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HomeMy WebLinkAbout213653 10/09/2012 CITY OF CARMEL, INDIANA VENDOR: 00352689 Page 1 of 1 a. ONE CIVIC SQUARE SILLY SAFARI SHOWS, INC CARMEL, INDIANA 46032 JUNGLE JOHN CHECK AMOUNT: $5,000.00 12106 SOUTHEASTERN AVE CHECK NUMBER: 213653 "0N` INDIANAPOLIS IN 46259 CHECK DATE: 10/9/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1203 4359003 26416 14053 5, 000 . 00 HOLIDAY ON SQUARE 201 Silly Safari Shows, Inc. 12106 Southeastern Avenue Indianapolis, IN 46259 317.862.9003 FAX 862.9008 ° wwW'.Aillysafaris.corn '". °•i:tv; .,.q�,h.^y ..Y:'�L' 'x't:'1�'s ...�.t.yi�rY:...A�`��s.fi _y�.P�,, _ \ _ � _ ` a13 INORMAT A QN .•S i'..:jkF.uY M,L.c:Ivt.i:'.E f• �ri,°-'i�k"ms s `C-ONTAC.T: FI: . 7�{{rv.= '3gk�,: r .,r•�w3�y rd''' City of Cannel - Holiday on the Square Me & Ait LLC The leader in conservation education Meg Associates, LIVE ANIMA1_.SHOWS Meg Gates Osborne 9875 Lakewood Drive East DATE INVOICE# OFFICIAL USE ONLY-. Indianapolis, IN 46280 9/17/2012 14053 PHONE 317-590-7522 roram Confirmation - -Additional Comments :�FRO-.;;�G.i<Re,c.A:M.n D,:An��_F Ts':Es:r='��`�"°.r'�:`."�x,.>°�:�•-��TIME.r:�=R."�_��: -'°�'- gr'�E. Special Repeat Performance UDIEN9mA Reindeer Appearance 11/17/2012 4:30 - 6:30PM Family Include W-9 & Cert of Ins REFERRED BY Carmel RULES! PROGRAM DESCRIPTION QTY RATE AMOUNT Reindeer Show Silly Safaris' Reindeer Reserve: TWO Elves with LIVE REINDEER for TWO 1 1500.00 1,500.00 HOURS! Animal Show Costumed Sami Reindeer Herder w/Other Animals from the North Pole. 2 300.00 600.00 Animal Show Costumed Sami Reindeer Herder for storytelling alongside Petting Area. 2 300.00 600.00 Consulting Supply ONE Elf Juggling in Holiday Fashion. 1 500.00 500.00 Consulting Supply ONE Candy Cane Stilt Walker. 1 500.00 500.00 Consulting Supply ONE Magician Strolling and Performing. 1 500.00 500.00 Consulting Supply THREE Elves Twisting Balloons for the Crowds 3 350.00 1,050.00 Discount We're giving you a discount! In order to qualify for discount, payment -250.00 -250.00 must be made on the day of show or before. THANKS FOR HAVING US BACK! DIRECTIONS TO YOU: ^ �'1 _Ple'aseretumtfiis�form`AND�nclude,drre`ctionsfo' our'locafiona6ove`'�'�-'�`-°"<��"`"�'� '.••;_:�'`r�'. 1;•� � _ ��"- •' ' =2 NSlli `Safa(I ;r N t1t`t0;r SI n; rf r :' ' a. y _ sx ese,es:the`ngn eas,ge.pe orm_e s as'necessaryn t, r -g.° :3,:. :`�.s_ .c.=.✓-� ,y,.y= ra •s-'.a.'�'-$r'+rL�l,_..:3E2;'�,s�?e '"�,T..e,,.��>�'€� :'�v�.-:.3?-y��'r._z�+i, r,_ ::�4.-i. `7„"F' ��f�:3:,Please:circle; our.cboice;m° „d�:P%lYAr1EN.T.INGLUDED'' .�a�WILL'P.,AY:L`ATER;.fir���'..,-.�F"�wa:���_..'.�.,�,E ',�-�.r�a'�.r.<,r :„�~�:F•r,.�v' _�,.� :^;.�>:.. F'T^�['-.+:."''.i'�'r'::- s .._w?.ih..... e.�.-,�,�>_.__s_. Signature Date Total: $5,000.00 Please Make .Payable To SILLY SAFARIS Form Request for Taxpayer Give Form to the (Rev.December 2011) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service Name(as shown on your income tax return) N Business name( regarded ntity name,if different from above °> S • t Sw •s rn CO a Check appropriate ox for federal tax classification: C Q Individual/sole proprietor ❑ C Corporation 40 S Corporation ❑ Partnership ❑ Trustlestate ry c 0 0 v Limited liability coma Enter the tax classification C=C corporation,S=S corporation,P=partnership)IM. Q Exempt payee ❑ rh P nY• ( rP rP P P) � N it ❑ Other(see instructions) Address(number,street,and apt or suite no.) Requester's name and address(optional) CL Sct.��ect S f-��e r to Ftve,- i G W City,state,and ZIP code U) - z�� -���, r- �GZ5 � List account.number(s).h e.(optional) Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number to avoid backup withholding.For individuals,this is your social security number However,fora _[11 _ 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(EIN).If you do not have a number,see How to get a FM 77N 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. -3s – z o 8 -1 To &Tq1 Certification Under penalties of perjury,1 certify that: 1. The number shown on this form is my correct taxpayer identification number(or 1 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 return.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 �,, / o Here U.S.persons . , � 4:t 2—x Date> General Instructs S Note.If a requester gives you a form other than Form W-9 to request your TIN,you must use the requester's form if it is substantially similar Section references are to the Internal Revenue Code unless otherwise 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 return 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 truss(as defined in Regulations section 301.7701-7). Use Form W-9 only if you are a U.S.person(including a resident alien),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) .�� SILLY-1 OP ID: RA CERTIFICATE ®F LIABILITY INSURANCE 1 DATE 05131D/YYYI) 05131/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CNTACT PRODUCER 317-846-4275 NAME: Fearrin Insurance Agency PHONE FAX 110 N.Rangeline Road 317-848-4246_(,vc,No,art): (A/c,N Jo: P.O.Box 126 E-MAIL Carmel,IN 46082 ADDRESS' Hot!iW Com'm`ercial INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Cincinnati Specialty INSURED Silly Safari Shows,Inc.dba INSURER B:Cincinnati Indemnity Amazon John 12106 Southeastern Avenue INSURERC: Indianapolis,IN 46259-1141 INSURER D: `INSURER E: `I I INSURER F: COVERAGES CERTIFICATE NUMBER: _ --REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I -TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IN SR WVD POLICY NUMBER MWDDIYYYY MMIDD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIALGENERALLIABILITY CS00010957 05/25/12 05/25/13 DAMAGE ETORENTED 100,000 PREMISES Ea occurrence $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,000 FGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED -- —I SCHEDULED AUTOS AUTOS I i BODILY INJURY(Per accident) $ NON-OWNED -PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WC 1622022 05/25/12 05125/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED' ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SILLY-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Sill Safari Shows Inc THE EXPIRATION DATE THEREOF, -NOTICE WILL BE DELIVERED IN' Silly ACCORDANCE WITH THE POLICY PROVISIONS. 12106 Southeastern Ave Indianapolis,IN 46259 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD VOUCHER NO. WARRANT NO. ALLOWED 20 Silly Safari Shows, Inc. IN SUM OF $ 12104 Southeastern Avenue Indianapolis, IN 46259 $5,000.00 ON ACCOUNT OF APPROPRIATION FOR Community Relations PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members 26416 14053 43-590.03 $5,000.00 I 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 Saturday, October 06, 2012 . Community Relations 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)) 09/17/12 14053 $5,000.00 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