212740 09/12/2012 CITY OF CARMEL, INDIANA VENDOR: 366519 Page 1 of 1
ONE CIVIC SQUARE PORTER SHANK II LLC CHECK AMOUNT: $28,400.00
CARMEL, INDIANA 46032 C/O NANCE PERRY REED
aN,�o 9785 NORTH 80TH PLACE CHECK NUMBER: 212740
SCOTTSDALE AZ 85258-1744
CHECK DATE: 9/12/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 28, 400 . 00 1099S
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Prior Deed References: Instrument #
9909904943 the Recorder's Office for Hamilton
County, Indiana
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WATER LINE EASEMENT AGREEMENT
This Water Line Easement Agreement (the "Agreement") is made and entered into this day
of , 2012, by and between Porter Shank II, LLC, an Indiana limited liability company
("Grantor") and the City of Carmel, Indiana("Grantee").
RECITALS:
A. Grantor is the owners of certain real property located in Hamilton County, Indiana
("Grantor's Propert y") more particularly described in Exhibit 1 attached hereto and incorporated herein.
B. Grantee, in connection with Grantee's improvement/construction of the Michigan Road
Water Main Installation — Retail Parkway to 1061i Street (the "Project") requires a permanent, exclusive
easement over, through, under, upon and across that portion of Grantor's Property more particularly
described and depicted on Exhibit A and Exhibit B attached hereto and incorporated herein, (the
"Easement Propert y") to provide for the laying, installing, constructing, maintaining, operating,
inspecting, altering, repairing, replacing and removing water utility lines, and all associated valves,
pumps, fittings, meters, accessories and equipment on, over, and across the Easement Property.
NOW, THEREFORE, for and in consideration of the foregoing recitals which are incorporated
herein by reference and the mutual covenants and agreements hereinafter set forth and other good and
valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as
follows:
1. Grant of Easement. Grantor hereby grants and conveys to Grantee an exclusive, perpetual
easement for the purpose of laying, installing, constructing, maintaining, operating, inspecting, altering,
reparing, replacing and removing water utility lines, and all associated valves, pumps, fittings, meters,
accessories and equipment [ (the "Improvements") on, over, through, under, upon and across the Easement
Property. Grantee shall have the right to: (a) remove from the Easement Property, without liability for
replacement or repair, any fences, structures, asphalt or concrete paving, curbing or other improvements,
trees, bushes, earth berming, landscaping and other structures that exist prior to, at the time of, or after
Grantee's acquisition of such easement; and (b) make such alterations and improvements to the Easement
Property as Grantee deems may be necessary or useful in the exercise of Grantee's rights hereunder. If the
Improvements are installed in good faith in a location other than the location that is described and
depicted in Exhibit A and Exhibit B then, and in that event, the Easement Property defined herein shall be
revised to include that strip of land that is centered on the line or equipment as installed, and in such an
event, Grantor and Grantee, shall join in the execution and acceptance of an appropriate substitute
easement instrument if either Grantor or Grantee shall deliver to the other a written request for such a
substitute easement instrument. Grantee shall also have the right of ingress and egress over, under, upon
and across the Grantor's Property for purposes of access to the Easement Property. The easement also
16469634. 1
and privileges to.temporarily use, from time to time, additional space'on the Grantor's Properly, where
available and.necessary;.for equipment and materials necessary for the'installation,repair-and maintenance:.
of the Improvements located in, under, upon, over; and/or across,the Easement Property, to do all acts and
things, requisite arid necessary for the full enj oymerit.of the-easement hereby granted; and-for .ne'arby-
property owners,.their:grantees, successors; agents;or employees, to. connect:the.premises of such nearby
property owners by_service pipes to the Improvements.installed_,by Grantee within the Easement Property,
provided such nearby property_.owners, their grantees, successors; agents, or employees restore the Portion '
of the Grantor's Property by their work to.:a condition'that is as near the condition that existed
�. ;
just prior'-to the time.thep' ion.was distuubed by them as is.practicable:
2: Obligations_of Grantee. To the extent practical and .within acceptable. construction
practices, Grantee-shall utilize directional boring for the initial-installation of the water. utility.lines that
area part of the Improvements. Open cutting or ditches shall be utilized to install service lines, taps
hydrants;"valves for.similar'items; ;as,needed:as-part of the directional boring process; where two_Water,.
lines intersect or connect;.or.if problems arise with the directional boring.process Grantee shall riot"be 4. .
required .use directional boring
for any future, repair, maintencnace; "replacement;. reconstruction,.
relocation of the Improvements: Grantee;shall maintain, repair, replace and service the br iprovments.
