HomeMy WebLinkAbout213987 10/23/2012 CITY OF CARMEL, INDIANA VENDOR: 00351017 Page 1 of 1
ONE CIVIC SQUARE KIRBY RISK ELECTRICAL SUPPLY
CARMEL, INDIANA 46032 PO BOX 664117 CHECK AMOUNT: $1,179.58
INDIANAPOLIS IN 46266 CHECK NUMBER: 213987
CHECK DATE: 10/23/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
609 5023990 106420061001 181 . 69 OTHER EXPENSES
609 5023990 106467126001 225 . 68 OTHER EXPENSES
601 5023990 106498553002 1 . 36 OTHER EXPENSES
651 5023990 S106521744 97 . 76 OTHER EXPENSES
651 5023990 5106532401 335 .20 OTHER EXPENSES
651 5023990 5106536256 310 . 68 OTHER EXPENSES
651 5023990 S106545126 27 .21 OTHER EXPENSES
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
CUSTOMER • • NU 6ER- RELEASE NUMBER
74918 S13283
SALESPERSON
• . : DATE
ED ZINK DIRECT Jeff Cooper FISHERS 317-598-6170 10/09/12
ORDER
-DESCRIPTION I I' E: UNIT EX AM NT CASH DISC�,
15ea 15ea 717A—HARDWARE-WELD WASHERS 8.49 lea 127.35
5 PIECE SET, BAGGED 316SS
KRPNM
`*SUBJECT TO VENDOR RETURN POLICY""
Delivery 3-5 days ARO
Billing Questions:Billing-request@kirbyrisk.com(765)446-3054 Invoice Number S106536256.001
Subtotal 127.35
S&H Charges 183.33
Invoice is due by 11/30/12. Sales Tax 0.00
• 310.68
0002:0002 Kirby Risk Page l of 1
'raws; AND CONDITIONS OF SALE
AC TPTANUE OF THE GOODS PURCHASED ON THE INWICL �..ON'STITUFF.S AND
OF THE TERMS AM) (JONDITIIONS OFSALE WHICH FOLLOW
(1) Mock Nierchavdise is subject to a rourn chaqo No g(xKls may he returneo "Khom a A lain IIC1Cet
-P ii 01 invOicc UUMIlCr and
(2) \on-Stock Mei-chandise is not • turnable Wow SNe can mcc,,irc a -Returuco Good s Authorky" fironi
vendor.
(3) 1 IK- ,grew th:il in all purchaws orgoods and wTkes from Swdm Seller
no cxllres's warranties.or irnplied wwondies of nwrchn llabilityanti for any p--J'-ular
1MUPOSC.
(4) 1 k Customer gross that SuBT Qll not be We kir any comeLpenuid am! ' wklcnml dowTes arising,
'Iic &ood purc' .,.tA fronn
(5) Taxes PAcc, Awwn do Welt holmle mats or when taxes injw)�,od on tll 1 (d good,', now or
hcr:-aftcr irnj)0,Qd LJJ1011 mats or shipments mili he added to the pUrChaw p1-1- 10
ruinburse Seller Fir any such L"or provide SAW mith nCCCj)1ahlC tax CffljfiC�Je.
(6) Delay in Delivery--Seller is not to be accounwhk for May, in delivery by ac,:,- ofGod or
,,:,hicr over which Scltr has no direct control. Factory shipin-ra or delivery Jals are the
lost varrunc,infour supplier, and in no caw hall Seller b� for any -11,CLILIC11tial w npocbl
arjsin.", 1rom any dr::Iciy in delivery.
(7) 11 aiver—'1 he thluc of ME to insist upon the peribmimme of any of the orris or coudans of
,OiuraCt or to,,:xcrcise any riy ii hereunder not be deemed to he a 1t'211 i1-OfSLICh
�onditions or "'ht in be Row, ha-MmIl A bo deemed ro be a waiver of any other term. umakion,or
right under 11w.contract,
M Modificatitat of Urms and CindHions—No wnus and ccumMions other uiwi those stand Wrchi and
no agweinent,x riulumaruhno in any %my purlwining to rno'h Fy these 1")rn,., or
011 S,1121-Without S-,ttr's \trittcn con',,ent.
I
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
74918 UV BUILDING
CUM
JASON WESOLEK PK PICK-UP LARRY FISHERS 317-598-6170 10/10/12
lea lea CARL E989N-CAR 1784.90 100ea 17.85
8X8X4 ELECTRICAL BOX
lea lea CARL E987R 935.68 100ea 9.36
6X6X4 JUNCTION BOX
Billing Questions:Billing-request@kirbyrisk.com(765)446-3054 10I10f2012923:53AM S106545126.001 Invoice Number S106545126.001
Subtotal 27.21
SOH Charges 0.00
Invoice is due by 11/30/12.
C�C�
Sales Tax 0.00
LARRY ® ® 27.21
0001:0001 Kirby Risk Page 1 of 1
A: tit W! , VAN W x A 11173 f 1 f S A i A 111 F i I
ANN Yl!:Y. ..:Ew" t !il
O¢m
i 1101WI - ' .� ;5, � e.,.. 3t'. q ponlun% .11.il
{i' n not :>coar-, .. ail!. '{='.. .:i?.. .. .I'll
(W _ . ._ :i q n . , 1 0.•'stiff-€€'. n v 4 he
.z: 41:1. ,
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
•MER,NUM B.Et'R CUSTOMER PO,NUMBER
74918 S13283
SALESPERSON . • • TE
CHRIS LENTS DIRECT JOE FAUCETT FISHERS 317-598-6170 1 10/09/12
ORDER'QTY SH P CITY DESCI IFTION -
10ea 10ea HITA WEARSTRIP 33.52 lea 335.20
3/8 X 2-5/8 1OFT, UHMW(FLOOR)
KRPNM
"SUBJECT TO VENDOR RETURN POLICY"
Billing Questions:Billing-request@kirbyrisk.com(765)446-3054 Invoice Number S106532401.001
Subtotal 335.20
SOH Charges 0.00
Invoice is due by 11/30112. Sales Taxi 0.00
® ® 335.20
0001:0002 Kirby Risk Page l of l
TERNIS AND (CONDITIONS OF SALF,
nATEPTANCE OF THE (JV)DS PURCHASED ON THIS INVOICL CONSTITUTES AND
ACCEPTANC'E OF THE TERVIS AND(J)NDITIONS OF SALE NV41CH FOLLOW
(1) Stock Merchandise is subject to a return chary, No Ws may be returned v%Rhout a ship?Ing ticket
invoiccn: mber and priorWthorizatior.
(2) Non-Stoch Merchandise is not RNurnable unless\Ne can sccurc a 600ds?%uII1'v-ir'" frorti
th, vendor.
(3) 1 Ac Customer achumvledgcs an,I agrees that i;[;Ill purchans ofgToodsarul ices from S;:;1cr- Seller
.'ill's no cxprc,, v�jrrantics,or implied \varrwiics flor any p.irL;cular
wpow.
(P i Kc Coshmar Pyncs that S6!vr QH not be We for any consequential ano incidentai d�ri,qa':sari'sing
\viflj ho goods from S,;I!c.!--
(5) 1 axes-- Prices vhu%vn A)not i is ludo sales or War taxes Qmod on be w&(Igmdv Uws w"-or
hersafter WPOIKI LWon Wes or shiprnertv,will be added to the Inwebase p0cm QycragrcwL0
rc imburn Sol Ir Or mW such La or provide Sollor Nvith accepiable tax cxCnIption certi fic,,Itc.
(h) Way in DeW cry--Seller is ial to be accommble Ra dWayq in delis man4med by acts of God or
„ihor circumsian es over which Seller has no direct control. ILictory shmm-nt or deliv cr.y,.mes am to
Wt ustinmics ormir suppliern and in no caw ;hall Seller be liable for any consequential or sychl
damages are inV Ifuni any dclay in delivery.
(P AValver--The iajiurc zo insist upon ihz:perfornianc.;of any oftlit: 1�2nn,,or condiLion,'�,of this
coutract or to cxcrcise an) rIght hereunder shill not be decirwd to be a vmW of W
conditions or riggla in be Rawo nor shall h be henad to be a \vaWr of wy o0cr tcrm4;omWrq or
rigin under this contract.
(t NlodiHcathm of 1'erms and ConditWns-it,terms and coiidiiions other the those sta%:J herein,and
no (w undumanIng, in any way Inn-poring k"WHI ten tuwN or condriwl QT be
011 , J.',T 0,1111OUT SCIICI"S Writterl Cof;�Cnl,
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
CUSTOMER CUSTOMER NUMBER
74918 S13269
ORDERED SALESPERSON SHIP VIA
ED ZINK 23 INDIANAPOLIS FAXED ORDER FISHERS 317-598-6170 10/04/12
ORDERQTYj
lea lea HOFF A42P36 97.76 lea 97.76 1.96
PANEL 39.00X33.00 FITS 42.00X3
7 in KR Indy stock
Billing Questions:Billing—request@kirbyrisk.com(765)446-3054 Invoice Number S106521744.001
Subtotal 97.76
If paid by 11/10/12 you may deduct$1.96 S&H Charges 0.00
Invoice is due b 11/30/12 net of an cash discount.
y y � e .1 '389j 10/04/12 Sales Taxi 0.00
i 'he P 44o6e/ 2 n�`�
Printe Mme i e � � 1 97.76
0001:0001 MR Kirby Risk Page 1 of 1
TERNIS AND CONDITIONS OF SALL
A—CEFT&NC[ 0F THE GOODS P[&C0A8CD#N THIS INVOICE CO*�'STXTUTFS AND
A[CEPTA��CEOFTR[ TER.MGAND CONDITION'S OFSA0C FOLLOW:
(11 Sowk)4rmhuudhti��subjcci ,�nun:umcharqn Nogvx]Y may heo/urnnuuoo/aApn'c: ticket
^n,/ orionoic�, / ymoex and pi-;orxu/horbmi`x',
(%) Sun-Mnd, Mcxhoodhoeis not returnable un|csnnccms"mnu ".QuuoeuGmW Ambnn@rbnm
`5.' ,cnd*r
(?) Qx agrees that inxUpmehusc�.`t goodsand icev rront ScUcr, Seller
QK's oocxp/c'awarranties. orhop|ied xvurxoAcSo[nOrJmoub]i\yand ho`c`a 6xuny Purdcu|ur
prPONC.
FA !:cCumomer.grow that ScUovd| not he hurtle I*ox any cvn�cqurutiu\ aj/Jisidunm| 6xmx��"u,�/n�
'Y�nzn}came �, ociutedvAbQ gads punbundIhoo Sol---
(5) [uscx— Pricc, !hromdo not Mode mks orMay taxes in4x ^xdonthe onfgxu ` lza now,nr
WnuD, impvnd upon mks urxkipmcnw"All hcuJJmJ to Ihc pun6ysCyricx, Duycrx:"c,`w
/`vnhucmSd|k.:for uuysuch tax nry/o,ido with uoccpmNe:u cxcn/vmn cextiOcxx-
(o) May ioDci.c,y—War(su.'/ ^` hcuocoy"wh|ek`r delays ird:|irxryo:r/"ion*dhyuoL..`f(jodor
vmcrcimum,'xncc~Over whuh Sella has m`dimnum,troilocxnyship/m'n�orJu|i,cry the
Lms/cuima|c,o[ooreppierc and ionucus 4mUScUrrbeUub|o6nau> uvSuluo!tiu| `r�pcciol
/xmugcyxrisio�, G,/m any delay iudelivery.
(7) `yuivor—The k0yon[Seller`oin*iauponWc performance ofunyo[thc urcnxJifi.m,�n[/hi»
,'ontr,
act ormcx',ziso ao, hod hcnuoJcrsh*i| not hcdccnwJ /m he now.v[such urns-,
`'mdidoo»nr,i�o in|kr 6ovo. oo,dm|| h h� Jcon�Ju`be: xuivcro[uny 'nhcr�no. uo'u|hiou,or
r� h| undr �h� 'moom�
.� under this
Modification uK]ermm and C +odbonx—No enns and cunditions other d'x^ those smuiiva luund
:''ugruxncntorpm|ce/unJm�,` iouoyoaypo,pnuin&mnuxify/kcve tcnu,. orcmuiinum AxOho
AM/xTon Sc|K/nidmut ScUc;`u written consent.
VOUCHER # 125951 WARRANT # ALLOWED
351017 IN SUM OF $
KIRBY RISK ELECTRICAL SUPPLY
PO BOX 664117
INDIANAPOLIS, IN 46266
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
S106521744.1 01-7202-06 $97.76
s fors��as�.�o
al.-�a�a.ot� 3ioo b�3
51o6sysla�.ao►
d7,3 1
S 10653a4oi,00 1
ow730a.06 335. 30
Voucher Total 6
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
351017
KIRBY RISK ELECTRICAL SUPPLY Purchase Order No.
PO BOX 664117 Terms
INDIANAPOLIS, IN 46266 Due Date 10/17/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/17/201: S106521744, $97.76
hereby certify that the attached invoice(s), or bill(s) is (are) true and
-orrect and I have audited same in accordance with IC 5-11-10-1.6
/0//91 v
Date Officer
..s i,,.K ; _-
CUSTOMER NUMBER CUSTOMER PO;NUMBER'; ` � RELEASE.NUMBER f # w ,.
rc�,.Ze',,'i
�{.,•. ��, $F"�y _ �r"6'B ti.*
z, SALESPERSON a SHIP VIA: %r ORDERE SALES,OFFICE PHONE NUMBER SHIP DATE
JAMIE �? 3.—S. °�t� k)�:;. 0"t' .,. ,�...�£'�'h,.'� •-,°..aaY za 'fi s€` s^+,4saF^x'.-
BOSTIAN PAR PARCEL DLVY • •i • •
:.�' �°i4♦ � Skt .- *e �4 - 4 F %r,� 5�
ORDER QTY SHIP.QTY „ DESCRIPTION ' r' ITEM PRICE UNITr! z EX f AMOUNT CASH DISC .
II •- 'iBUSS •A •• lea 67.60
250V
VENDOR—SUBJECT TO ••
•• lea 25.35
250V
TO VENDOR ••
A
• • • • • • • • • • Invoice •- t ',
S&H Char• • •,
, AMOUNTDUE '
iii Iii `�,�� .�� . , .•- •
I< `. .. .. WIT .;gip TH TV W' S A
-c w1a sit.
q&" S;&�.`
P OvSK.Nl „<:lt;( isv K na Ammubw un, "e can
Q Sia., ",.t Ioly . :'s.;.': i€w ". purooiny 1 Oml,r K .Wwb bap KIM,-
Y: d it':h . .'a it€I:_<;-%l "zlymd iz€}':#;i'ti- """
;.._N .:ill-o :., <:v3�w" ;€e
?:• in fail n Mun , 0.,1 b acix - w A)T'Why 3 Nov.: a� n':lcd i ." � . . (40 or
<'€' b,. 110 -`:E i::?€li?ol. t-`t'L '�i',i, Ji'E3?-"' - :tt`' J" '
t ,' t, ;r €m 'Et
< < ,t: . ':i;�:t,.t<r.. .., ,.� ic; "<a E OWN, icy€°.t}'"t w'< . < .. - h1
Ivvr-- iwR ct) NOW: ..b i 4 t,:7'3i;llil.t:,.., t'of 0 ' '
'l t ck,j'.: ; t I11;
C t < Z o! . ; a }li 4 ne. n t , 1 z h
l t
" . e, by We w n amd0 4n ,E #Pt.
' ... �i�f ..1�}-32=1 .).' _ ..'liii:3� '$:, •
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
CUSTOMER • • NUMBER RELEASE NUMBER
11788 BT082712A
SALESPERSON SHIP VIA ORDERED BY SALES OFFICE PHONE
MARK S BAYS WC51 WILL-CALL BRIAN TOLAN FISHERS 317-598-6170 09/06/12
ORDERQTYj • MESCRI I PTION •
lea lea ERIC TAC-2Q2Q 100.88 lea 100.88
MOLD
—SUBJECT TO VENDOR RETURN POLICY"
10ea 10ea ERIC 150 12.48 lea 124.80
CADWELD SHOT
"SUBJECT TO VENDOR RETURN POLICY"
Billing Questions: Billing-request@kirbyrisk.com(765)446-3054 9h412012 9:22:37 AM s106467126.001 Invoice Number S106467126.001
Subtotal 225.68
SOH Charges 0.00
Invoice is due by 10/06/12. Sales Tax 0.00
BRIAN TOLAN a 225'68
0002:0003 Kirby Risk Page 1 of 1
`r1[✓12$MS AND CONDITIONS OF SALE
ACCEPTANCE OF THE GOODS PURCHASED ON THIS INVOICE CONSTITUTES STITUTES:AND
ACCEPTANCE OF THE TERMS AND CONDITION'S OF SALE WHICH FOLLOW:
(1) Stock . lerchandise is subject to a return char t. No goods may he returned %.ithout a shipping ticket
and:or invoice number and prior authorization.
(2) Non-Stock Merchandise is not returnable unkss we can secure a"Retuned (. oods Authorit " from
the vendor.
(3) The Customer acknowledges and ,agrees that in:ill purchases of goods and serl ices [ro n Seiler. Seller
gives no express warranties.or implied warranties of merchantability and fitness for any particular
purpose.
(4) The Customer agrees that Seller will not be liable fix any consequential and incidental damages arising
from any cause associated with the (00d5 purchased from Scllcr.
(5) Taxes— Prices shown do not include sales or other taxes imposed on the ,ale ofgoods. Taxes now or
hcrealier impo,cd upon sales or shipments will be added to thy:purchase price. Buyer agree,10
reitnbtnse Seller for any such tali or provide Seller with acceptable tax exemption certificate.
(0) Delay in Delis ery—Seller is not to be accountable for delays in delivery occasioned by acts o;'God or
other circumstances over which Seller has no direct control. Factory shipment or delivery dates are the
best estimates of our suppliers.and in no ease shall Seller be liable fcx any consequential or special
damages arising from any delay in delivery.
(7) Waiver—The ictilurc of Seller to insist upon the performance of any of the terms or conditions of this
contract or to exercise any right hereunder shall not be deemed to be a waiver of such terms,
conditions or right in the future. nor shall it be deemed to be a waiver of any other term,condition.or
right tinder this contract.
(8) ;4'loditication of Perms and Conditions—No terms and conditions other than those stated herein, and
no agreement or understanding, in any way purporting to modify these terms, or conditions, ,hall be
hinding on Seller without Seller's written consent.
---------------------------------------------------------------------------------------------------------------------------------------=-=-. S,tT-= =-�-----==3--
DETACH UPPER PORTION AND RETURN WITH YOUR PAYMENT
CUSTOMER • • NUMBER RELEASE NUMBER
11788 BT082712B
SHIP I ORDERED BY SALES OFFICE PHONE
MARK S BAYS WC51 WILL-CALL BRIAN TOLAN FISHERS 317-598-6170 08/27/12
ORDERCITYJ . ..ESCRIPTION ITEM PRICE UNIT EXT AMOUNT
lea lea RAB FFLED18 161.25 lea 161.25
FUTURE FLOOD LED 18W COOL 120V-
277V BRONZE
lea lea T&B DSS-3-BR 305.68 100ea 3.06
SHRNK-WRP 3 HOLE RND CVR 1/2"
lea lea T&B DS-47-BR 587.32 100ea 5.87
SHRNK-WRP 5 HOLE RND BX 1/2"BR
lea lea INTE K4251 11.51 lea 11.51
120V PHOTOCONTROL
AAA
Billing Questions:Billing-request@kirbyrisk.com(765)446-3054 812812012 10:20:42 AM 5106420061001 Invoice Number S106420061.001
Subtotal 181.69
�OL� � �5, S&H Charges 0.00
Invoice is due by 09/26/12. Sales Tax 0.00
BRIAN TOLAN 0 181.69
0001:0003 Kirby Risk Page 1 of 1
TERMS AND (.,,0ND1T10'.\S OF SALE
ACCEPTANCE OF THE GOODS PURCHASED ON' THIS INVOICE C, ONSTITUTFS AND
ACCEPTAM:E OF THETERNIS AND (N)NDITR)NS OF SALE AIMICH MUMV:
(1) Viock Merchandise is subject ioa return charg,,e. No goods may lie returri4d vithouta shipping ticket
:anti.or invoice rutnber and prior authorization.
(2) '°;on-Sloch VierchandPise is nto inurriahl UVOSS �N4 CalISOC La-Ca "ReWITC-d (kiodsAuIllority" fjoill
he vendur.
(3) Tile' agrees fliat,in all ofgoods aril ,-ci-N ices from Seller- Seller
zivcs no exprCs';Warranties.or iniplied wanowics of MCMIlaniabilityand hm(:>s tbrany, particular
PWPAC.
(4) 1 inc Custontor ngroes that SAW will nM be lhblc Or ally C0I'1;C',_jUCutial aii,� arisnig
5-onlany cau:"" ,,,j1h :1." froni
(5) . xes Price; owwn do no hicludesaics orwhor taxes inywAY on Tc wW rFWw& 7"wAys or
1.11)011 o'�hipnicjw -,N W 1v added to To Inurchasc priz Buyu agi,cs w
!Ii'hurse sell"'- ilor any such t,i\ or provide Sc Jcr with acceputbic wx ewnVuin eadkwit(:
(6) 141m4 in Delivery--Seller is not to be accomMble Rw delay,. V deliveq unn"kined by act.;of(Aid or
-her cimurnsto wcs over whum Seller has no direct control. 1:,aciory shjpin�\.it or delivery Jai,:s are the,
estifnate�of our'supplwr, and in rw case WaH Seller be liable !'or any eon,equemi.d ur�'pocial
d HTIJ�CS J.1-i.,iMf from any delay jz"., delivery.
(7j %W%er--Ile Mac of SOW io insist iquoi On pot-Comianen of of th:, or coii('iiionl of this
:)iitract or to,.�,rk:iw w, rW" hwumdu sbH nW be den"wd U) be a man�7-f wch znni ,
'_"'ildilioils or : ',!Il i1i Ilic fitiur.,- aw shall A W dnnwd w lw a wAver of aw whar tunin cv- &:Kou, or
Sit under 11r, .:ontract.
M .%Wdilkadop of Terms and{,ondiliuns--W hmas and coiditions otfie, 1!�..n thoseslw.,-0 !",croin,an,!
rn aumernerA w "adUgandiho in any MMY POPWing 10 MIA FV these 10 IP ' or condhion.: dull be
nmAg on S • U.without sclicl's written consent.
VOUCHER # 122372 WARRANT # ALLOWED
351017 IN SUM OF $
KIRBY RISK ELECTRICAL SUPPLY
PO BOX 664117
INDIANAPOLIS, IN 46266
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
SI 07•IO2•01
s rl�cy67lab.c�i
G7.Ic952.o2 225.G�
\ �s I oG�1A8553.��
5 G 7•[C)50-()b
� c�Pir�e�� ►��' y0$�3
Voucher Total $4�-�i6
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
351017
KIRBY RISK ELECTRICAL SUPPLY Purchase Order No.
PO BOX 664117 Terms
INDIANAPOLIS, IN 46266 Due Date 10/3/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/3/2012 S106498553. $17.10
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
Date icer