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Home My WebLink About220335 05/21/2013 CITY OF CARMEL, INDIANA VENDOR: 358894 Page 1 of 1 t ONE CIVIC SQUARE SAFELITE AUTOGLASS CARMEL INDIANA 46032 PO BOX 633197 CHECK AMOUNT: $226.89 , CINCINNATI OH 45263-3197 CHECK NUMBER: 220335 CHECK DATE: 5/21/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 01830996999 226 . 89 OTHER EXPENSES SAFELITE FULFILLMENT, INC CUSTOMER SERVICE CENTER 1-800-835-2257 dba: Safelite Auto Glass, 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 -996999 INVOICE: 04/18/13 BD ORDERED: 04/16/13 INSTALLED: 04/18/13 PLEASE REMIT PAYMENT TO: W.O. # : 509207 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 PH1:765-413-9412 PH2:765-413-9412 CARMEL, CITY OF WATER DISTRIBUTION 3450 W 131ST CARMEL IN 46074 POLICY# : PO#/REF : 144 CLAIM # : LOSS LOC: --AUTH/VER: TRENT LOSS DATE/CAUSE: 04/18/13 ----------------------------------------- -_ 2006 CHEVROLET SILVERADO K2500 HD 2 DOOR STAN ARR: MOBILE MILEAGE: 100, 000 VIN: 1GCHK24U66E265359 LICENSE/ST: 71820 IN STOCK #: 144 -- - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - QTY PART # LIST SELLING LABOR KIT MATERIAL EXTENSION 1 DWO1549 GTY 192 .00 164 .95 50 .00 .00 .00 214.95 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 164 .95 LABOR TOTAL 61.94 SUBTOTAL 226.89 SALES TAX P A Y T H I S A M O U N T .44 TERMS: NET 30 ADDITIONAL INFO/CLAIMANT SERVICED BY: COUNTY/A SAFELITE AUTOGLASS # 01830 INDIANAPOLIS IN 46268-0000 SAFELITE TAX ID #: 36-4523816 042913-371835-371835 00609-371835-996999 01830-199265 CARMEL, CITY OF WATER DISTRIBUTION 3450 W 131ST 0000000020130429742 CARMEL IN 46074 I I Form ST-105 Indiana Department of Revenue State Form 49065 R4/8-05 General Sales Tax Exemption Certificate I Indiana registered retail merchants and businesses located outside Indiana may use this certificate.The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for purchases from Indiana vendors. This exemption certificate can not be issued for the purchase of Utilities, Vehicles, Watercra , or Aircroft, Purchaser must be registered with the Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unless all information in each section is fully completed by the purchaser.Purchasers not able to provide all required information must pay the tax and may file a claim for refund(Form GA-110L)directly with the Department of Revenue. NameofPurchaser CITY OF CARMEL 3 t✓, 50 1/V � � � St S �►�CL� City CARMEL State IN Zi Business Address p Purchaser must provide minimum of one ID number below.* Provide your Indiana Registered Retail Merchant's Certificate TID and LOC Number as shown on your Certificate............................... 0031201550 — 020 TID#(10 digits) LOC#(3 digits) If not registered with the Indiana DOR,provide your State Tax ID Number from another State................................................................ 'See Instructions on the reverse side if you do not have either number. State LD# State of Issue Is this a ®blanket purchase exemption request or a ❑single purchase exemption request? (check one) Description of items to be purchased. MM Purchaser must indicate the type of exemption being claimed for this purchase. (check one or explain) ❑ Sales to a retailer,wholesaler,or manufacturer for resale only. ❑ Sale of manufacturing machinery,tools,and equipment to be used directly in direct production. ❑ Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin#10. (May not be used for personal hotel rooms and meals.) ❑ Sales of tangible personal property predominately used(greater then 50 percent)in providing publit�transportation-provide USDOT#. A person or corporation who is hauling under someone else's motor carrier authority,or has a contract as a school bus operator,must provide their SS#or FID#in lieu of a State ID#in Section#1. USDOT# ❑ Sales to persons,occupationally engaged as farmers,to be used directly in production of agricultur I products for sale. Note:A fanner not possessing a State Business License#may enter a FID#or a SS#in lieu of a State ID#in Section#l. CO Sales to a contractor for exempt projects(such as public schools,government,or nonprofits). I ® Sales to Indiana Governmental Units(agencies,cities,towns,municipalities,public schools,and state universities). I ❑ Sales to the United States Federal Government-show agency name. Note:A U.S.Government agency should enter its Federal Identification Number(FID#)in Section#1 in lieu of a State ID#. ❑ Other-explain. l I I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act,Indiana Code 6-2.5,and the itern purchased is not a utility,vehicle,watercraft,or aircraft. I confirm my understanding that misuse. either negligent r' entional),and/or fraudulent use of this certificate may subject both me personally and/or the business entity I represen e imposition ter ,and civil and/or criminal penalties Signature of Purchaser Date Printed Name DIANA L CORDRAY Title CLERK-TREAURER The Indiana Department of Revenue may request verification o registration in another state if you are an out-of-state purchaser. Seller must keep this certificate on file to support exempt sales. I 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 of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee 358894 SAFELITE FULFILLMENT INC Purchase Order No. PO BOX 633197 Terms CINCINNATI, OH 45263-3197 Due Date 5/11/2013 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 5/11/2013 01830-99699 $226.89 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 Date Officer VOUCHER # 131551 WARRANT # ALLOWED 358894 IN SUM OF $ SAFELITE FULFILLMENT INC PO BOX 633197 CINCINNATI, OH 45263-3197 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO # INV# ACCT# AMOUNT Audit Trail Code 01830-99699 01-6500-05 $226.89 Voucher Total $226.89 Cost distribution ledger classification if claim paid under vehicle highway fund