175925 08/06/2009 CITY OF CARMEL, INDIANA VENDOR: 306840 Page 1 of 1
ONE CIVIC SQUARE TRACTOR SUPPLY CO
CARMEL, INDIANA 46032 PO sox 689020 CHECK AMOUNT: $89.61
DES MOINES IA 50368 -9020
CHECK NUMBER: 175925
CHECK DATE: 816/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMO DESCRIPTION
2201 4232100 050860 89.61 6035301200050860
�Z
page 1 of 4 TX 7 D 13 0 I
BUSINESS ACCOUNT
0000450
—g
M
Previous Balance 28.33- Closing Date 07/21/09
Payments 0.00 Next Closing Date 08/19/09 CARMEL STREET DEPT
Credits 0.00 Payment Due Date 08/15/09 CINDY
Purchases 89.61 3400 W 131ST ST
`Debits 0.00 Current Due 61.28 WESTFIELD, IN 46074 -8267
FINANCE CHARGES 0.00 Past Due Amount 0.00 Credit Line 5,250
Late Fees 0.00 Minimum Payment Due 61.28 Credit Available 4,804
New Balance 61.28
CURRENT ACTIVITY
h RrA
,�Transat:iloh Lacatiani m Mtount
N Ego
JUN 30 GOODS AND SERVICES WESTFIELD IN 59.99
JUL 8 GOODS AND SERVICES WESTFIELD IN 4.78
JUL 9 GOODS AND SERVICES WESTFIELD IN 1.29
JUL 13 GOODS AND SERVICES WESTFIELD IN 13.57
TOTAL 6035301200074803 $79.63
JUL 6 GOODS AND SERVICES WESTFIELD IN 9.98
TOTAL 6035301202896120 $9.98
This account is subject to the Alternate Balance Subject to Finance
Charge Calculation Method. See back for details.
FINANCE CHARGE SUMMARY
Current Billing Period Previous Billing Period
Balance Daily Days in ANNUAL Balance Daly Days in ANNUAL
Subject to Periodic 8illing PERCENTAGE Subject to Periodic Bilking PERCENTAGE
Finance Charge Rate Period RATE Finance Charge Rate Period RATE
REGULAR REVOLVE CREDIT PLAN 0.00 ODOOO 33 0.00 0. DO .0000D 3o 0' 00
This Account Issued by Citibank (South Dakota), N.A. CUSTOMER SERVICE 1- 800 -559 -8232 FAX NUMBER 1 -801- 779 -7425
a
Notify Us in Case of Errors or questions About Your Bill Copy Fee: On any matter unrelated to a billing error or disputed purchase,
we charge a $5. 00 fee for each duplicate statement for a billing period that
If you think your billing statement is wrong, or if you need more information is more than 3 months prior to your request. We add this fee to your regular
about a transaction on your billing statement, write to us (on a separate revolve credit plan balance.
sheet) as soon as possible at the billing error address on the front of your
statement. We must hear from you in writing no later than 60 days after we Payment Options Other Than Regular Mail:
sent you the first statement on which the error or problem appeared. In your
letter, give us the following information: Pay by Phone. You may make your payment by phone by using the Pay by
Phone Service. You will be charged $14.95 to use this payment service.
Your name and account number. Call by 5 p.m. Eastern time to have your payment credited as of that day.
The dollar amount of the suspected error. If you call after that time, your payment will be credited as of the next day.
Describe the error and explain, if you can, why you believe there is an We may process your payment electronically upon verification of your
error. if you need more information, describe the item you are unsure identity.
about. Send payment by courier or express mail to the Express Payments
address: Customer Service Center, Dept. CCS 8725 W. Sahara Blvd., Las
Important Payment Instructions Vegas, NV 89117. Payment must be received in proper form, at the proper
address, by 5 p.m. Pacific time in order to be credited as of that day. All
Crediting Payments: Payment must be received in proper form at our payments received in proper form, at the proper address, after that time
processing facility by 5 p.m. local time there to be credited as of that day. A will be credited as of the next day_
payment received at the processing facility in proper form after that time will
be credited as of the next day. Please allow 5-7 days for payments by Report a Lost or Stolen Card Immediately: Customer Service is available
regular mail to reach us. There may be a delay of up to 5 days in crediting a 24 hours a day, 7 days a week.
payment sent by mail if it is not in proper form or is addressed to a location
other than the address listed on the return envelope or on the front of the Your account is issued by Citibank (South Dakota), N.A.
payment coupon, or, for courier or express mail payments, to the Express
Payments Address set forth below.
Proper Form: For a payment sent by mail or courier to be in proper form,
you must;
Enclose a valid check or money order. No cash, gift cards, or foreign
currency please.
Include your name and account number on the front of your check or
money order.
Tractor Supply Co. Full Balance S902TV 10/06
902TV5741006 PCT
page 2 of 4 Tx 7 D 1300
WMY
®o BUSINESS ACCOUNT
�p
0000451
CURRENT ACTIVITY
Tr�nsactlon Lacaibnf�� 1 s 1 N
at
Blue Books are now available in stores.
Be sure to stop by to pickup your free copy packed with
product information, planning guides, comparison charts and more.
It's even easier to get what you need at Tractor Supply!
Now order any item available for sale online and
have it shipped to your nearest store for free!
Buy in bulk and save!
Check out our volume pricing on fencing, feeds, clothing and
maintenance, available on purchases as small as five items.
See a team member for details.
Remit To: Bill To page 3 or 4
TRACTOR SUPPLY CREDIT PLAN ACCOUNT: 6035301200050860CR
DEPT.30 1200050860 JEFF STEWART �SUMYCO-
PO BOX 689020 211 2ND ST SW BUSINESS ACCOUNT
DES MOINES IA 50368 -9020 0000452
Payment Due Date: 08/15/09 Please make checks payable to TRACTOR SUPPLY CREDIT PLAN
SHIP TO: INVOICE: SHIP TO: INVOICE:
431000938446010 431000944688010
Purchase Order: Purchase Order:
SHOP SHOPP
AMOUNT DUE: 8.37 AMOUNT DUE: 59.99
Store: 574000431 INVOICE DATE: 06108 /09 Store: 574000431 INVOICE DATE: 06/30/09
CAT PIN 7/8X1 -5 18IN I D 0268420 1.00 2.79 2.79 FUEL NOZZLE AUTOM UNLEA 3958236 1.00 59.99 59199
CAT PIN 718X1 °5 181N 1 D 0268420 1.00 2.79 2.79
CAT PIN 7/8X1 -5 /8IN 1 D 0268420 1.00 2.79 2.79 SUBTOTAL 59.99
TAX 0.00
SUBTOTAL 8.37 SHIPPING 0.00
TAX 0.00
SHIPPING 0.00 TOTAL 59.99
TOTAL 8.37
SHIP TO: INVOICE: SHIP TO: INVOICE:
431000946769010 431000946933010
Purchase Order: Purchase Order:
SHOP SHOP
AMOUNT DUE: 4.78 AMOUNT DUE: 1.29
store: 574000431 INVOICE DATE: 07/08 /09 Store: 57f.000451 INVOICE DATE: 07/09 /09
ELBOW MALE TPT HB 1/2 1 2110908 1.00 1.79 1.79 ELBOW THREAD BARB 1/2 3 2114295 1.00 1.29 1.29
1121N FEMALE PIPE COUPL 2114790 1..00 2.99 2.99
SUBTOTAL 1.29
SUBTOTAL 4.78 TAX 0.00
TAX -0.00- SHIPPING 0. 00
SHIPPING 0.00
TOTAL 1.29
TOTAL 4.78
Please Direct Inquiries to; Phone: 800 -559 -8232 Fax: 801- 779 -7425
Remit To: `Bill To: Rage 4 or 4
TRACTOR SUPPLY CREDIT PLAN ACCOUNT: 6035301200050860
DEPT.30 1200050860 JEFF STEWART
PO BOX 689020 211 2ND ST SW BUSINESS ACCOUNT
DES MOINES IA 50368 -9020 0000453
Payment Due Date: 08/15/09 Please make checks payable to TRACTOR SUPPLY CREDIT PLAN
SHIP TO: INVOICE: SHIP T o: INVOICE:
431000948021010 431000946114010
Purchase Order: Purchase Order:
SHOP 7062009
AMOUNT DUE: 13.57 AMOUNT DUE: 9.98
Store: 574000451 INVOICE DATE: 07/13 /09 Store: 574000431 INVOICE DATE: 07/06 109
PIPE PLUG 21M MALE 2100385 1.00 4.29 4.29 PAINT T8I SPR TRANSPORT 3449805 1.00 4.99 4.99
NYLON CAPS 2102311. 1.00 2.29 2.29 PAINT TBI SPR TRANSPORT 3449805 1.00 4.99 4.99
STO FLAT FAN 80 DEGREE 2102561 1.00 6.99 6.99
SUBTOTAL 9.98
SUBTOTAL 13.57 TAX 0.00
TAX 0.00 SHIPPING 0.00
SHIPPING 0.00
TOTAL 9.96
TOTAL 13.57
Please Direct Inquiries to: Phone: 800- 559 -8232 Fax: 801 779 -7425
REMIT TSC BUSINESS ACCOUNT
TI�CTOR� PAYMENTS To:
TRACTOR SUPPLY COMPANY
Faw "LYCOM &WT P.O. Box 9020 Tractor Sur'ply Company
Des Moines, IA 50368 -9020 18160 U.S, 31 Nor
TSC TEAM MEMBER TO-COMPLETE Please include 16 Digit Account Number Westf ie1d, IN 46074
6035 301# (317) 867 -3505
NAME CARMEL SfRLEf DEPT
3400 W 131ST ST
ADDRESS WE.STF'IELD IN 460748267
(317) 733 -2001
CITY STATE ZIP PHONE 431 431 2 948021
07/13/2009 10:20am
CUSTOMER TO COMPLETE 2100385 L'IF'E PLUG 21N MALE=
1.00 0 4.29 4.29 NT
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT: Government Asencies
The undersigned certifies The undersigned party certifies their exemption from 2102311 NYLON CAPS
compliance with the agricultural payment of sales and use tax on tangible personal 1 00 C' 2.29 2,29 NT
sales tax exemption law of the state property as indicated below and /or purchaser is Government Asencie5
indicated below and understands 2102361 STD FLAT FAN 30 DEUR
engaged in the business of agricultural production of
and agrees with the General 1 .00 G 6.99 6.99 N�T
Exemption Statement at right and food or fiber, horticulture, aquaculture of floriculture for the l'savernmen t Agencies
the applicable statement of resale and /or uses the farm machinery, equipment or
respective state printed on the other agricultural production items purchased free of Subtotal 13.57
reverse side of this form. tax, as defined by state law, and as indicated below. 7 00% Tax 0.00
PRODUCT IS TO BE USED IN THE FOLLOWING The undersigned party further certifies they Total 13.5'
STATE:
understand the y y p ayment ma be liable for of all taxes TSC Card 13.57
REQUIRED) due on the purchase price for the goods as allowed by Acct *:9*lt11*#sa1*4803
(Exceptions: Georgia, New Y ork a Kentucky state law should such goods be used or consumed in Au t Fro 013.559 Ref e 13091952 79
COMPLETE REVERSE SIDE) C f ha f: shop
a taxable manner as defined by state laws. h ,�ngs 0.00
PURCHASER IS ENGAGED IN: (REQUIRED) n Bac
Resale Under penalty of perjury, signee swears the
Government information on this statement is true and correct in
Exempt organization every material manner. Awillfully false representation Buyer acknowledses the receipt of a comple
Agricultural Production o i
of exemption will cause the, purchaser to be subject to'
Dairy Production penalty and /or other provisions as allowed under statfe copy of this sales Slip and the Purchase o
Livestock Production
El law Floriculture /A uaculture Production
q the described merchandise 5t1a11 be in
other: accordance with the Cardholder Asreement.
ITEMS PURCHASED WILL BE USED FOR: (REQUIRED)
Farm Machinery/Repair Parts Government Agency (Entity Signature:
Livestock Injestibles or Injectibles Exempt Organization (Entity
Fertilizer/Agrichemicals NC: only DOT and US Government are exempt
Consumed in Production (KS) Resale (Sales Tax Permit
Ingredient or Component Parts (KS)
❑Other: Call 800- 968 -0734 within 7 days to
complete a Survey and be entered in a
cu to S GNATURE: (REQUIRED) �J MGR. APPROVAL
O/ X
USE SHA DED AREA ONLY
C S CHECK VISA M/C DISCOVER TSC CHARGE ACCOUNT NO. CHG. EXCH. DATE
ITEM NUMBER DESCRIPTION UNIT PRICE
y Form No. 99 00401(12/05) CUSTOMER ORIGINAL
REMITTSC BUSINESS ACCOUNT y
PAYMENTS TO:
i1�IW i V TRACTOR SUPPLY COMPANY
slu— Pny CO P.O. Box 9020
Tractor U
3 C
Des Moines, IA 50368 -9020 No
TSC TEAM MEMBER TO COMPLETE 0 181 tf U 5 31 6 07
Please include 16 Digit Account Number Westf iel�d, IN 46074
6035 301 317) 867-3505
NAME
CARMEL STREET DEFT
3400 W 131ST ST
ADDRESS WESTFIELD IN 460746237
(317) 733 -2001
CITY STATE ZIP PHONE
431 431000172 2 946114
07/06/2009 09:40am
CUSTOMER TO COMPLETE 3449805 PAINT T &I SPR TRAf+1SP
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT: 1'00 4,99 4'99 NT
Government Asencies
The undersigned certifies The undersigned party certifies their exemption from 3449605 PAINT 11T. SPR TRANSP
compliance with the agricultural payment of sales and use tax on tangible personal 1.00 9.99 4.99 MT
sales tax exemption law of the state property as indicated below and /or purchaser is Government Asenc ies
indicated below and understands engaged in the business of agricultural production of
and agrees with the General food Lion Statement at right and food or fiber, horticulture, aquaculture of floriculture for Subtotal n
.96
Exemption g resale and /or uses the farm machinery, equipment or 7.00% Tax 0.00
the applicable statement of the Total 9.98
respective state printed on the other agricultural production items purchased free of TSC Card 9198
reverse side of this form. tax, as defined by state law, and as indicated below.
ACctf=3Y3fstitts336170
PRODUCT ISTO BE USED IN THE FOLLOWING The undersigned party further Certifies they Autho 006091 Re l t 0609400733
STATE: understand they may be liable for payment of all taxes Ca
OnyQ7062009 0.00
(REQUIRED) due on the purchase price for the goods as allowed by
(Exceptions: Georgia New York Kentucky state law should such goods be used or consumed in Cash Back
COMPLETE REVERSE SIDE) a taxable manner as defined by state laws.
PURCHASER IS ENGAGED IN: (REQUIRED) Buyer ac,knuwled:,es the receipt of a comele
L] Resale Under penalty of perjury, signee swears the d
Government information on this statement is true and correct in Copy of this sales slip and the purchase u
Exempt organization every material manner. A willfully false representation
Agricultural Production of exemption will cause the purchaser to be subject to the described merchandise 3h ill l 6e in
Dairy Production penalty and /or other provisions as allowed under state accordance with the Cardholder Agreement.
Livestock Production
Floriculture /Acluaculture Production law.
F7 Other: Sisnature:
ITEMS PURCHASED WILL BE USED FOR: (REQUIRED)
Farm MachinerylRepair Parts Government Agency (Entity
Livestock Injestibles or Injectibles Exempt Organization (Entity
Fertilizer /Agrichemicals NC: only DOT and US Government are exempt 3333 ;33 #333 #3333333333 #3##333 ;3333
F1 Consumed Resale (Sales Tax Permit#
3233 3;3#33 ;3333##33333Y33333## #Y#Y
Consumed in Pro uctian (KS) Call 800 °968 -0734 within 7 days to
F1 Ingredient or C ponent Parts (KS) complete a survey and he entered in a
Other: monthly drawins for a chance to win a
$2500 shoppins spree.
(Awarded as Gift Card) NO PURCHASE
i CUST IGN URE: (REQUIRED) MGR. APPROVAL
I
X
USE SHADED AREA ONLY WHEN REGISTER IS IN
C H CHECK VISA M/C DISCOVER TSC CHARGE ACCOUNT NO. DATE
CHG: EXCH.
ITEM NUMBER DESCRIPTIO
i
Form No. 99 (12/05) CUSTOMER ORIGINAL
REMIT TSC BUSINESS ACCOUNT
TRACTOR® PAYMENTS T
TRACTOR SUPPLY COMPANY
V SU"LYCOM P.O- Box 9020 Tractor Supply Comrany
Des Moines, IA 50368 -9020 18160 U.S, 31 North
TSC TEAM MEMBER TO COMPLETE Please include 16 Digit Account Number West f field IN 46074
6035 301# (317) 867 -3505
NAME CARMEL STREET DEFT
3400 W 131ST ST
ADDRESS WESTFIELD IN 460748267
(317) 733-2001
CITY STATE ZIP PHONE 431 796000104 2 944698
06/30/2009 03:12pp,)
CUSTOMER TO COMPLETE 3958236 FUEL NOZZLE AUTOM UN
1,00 59,99 59,99 NT
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT: Government Asencie5
The undersigned certifies The undersigned party certifies their exemption from
compliance with the agricultural payment of sales and use tax on tangible personal Subtotal 59.9°
sales tax exemption law of the state property as indicated below and /or purchaser is ?.00% Tax 0.00
indicated below and understands engaged in the business of agricultural production of Total 59.99
and agrees with the General TSC Card 59.
food or fiber, horticulture, aquaculture of floriculture for
Exemption Statement at right and Acct# t i i i i i i i i i i 4803
resale and /or uses the farm machinery, equipment or
the applicable statement of the other agricultural production items purchased free of Auth #:030944 Ref *:3014120376
respective state printed on the tax, as defined b state law, and as indicated below. PO 4 shorn
reverse side of this form. y Chanee 0.00
The u ndersigned art further certifies the Cash Back
PRODUCT IS TO BE USED IN THE FOLLOWING g P Y y
STATE: understand they may be liable for payment of all taxes Buyer acknowledses the receipt of a coerie� 'le
(REQUIRED) due on the purchase price for the goods as allowed Icy.
(Exceptions: Georgia, New York s Kentucky state law should such goods be used or consumed in
COMPLETE REVERSE SIDE) a taxable manner as defined by state laws. copy Of this Sales Slip and the FurchaSF o
f
PURCHASER IS ENGAGEDIN:(REQUIRED) t he described aterchandise shall be in
Resale Under penalty of perjury, signee swears the
Government information on this statement is true and correct in accordance with the Cardholder Agreement,
Exempt organization every material manner. A willfully false representation
Agricultural Production of exemption will cause the purchaser to be subject to
Fl Dairy Production penalty and/or other provisions as allowed under state Sisna
Livestock Production _______W__-
Flo riculture /Aquacultu re Production law.
Other.
ITEMS PURCHASED WILL BE USED FOR :(REQUIRED)
Farm Machinery/Repair Parts Government Agency (Entity
Livestock lnjestibles or lnjectibles Exempt Organization (Entity Call 900-969-0734 within 7 day5 to
NC: only DOT and US Government are exempt complete a survey and be entered itr a
Fertilizer /Agrichemicals monthly drawing for a chance to win a
Consumed in Production (KS) Resale (Sales Tax Permit x+ 2500 shorpin5 spree.
Ingredient or Component Parts (KS) (Awarded as Gift Card) NO PURCHASE
OR SURVEY NECESSARY, Ends 9/30/09.
Other: iEi#ii# iii ###i #i #t# #i# #i #ti #iit#ifii
UTOE NATURE: (REQUIRED) MGR. APPROVAL
x
USE SHADED AREA ONLY O'
77g CHECK VISA M!C DISCOVER TSC CHARGE ACCDUNT NO. CHG, EXCH. DATE
QUANTITY ITEM NUMBER NON DESCRIPTION UNIT PRICE
TAX r
Form No. 99 00401 (12105) CUSTOMER' ORIGINAL
REMIT TSC BUSINESS ACCOUNT
T PAYMENTS TO:
TRACTOR SUPPLY COMPANY
17 1anw "Lyco P.O. Box 9020 Tractor supply' Cr3,INany
Des Moines, IA 50368 -9020 10160 U.S. 31 Nor
TSC TEAM MEMBER TO COMPLETE Please include 16 Digit Account Number Westf i6d, IN 46074
6035301 (317) 567-3505
NAME CAfiMEL "IRCET DEPT
3400 W 131ST ST
ADDRESS WESTFIELD IN 46074G267
(317) 733-7001
CITY STATE ZIP PHONE 431 786000104 Z 946769
07/08/2009 02:45pni
CUSTOMER TO COMPLETE 2110908 ELBOW MMLE TPT H8 I/
1.00 1.79 1.79 NT
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT: Government Agencies
The undersigned certifies The undersigned party certifies their exemption from ?114790 1 /ZIN FEM!iLE F'IF'E CO
compliance with the agricultural 1 .00 L 2.99 2. 99 NT
payment of sales and use tax on tangible personal
sales tax exemption law of the state property as indicated below and /or purchaser is Government A5encies
indicated below and understands engaged in the business of agricultural production of
and agrees with the General Subtotal 4,76
food or fiber, horticulture, aquaculture of floriculture for
Exemption Statement at right and resale and /or uses the farm machinery, equipment or 7.00% Tax 0.00
the applicable statement of the Total 4.76
respective state printed an the other agricultural production items purchased free of 1 Card 4.78
reverse side of this form. tax, as defined by state law, and as indicated below. Acct 4: Y t t t; Y Y s t x Y t 2480:5
PRODUCT IS TO BE USED IN THE FOLLOWING
The under p arty y further certifies the Auth*:000246 Ref �:0813451552
PG SHOP understand they may be liable for payment of all taxes Change 0,00
REGUIRED) due on the purchase price for the goods as allowed by
(Exceptions: Georgia, New York Kentucky state law should such goods be used or consumed In Ca sh Back
COMPLETE REVERSE SIDE) a taxable manner as defined by state laws.
PURCHASER IS ENGAGED IN: (REQUIRED) Buyer acknowledses the receipt of a comple
Resale Under penalty of perjury, signee swears tW- 1
Government information on this statement is true and correct In copy of this Sales, Slip and the FLO'chase D
Exempt organization every material manner. A willfully false representati
Agricultural Production of exemption will cause the purchaser to be subject to the de5crlbed merchandise shall be in
Dairy Production penalty and /or other provisions as allowed under state accordance with the Cardholder Agreement.
Livestock Production
F7 Floriculture /Aquaculture Production law'
Other: Sisnat'ure:
ITEMS PURCHASED WILL BE USED FOR: (REQUIRED)
Farm Machinery/Repair Parts Government Agency (Entity
Livestock Injestibles or Injectibles Exempt Organization (Entity
Fertilizer /Agrichemicals INC: only DOT and US Government are exempt YttYYYYYitYYYYYYYY2YYYYYYYY ;tYYLiYYR
YYYYfYYYYYYYYfitYYYYEYYYYYYYtY YYYYYYY
Consumed in Production (KS) Resale (Sales Tax Permit
Call 800 968 -0734 within 7 days to
Ingredient or Component Parts (KS) complete a survey and be entered in a
monthly drawing for a chance to win a
F1 Other: $2500 5hoppins spree.
(Awarded as Gift Card) NO PURCHASE
CUS ER SIGNATURE: (REQUIRED) MGR. APPROVAL
X
SHA DED USE ONLY
CASH CHECK VISA M/C ;DISCOVER TSC CHARGE ACCOUNT N0. CHG. EXCH. DATE
ITEM NUMBER UNIT PRICE
Form No. 99 -00401 (12105) CUSTOMER ORIGINAL
REMIT TSC BUSINESS ACCOUNT
Ti1�aIV i V�� PAYMENTS TO:
TRACTOR SUPPLY COMPANY
SUY c o P.O. Box 9020 Suppy
Des Moines, IA 50368 -9020 Tr 10160 U.S. l 31 L Nor th
TSC TEAM MEMBER TO COMPLETE Please include 16 Digit Account Number Westfield, IN 46074
6035 301 (317) 867 3505
NAME CARMEL STREET DEFT
3400 W 131sT ST
ADDRESS WESTFIELD IN 460748267
(317) 733 -2001
CITY STATE ZIP PHONE 431 431000182 2 946933
07/09/2009 09:33am
CUSTOMER TO COMPLETE 2114795 ELBOW THREAD BARB 1/
1.00 8 1.29 1,29 NT
CERTIFICATE OF EXEMPTION: GENERAL EXEMPTION STATEMENT: Government Agencies
The undersigned certifies The undersigned party certifies their exemption from
compliance with the agricultural Subtotal 1.29
sales tax exemption law of the state payment of sales and use tax on tangible personal
property as indicated below and /or purchaser is 7.00'%. Tax 0.00
indicated below and understands engaged in the business of agricultural production of Total 1.29
and agrees with the Genera/ 1SC Card 1.29
food or fiber, horticulture, aquaculture of floriculture for
Exemption Statement at right and Acct #:tttsttttt3tt4803
resale and /or uses the farm machinery, equipment or
the applicable statement of the Auth #:009212 Ref *:0908332878
respective state printed on the other agricultural production items purchased free of defined b l d indicated
reverse side of this form. tax, as eney state law, an as ndicated below. Change 0.00
PRODUCT ISTO BE USEDINTHE FOLLOWING The undersigned party further certifies they Cash Back
STATE: understand they may be liable for payment of all taxes Buyer acknowledges the receipt of a code
(REQUIRED) due on the purchase price for the goods as allowed by
(Exceptions: Geor New York Kentucky red l d
state should such goods be used or consumed i
COMPLETE REVERSE SIDE) a taxable manner as defined b e state laws. copy of this sales slip and the f urchas€: o
PURCHASER IS ENGAGED IN: (REQUIRED) f
Resale Under penalty of perjury, signee swears the the described merchandise shall be in
Government information on this statement is true and correct in accordance with the Cardholder Agreement.
Exempt organization every material manner. A willfully false representation
Agricultural Production of exemption will cause the purchaser to be subject to
Dairy Production penalty and/or other provisions as allowed under state Si Srla tore
Livestock Production
Flo riculture /Aquaculture Production
Other:
ITEMS PURCHASED WILL BE USED FOR: (REQUIRED) 3t33YEti33ftit1 ;3 #113133333/333 #333
Farm MachinerylRepair Parts Government Agency (Entity# 33; 3;; E33323333t33tEE3t33333#tt33t333
Livestock Call 800 968-0734 within 7 days .to
1 1 Exempt Organization (Entity
Fertilizer /Agrichemicals NC: only DOT and US Government are exempt Complete a survey and be entered in a
Resale (Sales Tax Permit monthly drawing for a chance to win a
Consumed in Production (KS) $.500 shopping spree.
Ingredient or Component Parts (KS) (Awarded as Gift Card) NO PURCHASE
OR SURVEY NECESSARY. Ends 9%30/09.
Other: is 3333 ;3 ;3 ;3 #333 #33333#1 ;3333133
C ST R S NATURE: (REQUIRED) MGR. APPROVAL
X
USE AREA ONLY
A CHECK VISA M!C DIS TSG CHARGE ACCOUNT N0. CHG. EXCH. (7ATE
L3
ITEM NUMBER DESCRIPTIO
Form No. 99-00401 (ttios) CUSTOMER ORIGINAL
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 invoices) or bill(s))
07/28/09 $89.61
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
VOUC NO. WAR RANT NO.
ALLOWED 20
Tractor Supply
IN SUM OF
P. O. Box 9020
Des Moines, IA 50368 -9020
$89.61
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO Dept. INVOICE NO. ACCT /TITLE AMOUNT Board Member:
2201 42- 321.00 $8961 1 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
l r
i Thurs J i 0, 2009
Street Commissioner
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund