219889 05/07/2013 CITY OF CARMEL, INDIANA VENDOR: 358894 Page 1 of 1
ONE CIVIC SQUARE SAFELITE AUTOGLASS CHECK AMOUNT: $299.82
CARMEL, INDIANA 46032 PO BOX 633197
CINCINNATI OH 45263-3197 CHECK NUMBER: 219889
CHECK DATE: 517/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2201 4351000 01830-199180 220 . 89 AUTO REPAIR & MAINTEN
2201 4351000 01830-199220 78 . 93 AUTO REPAIR & MAINTEN
SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1-800-835-2257
dba: Safelite AutoGlass, Elite Auto Glass,
Auto Glass Specialists, and IF YOU HAVE ANY QUESTIONS REGARDING
Diamond Triumph Glass PAYMENT OF THIS INVOICE: 1-800-835-2092
INVOICE 01830 - 199180 INVOICE: 04/18/13 BD
ORDERED: 04/16/13 INSTALLED: 04/18/13
PLEASE REMIT PAYMENT TO: W.O. # . 509309 REFERRAL#: 000000
SAFELITE FULFILLMENT, INC INSURED:
P.O. BOX 633197 CARMEL, CITY OF
CINCINNATI, OH 45263-3197 3400 W 131 ST
PLEASE WRITE INVOICE NUMBER ON CHECK WESTFIELD IN 46074-8267
PH1:317-733-2001 PH2:
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074
POLICY# : PO#/REF
CLAIM # : LOSS LOC:
AUTH/VER: JEFF LOSS DATE/CAUSE: 04/18/13
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2004 GMC SIERRA K2500 HD 2 DOOR STAN ARR- MOBILE
MILEAGE:
VIN: 1GTHK24U64E376992 LICENSE/ST: 67116 IN STOCK #: 17
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - -- - - - -
QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION
1 DWO1549 GTY 192.00 158.95 50.00 .00 .00 208.95
SOLAR_W/THIRD VISOR FRIT
1 DISPOSAL FEE 4.95 .00 7 .95 .00 .00 7.95
DISPOSAL FEE
1 FUEL SURCHARGE 3.99 .00 3.99 .00 .00 3.99
FUEL SURCHARGE
PART TOTAL 158.95
LABOR TOTAL 61.94
SUBTOTAL 220.89
SALES TAX 0.00
P A Y T H I S A M O U N T 220.89
TERMS. NET-30
ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/A
SAFELITE AUTOGLASS # 01830
INDIANAPOLIS IN 46268-0000
SAFELITE TAX ID #: 36-4523816
041813-062398-062398 00590-062398-199180
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074 20130418 0000000020130418742
SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1-800-835-2257
dba: Safelite AutoGlass, Elite Auto Glass,
Auto Glass Specialists, and IF YOU HAVE ANY QUESTIONS REGARDING
Diamond Triumph Glass PAYMENT OF THIS INVOICE: 1-800-835-2092
INVOICE 01830 -199220 INVOICE: 04/18/13 BD
ORDERED: 04/17/13 INSTALLED: 04/18/13
PLEASE REMIT PAYMENT TO: W.O. # : 509467 REFERRAL#: 000000
SAFELITE FULFILLMENT, INC INSURED:
P.O. BOX 633197 CARMEL, CITY OF
CINCINNATI, OH 45263-3197 3400 W 131 ST
PLEASE WRITE INVOICE NUMBER ON CHECK WESTFIELD IN 46074-8267
PH1:317-733-2001 PH2:317-733-2001
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074
POLICY# : PO#/REF
CLAIM # : LOSS LOC:
AUTH/VER: JEFF LOSS DATE/CAUSE: 04/18/13
------------------------------------------------------------------------------------
2009 FORD F SERIES F250 2 DOOR STAN ARR- MOBILE
MILEAGE: 57, 590
VIN: IFTNF21529EA02259 LICENSE/ST: 79265 IN STOCK #:
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION
1 MWSREPAIR .01 .00 69.95 .00 .00 69.95
MOBILE WINDSHIELD REPAIR
1 SUPPLIES-REPAIR 4.99 4.99 .00 .00 .00 4.99
REPAIR SUPPLIES
1 FUEL SURCHARGE 3.99 .00 3 .99 .00 .00 3.99
FUEL SURCHARGE
PART TOTAL 4.99
LABOR TOTAL 73.94
SUBTOTAL 78.93
SALES TAX 0.00
P A Y T H I S A M O U N T 78.93
TERMS: NET 30
ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/A
SAFELITE AUTOGLASS # 01830
INDIANAPOLIS IN 46268-0000
SAFELITE TAX ID #: 36-4523816
041813-062398-062398 00590-062398-199220
CARMEL, CITY OF
3400 W 131 ST
WESTFIELD IN 46074 20130418 0000000020130418742
VOUCHER NO. WARRANT NO.
ALLOWED 20
Safelite Fulfillment, Inc.
IN SUM OF $
4625 W. 86th Street Suite 100
Indianapolis, IN 46268
$299.82
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
2201 01830-199180 43-510.00 $220.89 1 hereby certify that the attached invoice(s), or
2201 01830-199220 43-510.00 $78.93 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
i ay, M'123, 2013
Street Co i 1 n
99 n
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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))
04/18/13 01830-199180 $220.89
04/18/13 01830-199220 $78.93
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