216871 01/29/2013 CITY OF CARMEL, INDIANA VENDOR: 358894 Page 1 of 1
ONE CIVIC SQUARE SAFELITE AUTOGLASS
CARMEL, INDIANA 46032 PO BOX 633197 CHECK AMOUNT: $250.89
CINCINNATI OH 45263-3197 CHECK NUMBER: 216871
CHECK DATE: 1/29/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2201 4351000 01830-195089 250 . 89 AUTO REPAIR & MAINTEN
SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1-800-835-2257
dba: Safelite AutoGlass, Elite Auto Glass,
Auto Glass Specialists, and IF YOU HAVE ANY QUESTIONS REGARDING
Diamond Triumph Glass PAYMENT OF THIS INVOICE: 1-800-835-2092
INVOICE 01830 -195089 INVOICE: 01/17/13 BD
ORDERED: 01/11/13 INSTALLED: 01/17/13
PLEASE REMIT PAYMENT TO: W.O. # : 493040 REFERRAL#: 000000
SAFELITE FULFILLMENT, INC INSURED:
P.O. BOX 633197 CARMEL, CITY OF
CINCINNATI, OH 45263-3197 3400 W 131 ST
PLEASE WRITE INVOICE NUMBER ON CHECK WESTFIELD IN 46074-8267
PH1:317-417-5053 PH2:317-417-5053
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074
POLICY# : PO#/REF
CLAIM # : LOSS LOC:
AITTH/VER: JEFF LOSS DATE/CAUSE: 01/17/13
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2006 FORD F SERIES F550 2 DOOR STAN ARR: MOBILE
MILEAGE: 61, 000
VIN: 1FDAF57P36ED35490 LICENSE/ST: 70610 IN STOCK #: 51
- --- - - -- - --- - - - ----- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - -- - - - - - - - - - - -- - - - - - - - - - - -- - - ------ -
QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION
1 DWO1537 GBY 217.41 188.95 50.00 .00 .00 238.95
SOLAR-W/THIRD VISOR FRIT-AFTERMARKET
1 DISPOSAL FEE 4.95 .00 7.95 .00 .00 7.95
DISPOSAL FEE
1 FUEL SURCHARGE 3.99 .00 3.99 .00 .00 3.99
FUEL SURCHARGE
PART TOTAL 188.95
LABOR TOTAL 61.94
SUBTOTAL 250.89
SALES TAX 0.00
P A Y T H I S A M O U N T 250.89
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ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/A
SAFELITE AUTOGLASS # 01830
INDIANAPOLIS IN 46268-0000
SAFELITE TAX ID #: 36-4523816
011713-062398-062398 00590-062398-195089
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074 20130117 0000000020130117742
VOUCHER NO. WARRANT NO.
ALLOWED 20
Safelite Fulfillment, Inc.
IN SUM OF $
4625 W. 86th Street Suite 100
Indianapolis, IN 46268
$250.89
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT
Board Members
2201 1 01830-195089 1 43-510.001 $250.89 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
Friday, January 25,"2013
Street Commissioner
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))
01/17/13 01830-195089 $250.89
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