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217439 02/19/2013 CITY OF CARMEL, INDIANA VENDOR: 00350929 Page 1 of 1 ` ONE CIVIC SQUARE INDIANA DEPT OF REVENUE CHECK AMOUNT: $0.71 CARMEL, INDIANA 46032 PO Box 7229 INDIANAPOLIS IN 46207 CHECK NUMBER: 217439 CHECK DATE: 2119/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 101 5023990 GOLF F & B 1 . 71 F & B-GOLF 1/13 Authorized Jr ' FAB—10 3 0 812 signature A i,� �? I declare under p e5�f t/t 'v s c ,t/�i'�r turn. Date Phone I t Total Sales of Food&Beverages(Do Not Include Tax) A. 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. 7 JAN 2013 Collection Allowance(.73%ofLine D) / 0003120155 009 0 Due on or Before Do Not Use this Line if the Payment is Late E.MAR 04 2013 Net Tax Due(Subtract Line E from Line D) F. `7 I Penalty is Greater of$5 or 10%of Line F(Plus Interest)* County/Town Use this line only ifretum is filed late G. Check if Amended Hamilton-29000 *The 2013 Annual Interest Rate is 3% Adjustments(An explanation must be attached) H Itlllltl�l�llnnllnnlln��llnll�l Total Amount Due(Total Lines F and G plus or minus H)_ I. 7 / INDIANA DEPARTMENT OF REVENUE P•0• BOX 7229 INDIANAPOLIS, IN 46207-7229 I.I.,I�Il�t�tlllll���llllll��tlt�l�l�tl�llll�l,�I111�11111���1 08000011355495001025290001597013 1207,305 Xs"t N=ed --"14�6 FAB-103 0812 1 de cl e nde ��'c a u /Y Dat ( Phone � �� ( � Total Sales of Food&Beverages(Do Not Include Tax) A. 3 L Total Exempt Food&Beverage Sales_ B. BROOKSHIRE GOLF CLUB Cy 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. 7 J JAN 2013 Collection Allowance(.73%ofLine D) Do Not Use this Line if the Payment is Late E. G) 0003120155 004 0 Due on or Before MAR 04 2013 Net Tax Due(Subtract Line E from Line D) F. / Penalty is Greater of S5 or 10%of Line F(Plus Interest)* County/Town Use this line only if return is filed late G. E]Check if Amended Carmel-29291 *The 2013 Annual Interest Rate is 3% Adjustments(An explanation must be attached) _ A Ittliltltlill����llitt�lliitlllltllil Total Amount Due(Total Lines F and G plus or minus H) 1. 7 / INDIANA DEPARTMENT OF REVENUE P•0. BOX 7229 INDIANAPOLIS, IN 46207-7229 Itlttltlllt��l�ill��tltttll�l�l�tltl�ll�ll�l�t��l�ll�l�lll�t�l 080000113554951010252929115970131201305 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 0 ). '�t� Purchase Order No. Terms Date Due Invoice Invoice Description Amount Date Number (or note attached invoice(s) or bill(s)) 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 $ �n� 1z _��N -7 $ 6-71 ON ACCOUNT OF APPROPRIATION FOR 6e,111 � J 1Jv Board Members PO#or INVOICE NO. ACCT#/TITLE AMOUNT DEPT.# I hereby certify that the attached invoice(s), or ,71 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 Signatur Title Cost distribution ledger classification if claim paid motor vehicle highway fund