216758 01/29/2013 CITY OF CARMEL, INDIANA VENDOR: 365399 Page 1 of 1
'• ONE CIVIC SQUARE INSITUFORM TECHNOLOGIES USA INC CHECK AMOUNT: $836.06
CARMEL, INDIANA 46032 ATTN: BOX 674060
4400AMON CARTER BLVD,SUITE 110 CHECK NUMBER: 216758
FT WORTH TX 76155
CHECK DATE: 1/29/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
211 R4237001 26268 836 . 06 PIPE REPAIRS
Attn: David Huffman RChecks OI!BOX
TO: City of Carmel,IN Street Department-2012 TEGIE S USA,INC
3400 W.131st Street LOCK Payment Application: Two-Retainage
Carmel,IN 46074 VA s Bank Platform PO# 26268
Main 317-571-2400 itufhnol ies Appropriation 42-370/01
Direct 317-733-2001 Attn:Box 674060 JOB# 126355
Fax 317-733-2005 4400 Amon Carter Blvd.,Suite 110
Ft.Worth,Texas 76155 Work period: 4/1/2012 4/8/2011
INDY Office 317-489-3867 Direct Application Date: 418/2011
Project Emergency 15"CIPP Lining 12822 Cahating Crossing/126th and Grey Rd.
Carmel,IN 46032
ITEM CONTRACT COMPLETED THIS PERIOD COMPLETED-TO-DATE
NO DESCRIPTION QUANTITY UNIT PRICE QUANTITY I % 11AMOUNT QUANTITY I I AMOUNT
1 15'Insituform®CIPP 343 LF 48.75 LF 343 LF 100% 16,721.25 343 LF 16,721.25
Contract 16,721.25 EARNED THIS PERIOD: $16,721.25 EARNED TO DATE: $16,721.25
CONTRACT SUMMARY Month Gross $16,721.25 Less: Retain e 5% 0.00
Month Retention 1 $836.06
Total Contract Earned 16,721.25 Month Open $15,885.19 Previous Invoices 15,885.19
Less Retain a 0.00
Customer# Other
Add:
Attention Davide Huffman Total Deductions from
Less: Earned to Date 15 885.19
cc: DeAnn Ber
Net Amount Due: $16,721.25
AMOUNT DUE
Paid to Date: 0.00 THIS ESTIMATE: $836.06
TOTAL DUE: $16,721.25
If there are any questions regarding this payment application.please
AMOUNT PAST DUE: $0.00 contact Alex Sharpe at 317-489-3867 office 317-281-3767 mobil
Electronic Funds Transfer Information EFr
BBVA Compass 1 11
For Overni ht Davments 8080 North Central Expressway Prepared by:
Dallas Texas,75206 Alex Sharpe Indian,PM
Insituform Technol ies USA,Inc. ForAC11:111907445 Insituform Technologies USA,Inc.
Attn:Box 674060 For Fed.Wim:111907445
4400 Amon Carter Blvd.,Suite 110 Swift Code:CPASUS44 Approved by:
Ft.Worth,Texas 76155 Benficiary:Insituform To hnologies,lnc.
Account No:2520837755
I
! 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))
01/25/13 $836.06
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
VOUCHER NO. WARRANT NO.
ALLOWED 20
Insituform Technologies USA LLC
bbva Compass Bank Platform Attn: Box IN SUM OF $
4400 Amon Carter Blvd., Suite 110
Ft. Worth, TX 76155
$836.06
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. I ACCT#/TITLE AMOUNT
Board Members
26268 I I 42-370.01 I $836.06 1 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
Fridayl1 January,;25, 2013
_
yak
Street Commissioner/
-Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund