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Home My WebLink About217571 02/26/2013 CITY OF CARMEL, INDIANA VENDOR: 360614 Page 1 of 1 ONE CIVIC SQUARE BUREAU OF MOTOR VEHICLES CARMEL, INDIANA 46032 REGISTRATION DIVISION-SPECIAL PLAT CHECK AMOUNT: $30.00 100 N SENATE AVE N404 CHECK NUMBER: 217571 INDIANAPOLIS IN 46204 CHECK DATE: 2/26/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 30 . 00 PLATES .°F'F� {t'�� ¢ �� i��'h\ r' � �3 Sr°,j""�—r��" •;`ARS a,'.._t' �r �� "s ��i�`� '��a<°+�T'(' � '�z� ryes .,p x Az i Ell DATE INVOICE NO •a DECEMBER 13,2012 M178588 0 vEHr'LE IDEirTtP1CP.TION NO YEAR MARE 3FADP4TJ2DM178588 2013 FORD h 3 � aoerTYPE SHIPPING WEIGHT "� } z FIESTA 5DR HATCH S 2464 LBS. . H (SAE) G v W R NO CYLS SERIES OR MODEL *� 15.48 NCR 4 P4T CERTIFIED FOR SALE IN CALIFORNIA R � I the undersigned authorized representative of the company firm or corporation named below, hereby cer. S hfy that the new vehicle described above is the property of the said company,ftrm or corporation and is ' � transferred on the above date and under the Invoke Number indicated to the following distributor or dealer >, NAME OF DISTRIBUTOR,DEALER,Erc } a Pearson Ford, Inc. ��- 10650 North Michigan Road Zionsville IN 46077 MR 47FO33 it is further certified that this was the first transfer of such new motor vehicle in ordinary trade and commerce, MEMO DATA 4 3 4 63 4 s. .y t' ---------------------- FORD MOTOR COMPANY FINANCE SOURCE 000001 s BY WWI Ford Motor Credit Co BRADLEY M GAYT ,SECRETARY (AGENT) , y P.O. Box 1732, Room ; Dearborn MI DEARBORN MICHIGAN �t r`, 48121 CITY-STATE (l �� I IIII IIIII Il�fif I!I Illll il��l Illll IIIII IIIII IIII IIlI �tx �_ L1011ll IIIIII(1111 Illll lilllf Ni 1111111 III « a .�. ,"�+'.. ..<..h�,. w�`"w..aua'vfl aa.arLx.,�eA.«k,_ _ .._.....,.x.^.raWet .e�r�. ..� •n�+ry ..G°1,Y .d= ..v - ;a$..a -,.:79-,.<..:� --- = •� z ':; c - is i -d.. w _ � _ Y � v. ,.. a 1 rM K ,dx4h�R Yr° S W'✓ @ %N Y 5 34'h.4 _�9t S � Sj M ry" ✓S$hdA � L 'A.•,.. '• ','^; 104; M r b& X »_,.....-.....,,.. _—....,— _.x,........,.. ..». .,,x "Ta. Fn !�.�<F5:'r i�'•xY.,.c sz>�hat �____ --�- _ ._.. ....... .,,�...... s£ s Oar b. ., t d 3 :&� L e„LX. Y6 tR. 2 3 i r., 33! � Ys'1 1 � � jt� ,• Sr m L +w S .ai r.af.Fx ,.<'" l ,.M. AK! .i; 21':"° Y�R� l.: �' •, i xx V. 7 l t p YJ 2 1 Sz, 3 �` e �' 1 �..�,;• 4 f... � �} � 'fit. ' j ��?1I;'S'�_..—�--yllj'� �j ��—y T...,, f .,�4�t tt �'" t _ ?.40 3 `f 2K..P O(M ' .r Xi 9N !. c•JY5 t �,.)t.! s Pt.� �'t�t iY�1 �ry 09A4 %R41 a 1 Saw Y`!n'�s ati t-,yup^°. s h i,vi 3' tee-- , ..smt£. C4..,...«,"..»»..�..."_. ...u' .�F.. ..3a .w,.s..w. ....+A ,... ...,«a. 69613 APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA • BUREAU OF MOTOR VEHICLES Stale Form 44049(R41 -021 Approvad by State Board of Accounts 2002 TO BE COMPLETED BYAPOLICE OFFICER,BMV OFFICIAL OR BMV CERTIFIED DEALER SIGNEE I/WE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA- FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM. TION ENTERED ON THIS FORM IS CORRECT.INVE UNDERSTAND INED THE FOLLOWING VEHICLE AND FIND THE IDENTIFICATION NUMBER TO BE AS FOLLOWS. THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI- VEHICLE IDENTIFICATION NUMBER I TE THE CRIME OF PERJURY. FUTHERMORE, IJWE AGREE TO I INDEMNIFY AND HOLD RMLESS THE INDIANA BMV FROM ANY 3 F ;A D P 4 :T ;J ;2 :D ;IV',; 1 7,,;8 5 j 8 j 8„ LIA L ARISI M HIS NSACTION. YR. MAKE IMOOEL TYPE DATE X 13 FORD FIESTA 4S 102/15/2013 x INSPECTOR'S PRINTED NAME&TITLE CITY DATE; 02115/2013 S / ZIONSVILLE The Idw rogatres that you apply let Cardflcato of nee wW*n thirty-ono days from ft data of purchase a a INSPECTO 5 SIGN URE BADGE,BRANCH OR motor vehicle Theta Is a delinquent too for failure to do W.Attacn CoNncafo of Tine assigned by seller.On an. DEALER PLATE NO. amod Tleot,lone:nnnt he rotoacod.Supporting cl N arcs-dwa<1 Win this appicotlon camel to roltmod to In.optil- 0401267 cant,'ln aeeendance with Fadmi Codo 381 TITLE NUMBER BRANCH NO INVOICE N0. I BMV USE ONLY t. 'SOC.SECJFEDERAL LD.NO. APPLICANTS NAME BMV USE ONLY 2. CITY OF CARMEL STREETADDRESS CITY STATE ZIP CODE J. 1 CIVIC SQ ICARMEL IIN 146032-2584 VEHICLE I.D.NUMBER VEH.YEAR IVEH.MAKE VEH.MODEL NO.VEH TYPE JODOMETER 4. 3FADP4TJ2DM178588 12013 FORD FIESTA C 12 5, FORMER TITLE NUMBER PURCHASE DATE LIEN SPEED PICK UP MAIL 1;808M EALER NO. B 102/15/2013 NO FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS STREET ADDRESS 8. CASH CITY STATE ZIPCODE BMV USE ONLY 7. SECOND LIEN'S NAME STREET ADDRESS 8. CITY STATE ZIP CODE LICENSE NUMBER LICENSE I FORMS BMV USE ONLY g YEAR USED GROSS RETAIL 8 USE TAX AFFIDAVIT-IANE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW. SELLING PRICE LESS TRADE-IN' AMOUNT SUBJECT TO TAX AMOUNT OF TAX DEALER BRANCH EXEMPT JIFEM�MPT 10. S $ Q $ PIACE PARR.1 'Your Social Security number/Federal I.D.number Is being requested by this agency under IC 4-1.8-1. Disclosure Is manedelory and this document cannot be processed without it. APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION APPLICATION FOR CERTIFICATE OF TITLE • STATE OF INDIANA a BUREAU OF MOTOR VEHICLES BUREAU -TO BE MAILED WITH TITLE REPORT d °n4�a F°n" Indiana Department of Revenue ST-108E • State Form 48841 Certificate of Gross Retail or Use Tax (R4/3-o8) EXEMPTION for the Purchase of a Motor Vehicle or Wa ercraft 69613 NAME OF DEALER Dealer's RRMC#(Registered Retail Merchant Certificate Number) 8 0 8 M PEARSON FORD INC. TID#(10 digits) LOCH(3 digits) Dealer's FID#(Federal identification Number,s digits) Dealer's License Numbegseven digits) 8Q8M Address of Dealer City State Zip Code 10650 N. MICHIGAN RD. ZIONSVILLE IN 46077 NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TID,OR FID#(Mandatory) CITY OF CARMEL 3S-6dU0�7L Address of Purchaser City State Zip Code 1 CIVIC SO C IN 46032-2584 Vehicles Identification Information of Purchase VIN#(Vehicle Went ficalion Number)or HIN#(Hull Identification Number) Year Make Model/Length 3FADP4TJ2DM178588 2013 FORD FIESTA Calculation Of Purchase Price Trade in Information 1. Total Purchase Price......................... VIN#(Vehicle Identification Number)or HIN#(Hull Identification Number) 1. 14681.00 2. Trade-Allowance (Like-kind exchanges only).,.............. 2, N/A Year Make Model/Length 3. Net Purchase Price (Line 1 minus Line 2)......................... 3. 14681.00 CALCULATION OF PURCHASE PRICE LINES 1 2&3 MUST BE COMPLETED FOR ALL EXEMPTED PURCHASES NEW RESIDENT STATEMENT Must Be Completed if Exemption#8 is claimed,see reverse side. I certify that I became a resident of INDIANA on(month&year) My previous State of Residence was I hereby certify that the above statement is true and correct. Date Signature of Owner SALEWLISE TAX WORKSHEET To be completed if Sales and/or Use Tax was paid to a state other than Indiana,Exemption# 15. See reverse side. Dale of Purchase 1,Purchase price of property subject to sales/use tax 1. $ 2.Indiana sales/use tax due:Multiply Line 1 by sales/use tax percentage(7%)..................................2. 3.Credit for sales tax previously paid to another state......................... (Do not include flat fees,local,and/or excise taxes.)In what state was the tax paid? 4.Total amount due:Subtract Line 3 from Line 2. 4 $ (Line#3 can not exceed Line#2) DIRECT RELATIVE IDENTIFICATION EXEMPTION(Must Be Completed if Exemption#11 is claimed,see reverse side). Name(s)on original title Relationship of above parties Name(s)being added/deleted PUBLIC TRANSPORTATION EXEMPTION(Must be completed if exemption#6 is claimed and you are not a school bus operator.) USDOT#(U.S.Department of Transportation Number) I certify that the above vehicle or watercraft is exempt from sales/use tax under exemption# / (see reverse side). I also certify that any sales tax credit shown as paid to an.out of state dealer using exemption#15 was actually collected by the deal of perjury. or and the dealer has not provided the buyer with a check to be paid to the BMV.I understand that making,a.-false state n this form y d stitute the crime m�Date 02115/2013 Signature of Purchaser GENERAL INFORMATION INDIANA CODE 6-2,5-9-6 requires that a person tiding a vehicle or watercraft present certification indicating the state gross sales and use tax has been paid;otherwise,the payment of the tax must be made directly to a Bureau of Motor Vehicles license branch. If NONE of the exemptions apply to the purchase, Form ST-108 must be completed by the dealer and the purchaser to indicate that the i sales/use tax was collected by the dealer. The dealer is then required to submit the sales/use tax to the Department of Revenue. A purchaser's ID# (SSN-Social Security#, TID - Indiana Taxpayer Identification #, FID - Federal Identification#) is mandatory to claim an exemption. Calculation of Purchase Price lines#1,#2 and#3 must be completed for all exempted purchases. The exemption claim is not valid without providing a required ID#and Purchase Price information. Exemptions available are: 1. Vehicles or watercraft purchased by Indiana or Federal governmental units or their instrumentalities. 2. Vehicles or watercraft purchased by nonprofit organizations operated exclusively for religions, charitable,or educational pur- poses and using the vehicle for the purpose for which such organization is exempt. The applicant MUST indicate its 13 digit Indiana TID and LOC number on the front of the form.The nonprofit name must be on the title to claim this exemption. 3. Issue title for the sole purpose of adding lien holder information. This exemption is not available to add, delete,or change the name on a tide. 4. Trucks,not to be licensed for highway use,and to be directly used in direct production of manufacturing,mining, refining or harvesting of agricultural commodities. Ready-mix concrete trucks are exempt under this paragraph even though they are to be licensed for highway use.Vehicles registered with farm plates are not exempt. 5. Sales of motor vehicles or watercraft to Registered Retail Merchants acquiring the vehicles or watercraft to rent,or lease to others and whose ordinary course of business is to rent or lease vehicles or watercraft to others. 6. Vehicles or watercraft to be predominately used for hire in public transportation.(Hauling for hire.)Your USDOT number must be shown on the reverse side of this form.Predominate use is greater than 50%. 7. Vehicles or watercraft transferred from one individual to another with no consideration involved or received as outright gift or inheritance.Assumption of loan payments by the purchaser constitutes consideration and is therefore NOT exempt unless the transferred party was listed on the original security agreement. A copy of the original security agreement must be submitted with the title paperwork. B. Vehicles previously purchased,titled and licensed in another State or Country by a bonafide resident of that State or Country, who subsequently has become an Indiana resident,are exempt from Indiana salestuse tax upon tiding and registration of the vehicle in Indiana. Watercraft previously purchased,titled,or licensed in another state,by a bonafide resident of that state, who subsequently has become an Indiana resident,are exempt from sales/use tax upon titling or registration of the watercraft in Indiana.The New Resident Statement on the front of the form MUST be completed. 9. Vehicles or watercraft purchased to be immediately placed into inventory for resale. Nonlndiana dealers must enter both their FID number and their state's Dealer License Number on this form in lieu of the Indiana TID number if they are not registered with the Indiana Department of Revenue. Note: Motor vehicle dealers are only exempt from sales tax on a2A motor vehicles purchased for which they possess a manufacturer's franchise to sell that particular vehicle. If a dealer does not possess a manufacturer's franchise to sell the new vehicle purchased the dealer must pay sales tax and the resale exemption is Invalid. (I.C.6-2.5-5-8) 10. Vehicles or watercraft,not to be licensed for use,which are eligible for a repossession tide issued by the State of Indiana as a result of a bonafide credit transaction or salvage title resulting from an insurance settlement. 11. Transactions consisting of adding or deleting a spouse,child,grandparent,parent,or sibling of the owner of a motor vehicle only per 6-2.5-5-15.5. The Direct Relative Identification Statement on the front of the form MUST be completed. 12. Vehicles or watercraft won as a prize in a raffle or drawing which were previously tided by a qualified nonprofit organization. A valid Federal Miscellaneous Income Statement, Form 1099-MISC or an affidavit completed by the nonprofit organization must be submitted with the title paperwork in order for this exemption to be claimed.The affidavits must state the nonprofit organi- zation name and exemption number,the winner's name,address and social security number and the fair market value of the vehicle awarded as the prize. 13. Redemption of repossessed vehicles or watercraft by the original owner. 14. Indiana Department of Revenue use only.This exemption may not be used unless authorized by the Department by calling (317)233-4017. A complete copy of each transaction claiming this exemption must be sent to IDOR, Enforcement Division. 15. Sales tax paid to a non-BMV licensed dealer.The seller may be either an Indiana seller or an out of state seller.This amount will be used as a nonrefundable credit against the amount of Indiana sales tax due. This agency is requesting the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it. 69613 ODOMETER DISCLOSURE STATEMENT Federal law (and State law, if applicable) requires that you state the mileage upon transfer of ownership. Failure to complete or providing a false statement may result in fines and/or imprisonment. PEARSON FORD, INC. state that the odometer now (TRANSFEROR'S NAME PRINT) reeds 12 (no tenths)miles and to the best of my knowledge that it reflects the actual mileage of the vehicle described below,unless one of the following statements is chocked. a (1) 1 hereby certify that to the best of my knowledge the odometer reading reflects the amount of mileage In excess of its mechanical limits. ❑ (2) 1 hereby certify that the odometer reading is NOT the actual mileage. WARNING-ODOMETER DISCREPANCY. MAKE FORD MODEL FIESTA TYPE 4S VEHICLE IDENTIFICATION NUMBER 3FADP4TJ2DM178588 YEAR 2013 TRANSFEROR'S NAME PEARSON FORD, INC. (PRINTED NAME) TRANSFEROR'S ADDRESS 10650 N. MICHIGAN RD. (STREET) ZIONSVILLE IN 46077 (CITY) (STATE) (ZIP CODE) TRANSFEROR'S NAME n-/� 2 DATE OF STATEMENT 02/1512013 TRANSFEREE'S NAME CITY OF CARMEL (PRINTED NAME) TRANSFEREE'S ADDRESS 1 CIVIC SQ (STREET) CARMEL IN 46032-2584 (CI ! f A E) (ZIP CODE) i TRANSFEREE'S NAME (SIGNATURE) CITY OF CARMEL (PRINTED NAME) Prescribed by State Board of-Accounts Form No.301(Rev?1995) ACCOUNTS PAYABLE VOUCHER TO ADDRESS Invoice Date Invoice Number Item Amount 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 19 Signature Title 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. L/ 25// l°� ✓Y�z- �-�- Ci�� Officer Title I Voucher No. Warrant No. ACCOUNTS PAYABLE DETAILED ACCOUNTS MUNICIPAL WATER DEPT. ACCT. I NO. CARMEL, INDIANA Favor Of /fjdf0� I>P�7,C ��S f Total Amount of Voucher Deductions 011500 (D 3D 5 i Amount of Warrant $ 30 60 Month of 19 Acct. 1t VOUCHER RECORD No. t Source of Supply I Water Treatment Transmission and Dist. Customer Accounts Administrative and General Operation-Maintenance I Utility Plant in Service Constr.Work in Progress Materials and Supplies Customers Deposits I I V Total I Allowed i I Board of Control Filed Official Title I� BOYCE FORMS•SYSTEMS 1-800-382-8702 325