SMOCK FANSLER CORPORATION -002229 -8/25/2011 CARMEL REDEVELOPMENT COMMISSION 002229
Smock Fansler Corporation Check: 2229
2910 W Minnesota Street Date: 8/18/2011
Indianapolis, IN 46241-4541 Vendor: SMOCKFA1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
3046 5,000.00 5,000.00 0.00 0.00 5,000.00
Decomposed Granite Mock-up
5,000.00 5;000.00 0.00. 0.00 5,000.00
Smock Fansler Corporation Invoice Date Customer ID Invoice ID
2910 W. Minnesota St. 12/31/10 090178 3046
Indianapolis, IN 46241-4541
Draw ID SEC Job* PO Number
1 10-106
Project DECOMPOSED GRANITE MOCK-UP
To:
CARMEL REDEVELOPMENT COMMISSION
30 W. MAIN ST.
CARMEL, IN 46032
DECOMPOSED GRANITE MOCKUP( CARMEL CITY CENTER
1 TOTAL AMOUNT DUE $5,000.00
Director of Redevelopment/4/716 a 807
Total Amount Due: $5,000.00
PAYMENT DUE 01-30-11
AFFIDAVIT AND WAIVER OF LIEN
[X]Final [ ] Partial [X]Payment to Follow
State of Indiana
County of Marion
Thomas M. Fansler III , being duly sworn states that he is the President of SMOCK FANSLER
CORP. having contracted with: Carmel Redevelopment Commission to furnish certain labor,
materials, and/or services as follows: Misc. Construction for a project known as: SFC#10-106
Decomposed Granite Mock-up located at Carmel, IN and does hereby state on behalf of the
aforementioned contractor:
(PARTIAL WAIVER)that there is due from the owner the sum of: ($0.00)
[ ] receipt of which is hereby acknowledged;or
[ ] the payment of which has been promised as the sole consideration of this Affidavit and Partial Waiver of
Lien which is given solely with respect to said amount,and which waiver shall be effective only upon
receipt of payment thereof by the undersigned;
(FINAL WAIVER)that the final balance due from the owner is the sum of($5,000.00)
Five Thousand Dollars and No/1.00
[ ] receipt of which is hereby acknowledged;or
[X]the payment of which has been promised as the sole consideration of this Affidavit and Final Waiver of
Lien which shall become effective upon receipt of such payment.
THEREFORE,the undersigned waives and releases unto the Owner of said premises,any and all lien or
claim whatsoever on the above-described property and improvements thereon on account of Labor,
Materials, and/or Services, furnished by the undersigned thereto, subject to limitations or conditions
expressed herein, if any; and further certifies that no other party has any claim or right to a lien on
account of any work performed,materials,or services furnished to the undersigned for said project, and
within the scope of this affidavit and waiv- ,
SMOCK FANSLER CORP. B ^ Title President
Tho as M-:Fansler III
WITNESS MY HAND AND NOTARIAL SEAL,this 31's day of December,2010. ��a��a1',1ARY�p''oi,,G•
` � fyn. y •
•
Melissa J.Bisp NoPublic _
4
My commission expires November 30,2016 Residing in Morgan_County s ••. ����
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
z9eA A-4,64°/- � ,G'ow/� a -� Purchase Order No.
2 2/ ,_57` Terms
/r/<4 /, /G2 '/ 4.54// Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
/2/3i//2 .. J C����f,°
cz
0
Total S�o,OO
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct a • •> . . -d same in accordance sti
with IC 5-11-10-1.6.
- - Treasurer
VOUCHER NO. WARRANT NO.
ALLOWED 20
S477c c,Z • a��
IN SUM OF $
2 9/U e/ ')30- ��.
, • '625'/-1!5-11/
$
ON ACCOUNT OF APPROPRIATION FOR
IF
Board Members
Po#or INVOICE NO. ACCT#!TITLE AMOUNT hereby certify invoice(s),DEPT.# I hereb certif that the attached invoices , 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
•
e"--/G 201/
ignature
Execuilve
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund Carmel Redevelopment Commission
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