Notwithstanding anything iri this Agreement to the contrary;Grantee shall restore the."Ease ment Property
and Grantor's Property,to.the extent practicable,to the condition as existed prior to the :commencement of, !
.the Project; including driveways thereon. This obligation to restore the.driveways shall`apply to all future
work, including repair;replacenient'or`relocation of the Improvements.
3. ": Rights Retained by Grantor. Grantor shall retain unto.itself the right to use,ihe.Easement
Property for-any and all purposes and uses not inconsistent with _the foregoing easement. 1 Subject to
Grantee's,rights and obligatioris in Sections 1" and 2 with respect to the Easement Property, Grantor shall
be .entitled to ri aihtain.all improvements .on. the Grantor's Property in exi tence"as of the date.of this
Agreement. With the exception of those liiiprovements in existence'"on_the:date of this Agreement,
Grantor shall.not erect or.maintain any permanent structures; obstructions, or.other improvements under
and/or upon the surface of or over the Easement Property. Grantor shall not..perform"any:act which would`
impair or 'interfere°with Grantee's use and enjoyment of the Easement Property or the.easement Herein
granted. The immediately preceding sentence prohibits(among the other prohibitions effected by it)the
erecting or maintaining in'the Easement Property of,any.earthen mound.or series. or system of earthen
4.., Obligations.:of Grantor: Grantor shall` keep the Easement.Property free. of any.fence;
structure;asphalt,:gravel',planf s, concrete or other..,improvements.(other than those installed.by.Grantee).
Grantor shall mow and care'for the grass aocated within the Easement.Property and,shall maintain all other I"
parts of the Easement Property in good condition., Grantor shall not-block' impede or interfere with the
Improvements or Grantee's access'to or use of the Easement Property. _
5. Easement and Covenants,Appurtenant. The easement.granted, created and made herein,
together with the benefits thereof, shall'run with the Grantor's Property and the Easement Property,:inure
to the benefit of Grantee and its grantees, successors and assigns and shall bind Grantor-and its grantees,"
successors and assigns. All" covenants and- agreements, hereunder may,be enforced by an_action or
specific performance, and' in the event that a_party breaches any such covenant or agreement, the other
party may exercise,any remedy.available hereunder, at law or in equity, and_recover from the breaching
1646963 4. 2
party all amounts expended in connection with'exercising any such remedy (including without limitation, -
court,costs and attorneys' fees).
b. Environmental Matters. Grantor covenants and represents that to the best of its knowledge,
neither the Grantor's Property nor the Easement Property is not presently the subject of; nor is there the
threat of any federal, state or-states, or local environmentally related-lien, proceeding, claim,'liability-or.
action. Grantor,agrees,that between Grantor and..Grantee, the acceptance of this Agreement by Grantee
shall not increase the liability entally of Grantee for environm related claims arising from or related.to'(i)
conditions on the=Grantor's Property or.the°Easement Property prior to the acceptance of this -
Agreement; (ii) acts of Grantor or any-other third party; or(iii)conditions on.the Grantor's
Property or the ;.
Easement Property"not created by Grantee."f
Jurisdiction: .Grantor and Grantee agree that any litigation associated with or.arising from . .
this indenture shall'be.filed with a court of competent jurisdiction within the State of Indiana. .
8: . Other Obligations:. Grantor agrees that this Agreement shall-;not transfer to Grantee any
past, present, or future obligation(s)-of Grantor to be responsible for, or to pay,:any.taxi assessment, orfe, r
associated with or related'to the Grantor's.Property or Easement Property."
9. Waiver.."Waiver by either party of any one default-hereunder will not be deemed to be a
waiver of any:other default under this Agreeziient.-. Any remedy or election.under this Agreement will'not .
be deemed exclusive, but instead; whenever legally permissible; will be:cumulative:with all-.other, i
remedies at law or in equity., .
10.- Ame'tidment.. Grantor and Grantee agree that,this 'Agreenienf`shall:only:be modified or
released by the express,-wri tten consent of both Grantor and-Grantee. Said consent; when.duly.recorded;
shall run with the Grantor's Property and the Easement Property.',
11. Entire A egx emerit. This Agreement contains the entire agreement of the parties with respect
to the subject matter hereof, and all prior agreements;communications and negotiations between
the'paxties,
either: verbal. or written, are hereby merged into this Agreement: This Agreement may lie terminated;
modified;_or amerided'only by a:writing signed by the parties; and no agreement or consent of any.'other
persons shall.be necessary for such termination,modification,or amendment.`.
12. 'Governing Law This Agreement will be governed by and construed in,accordance with the
laws of the.State of Indiana. :
13. Notice. Any and all notices,'demands; requests, submissions,approvals, consents, or other
communications or documents required to be given; delivered or served or which may be given; delivered
or served under or by the terms and provisons of this Agreement'or pursuant fo law. or otherwise, shall be
in. writing. All notices shall be either (a) sent.by overnight delivery using a nationally recognized
overn ight courier;in which case notice shall be deemed delivered one business day after deposit with such
courier, (b)_sent by certified or regular U:S. mail,,postage prepaid, in which case notice shall be.deemed .
delivered two business days after deposit in such,mails; or (c) sent by personal.delivery, in which case
notice shall be deem, delivered upon receipt or.refusal of delivery. All notices shall be addressed to the ! .
respective partiesas follows:.
- E
[646963 4. 3
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If to Grantee: City of Carmel
I. .
One Civic Square !,
Carmel,Indiana 46032 f_
Attn: Carmel City Attorney i
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_ With a Copy to: City of Carmel
One Civic Square'
Carmel,Indiana 46032
Attn: Director of Utilities: i
If to Grantor: or
.n \VR1
i
Any such.notice:will lie effective three days after the notice has been deposited in the United States mail', as
provided above-or if earlier upon receipt..
14: Severability. If.any .term, covenant, condition or provision of this-Agreement or,the
application thereof._to any person or circumstance, shall`at any tune.or to any extent be held invalid or
unenforceable, the remainder of this Agreement, or the application;of such term'or provision.to persons or
circumstances other than;those as to whieh'it is held invalid or unenforceable;. shall not.be affected
thereby,. arid each such term, covenant, condition and provision'of this Agreement shall continue ao be
valid,binding and enforceable to the fullest extent-.permitted by'law..,
15. Authori . .:The.person executing this instrument on behalf of Grantor hereby-represents that
he/she has the authority to bind Grantor'to the terms,and conditions set forth herein and that all necessary_
action therefore has,been taken. Grantor further represents and warrants to Grantee that Grantor is the fee
simple owner. of'the Easement Property- that Grantor has the right fo grant`this easement;that Grantor-
guarantees:the.'quiet possession of the Easement Property to the Grantee; that.the,Easement.Property is
free of any liens:or encumbrances, except the"lien of current taxes.and any other lien:or encumbrance that, i
as of the date.of execution hereof,-appears of public record; and that; subject tothe foregoing,Grantor.will .
warrant and defend Grantee's'title to.the•easement granted hereby against all claims thereon.
16. Attorneys' Fees. In the event of any'action or proceeding brought by either party against '
the-other under this Agreement, the prevailing party shall "be.entitled to recover all costs and expenses;
including reasonable attorneys' fees. .
IN WITNESS WHEREOF,the parties hereto have executed.this Water Line Easement Agreement
as of the day and year first above written.
1646963_4. 4
Porter Shank II,LAC. .-.
Nancy Pe Re'
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Sole Member
Date
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1646963_4. 5
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GRANTEE:
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THE CITY_•OF CARMEL :
By and through its Board of Public Works'and.:Safety-
By:
James Brai_ d, Presiding Officer
Date:
By:
M Ann Burke, Member ,
Date:
By:
Lo ' a son,-Member
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Date: ,I
ATTEST:
iana L: Cordray, C,•Clerk-Treasurer
Date:
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1646963 4.
6 .
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STATE OF INDIANA )
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COUNTY.OF.HANIILTON )
Personally appeared before me this day:James B"iainard,,,Mary Ann Burke, and Lori Watson; who having f"
been duly sworll%affirmed, state(s)"that.they ate,members"of the City of Carmel's Board of Public Works I,
and-Safety'and have executed the foregoing Water,Line Easement Agreement.on behalf of such entity.
WITNESS in hand and notarial seal this - day" of �' r lrb/_ O1
y , y P 2 ,2 Z
M Conu—mssion Ex ices:
Y p `1�.�� fi/ Signed Naive: .�/✓i�r, Or�x
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My County of Residence. "�,g-i/j/,CAD/� Punted Name: . ��.�,�/�/�,Cf a�/�5 •
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1646963_4. • 7 .
rr 1,T BOBBIE HALEY.. II
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Notar `public-"Arizona
STATE OFQ� Marico a County-
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SS: yr ' MY Comm. Expires Sep 2,,2013
COUNTY"OFC�r
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Before`me; a Notary'Puble in acid for the State of Z ,.personally appeared Nancy.Perry 4 "
Reed, by me.known;to be the Sole Member of the Grantor; who acknowledged the execution:,of the -. .
foregoing.Water Line Easement Agreement for and on.behalf'of said Grantor.
Witness my,hand and Notarial seal this day of y: j. ;2012. .
My Comm_ission Ex
S
otary Public_
My County of.Rekd"ence: • U�j�j�'' /7�/��
[Printed] i
This instrument was`prepared"by and after recording,return to: Douglas C.-,Haney, "City of.Carmel, One
Civic Square,Cannel; IN ;46032.
I affirm' under the,penalties for:perjury,-.that I have taken reasonable care to redact each Social Security :
number in this document,unless required by law. -Douglas C. Haney
16469634.
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"A"
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EASEMENT
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A PART OF THE NORTHWEST QUARTER OF SECTION.7,TOWNSHIP 17 NORTH,RANGE 3 EAST OF THE SECOND
PRINCIPAL MERIDIAN,HAMILTON COUNTY,INDIANA,MORE PARTICULARLY DESCRIBED AS:FOLLOWS:. .
-
Commencing at the Southeast comer of said Northwest .Quarter.; thence. North 00 degrees 10 minutes 05.
seconds _West, a distance of 104.33 feet; thence South 89 degrees 25 minutes-22 seconds West, a- ,
distance of 336.26 feet to the PLACE OF BEGINNING; .thence South 19 degrees 37 minutes 25 seconds I
East, 'a.distance of 1.10.37 feet; thence South 89-degrees-25 minutes 22 seconds West; a distance of
15.87 feet; thence North. 1.9"degrees. 37 minutes- 25 seconds West, a distance of 110.37; thence North 89
degrees:25 minutes '22 seconds East,, a-distance. of,15.87 feet to.the PLACE OF.BEGINNING CONTAINING.
0.0380 ACRES(1:656-SQ FT.)MORE OR LESS. i
t
I; Trent.E. Newport,:.a Registered Land Surveyor in,#he..Stattg. of,Indiana, do hereby certify that.this:
description was prepared from information obtained from .lnstrum,ent_Number 200000003708, as recorded in
the Hamilton.County Recorder's Office. Na fieldwork was.performed and..therefore, this. description is
subject to any overlaps, gaps:or inconsistencies:that,a-field survey:might.reveal:
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OISTEREO O�J
.:No. 29600021-, Trent E.Newport Date
Reg.-Land Surveyor No. 296.00021-
STATE oF. State of lndidna
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PREPARED BY-
Development Coultants
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EXHIBIT 1 j
Grantor's Property I
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Part the:Northwest,Quarter of Section 7,Township 17 North, Range-3 East in Hamilton,County,Indiana, more
particularly described as'follows:
BEGINNING at the Southeast corner of the Northwest Quarter of Section 7, Township 17 North; Range 3 East; thence
North 00 degrees.00:minutes 00 seconds(assumed bearing)on and along the East line:of said Northwest Quarter 104.33 i
feet; thence-South 89 degrees 35 minutes 27 seconds West parallel with.the South line of said Northwest Quarter 437.-11 I
feet to.the,centerFine_of_U:S. Highway 42.1;thence.South 20 degrees 37 minutes 15 seconds East on and,along:said I .
centerline 111,17 feetao the South line-of said.Northwest Quarter;thence North 89 degrees 35 rrtinutes.27 seconds East
on and along said South line 3.97:96 feet to the Point of Beginning;containing 1.00 acres,.more-or.less.
EXCEPTING THEREFROM:
A part of the Northwest Quarter of Section 7,Township 17'North,Range 3 East of the Second PrincibaV Meridian; _
Hamilton County,.Indiana, and being
all that part of the.owtner's.land lying within.the right of way lines depicted on'the
attached Right of Way Plat of Parcel 16,also described a_s foilows: Commenting at the Southeast corner of the Northwest .
Quarter of Section 7,Township,17 North, Range 3.East; thence_North 00 degrees 10 minutes.05 seconds West 31.800
meters(104.33 feet).on and along the.East line of said Quarter Section to the-Northeast corner of the owner's land; .
thence South 89 degrees 25 minutes 22.seconds.West.117.151, meters;(384:35:feet}along the North line of.ahe owner's
land to the Northeaster boundary.of.U.S.421 and the POINT OF BEGINNING of this description;,thence North 89
degrees.25.minute 22.second8 East4,007-meters(13.15 feet)along the North line of the ownees.land.to.point"100.7"as.,
shown on said plat;thence Southeasterly 33.895 meters(11-1.20 feet)along an arc to the left and having a radius.of j
69603.938-meters(228359.38 feet)and subtended by a long chord having a bearing of South 20 degrees 49.minutes'49 I.
seconds East and.a length.of 33.895 meters(111.20 feet}to point"748"'as shown on said plat,which point is on the
South line of the Northwest Quarter of said.Section; thence South 89 degrees 25.minutes 22 seconds West 4.008 meters
13.15 feet alon said South line to the Eastern bounds ry,of-said U.S..421; thence.alon the boundary of said.U.S.:421-
Northwesterly 33.894 meters(111.20 feet)along an arc:to.the right and havirig-a radius of 69607.6.98 meters(228371.71
fleet)and subtended by a long chord having a bearing of North.20.degrees 49 minutes 4S'seconds West and a length,of '
33_894 meters(111.20 feet),to the paint of beginning and containing 0.013 hectares(0.031 acres), more or less.
I
CArmel Michigan Road Water main West Carmel MArketplace Owners Assn}l.doc
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ROAD: MICHIGAN :ROAD: DRAWN BY : CJL 12-13=11
PROJECT: MICHIGAN ROAD FDR MAIN �. REVISED-BY : CAW 02-10-12 j
96th ST.-106th ST. CHECKED BY : TEN: V__E
COUNTY: HAMILTON SCALE : 1" = 60' `
SECTION: 7 EASEMENT EXHIBIT
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TOWNSHIP: 17 NORTH- OWNER: PORTER SHANK II, LLC r .
RANGE: 3 EAST RECORD DOCUMENTS: SPECIAL WARRANTY DEED, INST.#9909904943
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�1Ll.LC1L� HATCHED AREA IS THE
srnr•.i•.so': APPROXIMATE EASEMENT
1
NORTH, .::
DRIVEWAY EASEMENT I
INST.#8926921
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N89'25'22°E 15.87'
PLACE.OF BEGINNING
S89'25'22'W 437.11'
S89'25'22°W 336.26'
— - - - ---- — .- -- — - - - -- -
DR /(J EASEMENT
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PORTER SHA N -
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PREPARED_BY:=
� ST-r 0 No fieldwork was performed and therefore, this description is.subject to
�
J any overlaps, gaps or inconsistencies that a field survey might reveal.
This plot was prepared from information obtained from Instrument Number
No.-.29600021 200000003708, as,recorded in the Hamilton County Recorder's Office.
1.
STATE.OF °z
l AND I AIA 02-10=12 1
�l� Trent E. Newport_ Date
S U'R� Reg. Land Surveyor No. 29600021 Tratuporiatioo&"
State of Indiana Development Consultants i U17 gum
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Form W U 5 W.
Request for Taxpayer Give Form to the
(Rev.December 20 11) requester.Number and Certification + ester•Do not
De{,a'mertt of the Treasury send to the IRS.
Internal Revenue Service
Name(as shown on your income tax retum)
Porter Shank It,LLC
N B ess nama/disregerded en'ty name,f diff er from above
'o
a Check appropriate box for federal tax classification;
c
N
❑Individuallsole proprietor C Cor por ation
❑S Corporation El Partnership ❑Trust/estate
chi Limited liability company.Enter the tax classification(C=C corporation,S= p
S corporation,P=partnership)► El 6 empt payee
G ----------------- ---------
c�
cS
y o ❑ Other(see instructions)►
g Address(number,street,and apt.or suite no.) Requester's name and address(optional)
JSS y City,state,and ZIP code
W 5C e. &Z S&Z5'9-- 11
List account number(s)here(optional)
NRM Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"fine Social h number
to avoid backup withholding.For individuals,this is your social security number However,for a -m _
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on n page 3.For other
entities,it is your employer identification number(EIM.if you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter. FgTs] _ O tF r 3
IMM Certification fG
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax retum.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 4.
Sign Signature of
Here U.S.person► Date b. J l JA U 1,:A
General Instructions 0 Note.If a requester gives you a form other than Form W-9 to request
Section references are to the tntemal Revenue Code unless otherwise your TIN,you must use the requester's form if it is substantially similar
to this Form W-9.
noted.
Definition of a U.S.person.For federal tax purposes,you are
Purpose of Form considered a U.S.person if you are:
A person who is required to file an information retum with the IRS must •An individual who is a U.S.citizen or U.S.resident alien,
obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or
example,Income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
you paid,acquisition or abandonment of secured property,cancellation .An estate(other than a foreign estate),or
of debt,or contributions you made to an IRA. •A domestic trust(as defined in Regulations section 301.7701-7).
Use Form W-9 only it you are a U.S.person(including a resident
alier),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade or
requester)and,when applicable,to: business in the United States are generally required to pay a withholding
tax on any foreign partners'share of income from such business.
1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been received,a
number to be issued),
partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United
payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners'share of
effectively connected income.
Cat.No.10231X Form w-9(Rev.12-2011)
CLOSING STATEMENT
Information for Real Estate 1099-S Report Filing:
Section 6045 of the Internal Revenue Code, as amended by the Tax Reform Act of 1986,
requires the reporting of certain information on every real estate transaction. From the
information you provide below, a Form 1099-S will be produced, and a copy of it will be
furnished to the IRS and to you no later than January 31, of the next year. If you fail to furnish
adequate information, in particular a taxpayer ID number, then you will be subject to all IRS
regulations, including the possible withholding of twenty percent (20%) of the current sales
price.
FEE OWNER: Porter Shank II, LLC
ADDRESS: 10111 N. Michigan Road, Carmel, IN 46032
DESCRIPTION OF PROPERTY: (see attached)
PROJECT: Michigan Road Water Main Install SOCIAL SECURITY NO.:
OR TAXPAYER ID NO.:
PARCEL: 1713070000012000 COUNTY: Hamilton
CLOSING DATE: PURCHASE PRICE: $28,400.00
LAND AND/OR DAMAGES:
IMPROVEMENTS:
I (we) certify that the above is true and correct, and that it will appear on a Form 1099-S that will
be sent to the Internal Revenue Service and acknowledging receipt of payment.
Fee Owners:
Signature Date
Signature Date
Please return one copy using the enclosed, stamped, self addressed envelope.
VOUCHER # 122103 WARRANT # ALLOWED
T0679 IN SUM OF $
PORTER SHANK II LLC
10111 N MICHIGAN ROAD
CARMEL, IN 46032
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
091012 06-1050-66 $28,400.00
Availability
Voucher Total $28,400.00
Cost distribution ledger classification if
claim paid under 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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T0679
PORTER SHANK II LLC Purchase Order No.
10111 N MICHIGAN ROAD Terms
CARMEL, IN 46032 Due Date 9/10/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
9/10/2012 091012 $28,400.00
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
/ '0V
Date Officer