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Home My WebLink About219385 04/24/2013 CITY OF CARMEL, INDIANA VENDOR: 00353243 Page 1 of 1 ONE CIVIC SQUARE MICHAEL A. KAUFMANN MD CHECK AMOUNT: $2,400.00 CARMEL, INDIANA 46032 5245 NORTH CO.ROAD 600 EAST BROWNSBURG IN 46112 CHECK NUMBER: 219385 CHECK DATE: 4/24/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1120 4357003 2 , 400 . 00 INTERNAL INSTRUCT FEE Invoice Appropriation# 570-03 P.O. Box# 12455 Date: 4/16/2013 —Q1 Name of Company: Michael A. Kaufmann, M.D. Address/Zip: 5245 N County Road 600 East Brownsburg, Indiana 46112 Telephone: 317-858-8471 Fax: 317-858-8718 Project Name: EMS Medical Direction Services Provided: Monthly chart review and audit of medical care provided by CFD Preparation and delivery of CQI report and monthly review Direct medical oversight/observation of paramedics General training and education Administrative meetings as requested Date Hours January 8 February 8 March 8 Grand Total 24 X Michael A. Kauf nn, M.D. Form w- Request for Taxpayer Give form to the (Rev.January 2003) Identification Number and Certification requester. Do not Department of the Treasury send to the IRS. Internal Revenue Service Name Michael Kaufmann n Business name,if different from above c 0 d N c Individual/ Exempt from backup Check appropriate box: ❑✓ Sole proprietor El Corporation ❑ Partnership ❑ Other ► ------------------ ❑ withholding y Address(number,street, and apt.or suite no.) Requester's name and address(optional) c 5245 N County Road 600 E ac ?� City,state,and ZIP code CL Brownsburg, IN 46112 N List account number(s)here(optional) a) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. For individuals, this is your social security number(SSN). Social security number However,for a resident alien,sole proprietor,or disregarded entity,see the Part I instructions on 3 5 2 6 6 9 6 9 7 page 3. For other entities, it is your employer identification number(EIN). If you do not have a number, see How to get a TIN on page 3. or Note:If the account is in more than one name, see the chart on page 4 for guidelines on whose number Employer identification number to enter. Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or(b) I have not been notified by the Internal Revenue Service (IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends, or(c)the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S. person (including a U.S. resident alien). Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement(IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. (See the instructions on page 4 Sign Signature of Here U.S.person ► ,..' Date ► 2-6-2013 Purpose of Form Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the A person who is required to file an information return with terms of a tax treaty to reduce or eliminate U.S. tax on the IRS, must obtain your correct taxpayer identification certain types of income. However, most tax treaties contain a number(TIN) to report, for example, income paid to you, real provision known as a "saving clause." Exceptions specified estate transactions, mortgage interest you paid, acquisition in the saving clause may permit an exemption from tax to or abandonment of secured property, cancellation of debt, or continue for certain types of income even after the recipient contributions you made to an IRA. has otherwise become a U.S. resident alien for tax purposes. U.S. person. Use Form W-9 only if you are a U.S. person If you are a U.S. resident alien who is relying on an (including a resident alien), to provide your correct TIN to the exception contained in the saving clause of a tax treaty to person requesting it (the requester) and, when applicable, to: claim an exemption from U.S. tax on certain types of income, 1. Certify that the TIN you are giving is correct (or you are you must attach a statement that specifies the following five waiting for a number to be issued), items: 2. Certify that you are not subject to backup withholding, 1. The treaty country. Generally, this must be the same or treaty under which you claimed exemption from tax as a 3. Claim exemption from backup withholding if you are a nonresident alien. U.S. exempt payee. 2. The treaty article addressing the income. Note:If a requester gives you a form other than Form W-9 3. The article number (or location) in the tax treaty that to request your TIN,you must use the requester's form if it is contains the saving clause and its exceptions. substantially similar to this Form W-9. 4. The type and amount of income that qualifies for the Foreign person. If you are a foreign person, use the exemption from tax. appropriate Form W-8 (see Pub.515, Withholding of Tax on 5. Sufficient facts to justify the exemption from tax under Nonresident Aliens and Foreign Entities). the terms of the treaty article. Cat. No. 10231X Form W-9 (Rev. 1-2003) 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)) Medical Director Fees $2,400.00 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 Michael Kaufmann, MD IN SUM OF $ 5245 North Co. Road 600 East Brownsburg, IN 46112 $2,400.00 ON ACCOUNT OF APPROPRIATION FOR Carmel Fire Department PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members r 1120 I I 43-570.03 I $2,400.00 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 ADD n A 2013 Fire Chief Title Cost distribution ledger classification if claim paid motor vehicle highway fund