATION AND CERTIFICATION FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF 2 PAGES2
TO OWNER CRC at City of Carmel PROJECT: Carmel City Phase 1 PI 10 APPLICATION NO Invoice 6 1 Distribution to:
One Civic Square Signature costs =OWNER
Carmel Indiana 46032 =ARCHITECT
PERIOD TO: 09/22/09 F71CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction Services LLC 0
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment, as shown below, in connection with the Contract. information and belief the Work covered by this Application for Payment has been
Continuation Sheet, AIA Document G703, is attached. completed in accordance with the Contract Documents, that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner, and that current payment shown herein is now due.
I. ORIGINAL CONTRACT SUM 65,896.72
2. Net change by Change Orders 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE (Line 1 f 2) 65,896.72
4. TOTAL COMPLETED STORED TO 49,480.90 r p
By: *iswom Date: IZ-
5. RETAINAGE: resident
a. 0 of Completed Work 0 Su scbefore in this b day of S eptember, 2009
(Column D E on G703)
b. of Stored Material
LINDA BUCHANAN
RY
(Column F on G703) g Hancock County
NOTA
Total Retainage (Lines 5a 5b or s My Commission Expires
Total in Column I of G703) 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT °�i August 20, 2011
6. TOTAL EARNED LESS RETAINAGE 49,480.90 In accordance with the Contract Documents, based on on -site observations and the data
(Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated,
PAYMENT (Line 6 from prior Certificate) 48,421.15 the quality of the Work is in accordance with the Contract Documents, and the Contractor
8. CURRENT PAYMENT DUE 1,059.75 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH, INCLUDING RETAINAGE 16,415.82
(Line 3 less Line 6) AMOUNT CERTIFIED
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanati i amount certified differs from the amount applied Initial all figures on this
Total changes approved Application r t an e Contit uon Sheet that are changed to conform with the amount certified.)
in previous months by Owner ARCIFIIT T:
Z°J
Total approved this Month By: Dale:
I 9 Q
TOTALS $0.00 $0.00 This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the �(`r�0 ff)tLC�tArt:7
Contractor named herein. Issuance, payment and acceptance of payment are without
NET CHANGES by Change Order $0.00 prejudice to any rights of the Owner or Contractor under this Contract.
AIA DOCUMENT G702 APPLICATION AND CERTIFICATION FOR PAYMENT 1992 EDITION AIA 01992 THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK AVE., NW., WASHINGTON, DC 20006 -5292
Users may obtain validation of this document by requesting a completed AIA Document D401 Certification of Document's Authenticity from the Licensee.
1 r
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice 6
9/22/09
Carmel City Phase 1 P110
Carmel, Indiana
Total Work RETAINAGE BALANCE
Scheduled Com WITHHELD PREVIOUS TOTAL COt�LETED TO
DESCRIPTION Value This period THIS PERIOD APPLICATIONS TO DATE I FINISH
I
General Requirement:
Testin Ins pectin 3,000.00 2,128.32 0.00 1,387.51 3,515.83 117% 515.83
Pro Mana 6,000.00 (2,927.57) 0.00 5,932.81 3,005.24 50 2,994.76
Site Supervision 16,153.85 0.00 0.00 18,061.90 18,061.90 112% 1,908.05 8
Site Safet Director 1,333.33 0.00 0.00 0.00 0.00 0% 1,333.33
Desi Drawin 5,000.00 24.00 0.00 1 1,262.93 25% 3,737.07
Sanita Facilities 1,248.00 0.00 0.00 0.00 0.00 0% 1,248.00 tl
Field Office 1,512.00 0.00 0.00 0.00 0.00 0% 1,512.00
Tem porary Electric 225.00 0.00 0.00 0.00 0.00 0% 225.00
Office Su 225.00 0.00 0.00 0.00 0.00 0% 225.00
Tem porary Telecommunications 225.00 0.00 0.00 0.00 0.00 0% 225.00
Temporary Water 225.00 0.00 0.00 0.00 0.00 0% 225.00
Tools and Eq 600.00 0.00 0.00 0.00 0.00 0% 600.00
Pro ject Signag 100.00 0.00 0.00 0.00 0.00 0% 100.00
Field En and Sury e ying 5,000.00 1,835.00 0.00 0.00 1,835.00 37% 3,165.00
Health and Safe 1,000.00 0.00 0.00 0.00 0.00 0% 1,000.00
Waste Dis posal 1,083.75 0.00 0.00 0.00 0.00 0% 1,083.75
Final Clean 1,000.00 0.00 0.00 0.00 0.00 0 1,000.00
Construction Management Fee 21,965.79 0.00 0.00 21, 800.00 21, 600.00 99% 165.79
65,896.72 1,059.75 0.00 48,421.15 49,480.90 75 16,415.82
I I
27,680.90
27,680.90
0.00
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No. 201 (Rev. 1995)
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
L
���r �o�sf✓��T /v ��r��� ZZ G Purchase Order No.
Terms
Z Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
/z z a 9 2 i„� 2 .73 /�q�� %��7 X7/9 �7
12 2lo9 (o 'y v P 5 /'7v f d r �o 1 0 5 9, 7S
a 1
Total /`5,2 s 026.
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. f
20
Clerk- Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF
720
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO# or DEPT INVOICE NO. ACCT #!TITLE AMOUNT I hereby certify that the attached invoice(s), or
�yaz 2 1 Ye Of7,3 715.7, bill(s) is (are) true and correct and that the
6 `ly(�O�oS I,OS'9 materials or services itemized thereon for
�5 2 1g6a ?o5 )Y3, Z which charge is made were ordered and
received except
o- 3 20 0�
Sig ture rations
-Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund