213760 10/17/2012 CITY OF CARMEL, INDIANA VENDOR: 00350929 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF REVENUE CHECK AMOUNT: $168.22
CARMEL, INDIANA 46032 PO BOX 7229
< o� INDIANAPOLIS IN 46207 CHECK NUMBER: 213760
CHECK DATE: 10/17/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
101 5023990 1 168 . 22 F & B TAX-9/30 GOLF
XAuthori,ed AB-103 0 811
Signature LA44
I declare under penaltief o perjury that this is a true,correct and*c�omplete
Total Sales of Food&Beverages(Do Not Include Tax)......... A.
Total Exempt Food&Beverage Sales................................... B.
BROOKSHIRE GOLF CLUB a )_
CARMEL UTILITIES Net Taxable Sales(Subtract Line B from Line A)................... C. ( � 1 q-
Taxpayer �/-
ID Number For Tax Period Tax Due(1%of Line C).................................................. D. `P
SEP 2012 Collection Allowance(.73%of Line D)
0003120155 009 0 Due on or Before Do Not Use this Line if the Payment is Late............................ E. t/{
OCT 30 2012 Net Tax Due(Subtract Line E from Line D)............................ F. Z
Penalty is Greater of S5 or 10%of Line F(Plus Interest)*
County/Town Use this line only if return is filed l ate..................................... G,
❑Check if Amended Carmel *The 2012 Annual Interest Rate is 4%
Adjustments(An explanation must be attached)...................... H.
Ini�l�l�ln�ll�liunlnlu�lin1111 Total Amount Due(Total Lines F and G plus or minus H) I.
INDIANA DEPARTMENT OF REVENUE
P.O. BOX 7229
INDIANAPOLIS,IN 46207-7229
❑8❑00011,3554951010252929115970930201208
XAuthori2,
y FAB-103 0811
Signature
I declare and rII'p-e7na Pes of perjury that this is a taste,con m
correct complet .
�1 I
Date h�l 1 (Phone I �j Total Sales of Food&Beverages(Do Not Include Tax)......... A.
F
Total Exempt Food&Beverage Sales................................... B.
BROOKSHIRE GOLF CLUB
Net Taxable Sales(Subtract Line B from Line A)................... C.
CARMEL UTILITIES
Taxpayer ID Number For Tax Period Tax Due(1%of Line C).................................................. D.
SEP 2012 Collection Allowance(.73%of Line D) i
Do Not Use this Line if the Payment is Late............................ E.
0003120155 004 0 Due on or Before
OCT 30 2012 Net Tax Due(Subtract Line E from Line D)............................ F.
Penalty is Greater of$5 or 10%of Line F(Plus Interest)*
County/Town Use this line only ifretum is filed l ate..................................... G.
❑Check if Amended Hamilton
The 2012 Annual Interest Rate is 4%
Adjustments(An explanation must be attached)...................... H.
Inl�l�l�ln�ll�ilnnlnl���ll��l�ll Total Amount Due Total Lines plus I.
c p �
INDIANA DEPARTMENT OF REVENUE
P-O- BOX 7229
INDIANAPOLIS,IN 46207-7229
080 0001135549500102529000159709302 01208
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
g V1
6
Total
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.
20
Clerk-Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Board Members
PO#or INVOICE NO. ACCT#/TITLE AMOUNT
DEPT.# 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
20
If A4
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund