HomeMy WebLinkAboutService Supply Ltd. - $3,668Exhibit D
Disbursement Instructions
Mercantile Bank hereby is instructed to make a disbursement of Loan Proceeds from the
Borrower Loan Account to (or for the account of) Borrower in: (a) the amount of the "Total
Authorized Disbursement: line in the "Amount of Authorized Disbursement" column below;
and (b) accordance with the terms and conditions of the Agreement, the other Loan
Documents, and the Disbursement instructions.
Purpose of Authorized Disbursement
Amount of Authorized Disbursement
Service Supply Ltd., Inc. Invoice #18998
$3,668.00
Total Authorized Disbursement
$3,668.00
All terms used in these Disbursement Instructions without definition shall have the meanings
ascribed thereto in that certain Loan Agreement (Hanover Square Improvements), dated , as
of May , 20011, by and between Lender and Village Financial, LLC.
Dated: l 2- — 19- ) 2 CITY OF CARMEL REDEVELOPMENT
COMMISSkON
By
Printed Les s Q id 5 II
Title EXeCJIVe ulre (4)-
Sr'rvice Supply Ltd., Inc.
1524 South Hamilton Road
Columbus. OH 43227
Local (614 861 -3681 Ohio: 800 -282 -1900
WV & Indiana: 800- 848 -7556 Fax: (614)
863 -0113
Bill To
VILLAGE FINANCIAL, LLC
DELORES KROHNE
ONE PEDCOR SQUARE
770 3RD AVE. S.W.
CARMEL, IN 46032
Invoice
Date
Invoice #
12/12/2012 18998
Ship To
CARMEL STREET DEPARTMENT
MATT WORTHLEY
3400 WEST MAIN STREET
CARMEL, IN 46032
P.O. No,
Terms
Payment Due
Salesperson
Date Shipped
Ship Via
FOB
No Statement Rendered.
20 days
1/1/2013
JG
12/11/2012
DELIV...
Item
Quantity
Shipped
Description
Price Each
Amount
84 -32DM
4
4
32 GALLON RECEPTACLES
WITH DOME TOP, COLOR
BLACK
917.00
3,668.00
THANK YOU FOR YOUR ORDER.
A charge at the rate of 1 1/2 per month, ANNUAL PERCENTAGE RATE
18% may be applied to past due balances.
Total $3,668.00
Service S Ipn .5 , 1.d..,
1 524 South Hamilton Road
Cohimbus, OH 43227
Ohio 1 -800- 282 -1900
WV -IN 1 -800- 848 -7556
Phone # 614-861 -3681
Fax # 614- 863 -0113
Project
TRASH RECEPTACLES W /DOME LID
CARMEL REDEVELOPMENT
Date
Quotation #
9/6/2012
243
Customer
CARMEL REDEVELOPMENT
MATT WORTHLEY
3400 W. MAIN STREET
CARMEL, IN 46032
317 - 571 -2788
Description
Qty
Unit Price
Total
84 -32DM - 32 GALLON TRASH RECEPTACLE WITH DOME TOP LID
FREIGHT & HANDLING
MATERIAL ONLY DELIVERED
1R Y „
t} L
as , ,� ,
, 3. Ya
><,
917.00
272.00
-- •4;5585.0�0^y-` •
272.00
NO TAXES ARE ?: CI.Ui1)EL IN AFOVE_. KU i1. ADD •_ I ;F ANT:CAPLE .
IN] ON A D 1. RE vA!I;.a?+ G WA f3•P,S Nf) i APP? CA.' LE. FOR ..i Aiva f'Y
p
Total _.....841•837:06•°.,.
gg
,_I••t .s t. ,:tit . s L.Y 1 1 JNL. 1S JyICi +11eE ?.k , C? I.,., P, -
RAi' F )
FOB:. SHIP POINT Delivery A.R.O.: 6 -8 WEEKS
QUOTATION BY - CONNIE TRI.PLETF, SECRETARY
Quotation typed by - Connie Triplett
Payment Term: NET 20 DAYS
PURCHASE ORDER
Village Financial, LLC
Dolores Krohne
One Pedcor Square
770 3rd Ave. SW
Carmel, IN 46032
(—ro: pC 1_44.
'sat 444,31., c:)ax.ssvt
tt3Z27.
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ORIGINAL MADE IN Q.S.A.
From:Service Supply Ltd. inc.
Form Wft..9
t>. Jamey 201 r)
Deponent of tfolyssouly
Wend atovenun Swan
None
614 863 0113 12/18/2012 08:21 #545 P.002/002 •
Request for Taxpayer
Identification Nurnlbeir and Certification
for Yaw Inowne tor *urn)
RVICE SUPPLY LTD. INC.
IGibe Form to the
requester. Da not
se na to the IRS.
nonitidoregercion entity name.
aome
chola appropnett Lon for tedwel to
dnantaoon Itsvirvoli ❑ trtsktittee Pmeoleter E c Corporation 0 S t:erpomtiOn ❑ Partnership U True
0 Umlted Malty company. We the tax el>mentaitoe , t;-.s oorpondon, Papartrteship) t• ___.
❑ Other One inseedtorm P
Address m unbar, street ere apt. at out* n*.)
1524 SOUTH HAMILTON ROAD
City. state, end ZIP mate
COLUMBUS, OHIO 43227
oat esasust ntrnowtr) lots Option
Tw yes Nufnbe'� (I1N
Enter your TIN In the oppropriete box. The TIM provided must match the warty gOien an the °Name 6ne
to avoid bteckup wltthhottang. For Individuals, this la tour soda see-tatty number 9t3SI4). However. for a
resident ellen. sole proprietor, or dleregarded y,
hire, it to Identi sea bar t, you do not hum a ra1nnb page 10 gnat a
77■ on page 9.
Note. If the account Is In mere titan use creme, see the COM on page 4 tot guidelines nn whose
number to enter.
Mos
Requeele►'aname ad • ,ea
Oe
6
2
4
5
9
Under penalties of penury, h certify that
1. The number shown on inks form is my correct taxpayer iden1Jfesti n number (ar 1 tan waft for a number to be issued to me), and
2• t arts rat subjoa to borit4 vAttowtding bersausae I em exempt from beatW w*Ct sitting, or (b) t have not been twilled by Me beanie Ramme r
Sandal rut j� • +Jitdroldal' g as a result of a failure to revert of Interest or dividends, or (c) the IRS has twined me that 1 am end
no 3. t sum a U.S. citizen er other U.S. person Weaned belev .
Certification Instrutillems. You reuse cross out Item 2 above tf you Nava been notified by de IRS that you ere currently aksjal* to backup withnokiing
because you have tailed to +apart all Inmost and dividends on your tax Men. For real estate transactions, ins, I 2 does rot PPply. Pot wattage
kearoat past, awn or abandonment of secured property, cancellation of debt, oxitnbutions to an Individual retirement arrangement (IRA), end
ge+oaily, payments other than interest and dividends. you are not required to alpri the certification, but you mast provide yew► correct Tiff. See the
Instructions on potge 4,
eleanture
Here U.S.
General Inert •; s
Section references am to ate Internal Revenue Code teases oatem/lee
noted
!Purpose of Form
A parson who t9 required to Me an itlahna ion Ashen yr th the IRS must
*tenet your canoe taxpayer reerefileation number (TIN) to report, for
example, Income pate to u, mai estate transactions, mortgage Ut�emat
you debt. o R� � property, ear heron
or Use Form W-9 only If you ere a U.S. person gnaw:Eng a resident
ale*, to provide your ccniet TIN to the person requesting It (the
requester, and. when vermeil* to
t Candy mat the 11N you we giving Is correct for you are waiting for a
number to be ts8ueaq,
2. Certify amt you aro net subject to backup withholding, or
S. Claim sxempttan from bedatp withholding if you are a U.B. exempt
share Mao 9 , you are also coralytng that as a U.S. portion, your
partnership Income from na e. bade Wiriness
Is nt **eta to wttIthot ert tn share
OWN* connected Intone
Rate/. December 18, 2012
Note. if a requester giver you a form other than Form W-9 to request
y
to owlibt, you must use tine requeater'e form If d a aute*a i a ty eM*tar
battalion or a Q.B. person. For federal tax purposes. you are
cow a U.S. parson 11 you era
Ash individual *iv is a U.B. cltrren or US, reskdeni alien,
• A partnership, corperatlas, company, or aseodotion excreted or
°t mad In eta United States or under ate laws of the United Sta tea,
An estate (other than a terelgn tuba), or
A domesbe bust (As defused In Regulations seedat 901.77014).
ihreoial rules for pertnerships. Partnerships that conduct a bade or
winos to the United Stales are generally required to pay a withhavarre
tax an any tore+ tweeters' stave or 1neorrle from such busineat.
Further, to cattail asses where a Form W4 hoe tiCit bean received, a
partnership Is required to presume that a partner Is a Foreign person,
mtra pay eta Vietthdidirea tux. therefore, If you Pro a U.S. person that to a
Stain, prproalde conducting paste * to h your voted
status and et wad withholding on your shahs of pw tnerehlp income,
Cat. No. tent x
aonrtY .: (Rev. 14011)