HomeMy WebLinkAbout220456 05/28/2013 CITY OF CARMEL, INDIANA VENDOR: 360614 Page 1 of 1
0 ONE CIVIC SQUARE INDIANA BUREAU OF MOTOR VEHICLE&ECK AMOUNT: $36.00
CARMEL, INDIANA 46032 100 N SENATE AVE ROOM N415
+ o�_ INDIANAPOLIS IN 46204 CHECK NUMBER: 220456
CHECK DATE: 5/28/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 36 . 00 TRANSPORTATION EXPENS
STATE OF INDIANA
B Michael R. Pence, Governor R. Scott Waddell, Commissioner
MUNICIPAL, ADMINISTRATIVE, AND LAW ENFORCEMENT
TITLE AND REGISTRATION APPLICATION CHECKLIST
Municipal,Administrative,and Law Enforcement title and registration applications are processed by BMV
Municipal Processing to improve the security and efficiency of these transactions. Prior to submitting
each application, please verify that all required information is included. Contact (888) 692-
6841 with any questions.
Title Application Requirements
mpleted and signed Application for Certificate of Title—State Form 44049
iginal Certificate of Title or Certificate of Origin
Physical Inspection of a Vehicle or Watercraft—State Form 39530. Required for vehicles
purchased outside of Indiana.
ometer Disclosure Statement—State Form 43230, if odometer statement is not completed on
e certificate of title or certificate of origin.Trailers and motor vehicles over 16,000 lbs exempt.
Certificate of Gross Retail or Use Tax Exemption—ST108E
❑
title'application fee. Fees are payable by credit card(MasterCard or Visa),check, electronic
check, or money order.FA$2'1-00 delinquent fee will be assessed on packets received 31 days
after the purchase date listed on the certificate of title or certificate of origin.
Re istr ion Application Requirements
Application for Municipal,Administrative,or Law Enforcement License Plates—State Form 53565
❑ Report of School Bus Inspection (required for school bus applications)
❑ Copy of title or title application(if all ready titled to applicant)
If the Bureau of Motor Vehicles determines that sufficient credible evidence exists to substantiate the
applicant's claim of ownership, a title and registration will be issued. For your convenience,the required
forms are included with this checklist. The forms are also available at myBMV.com. Mail the completed
packet to:
Central Office Municipal Processing
100 North Senate Avenue, Room N415
Indianapolis, IN 46204
Note: Include this checklist on the top of your application with contact Information provided
below. If all required documents are not submitted or information is incomplete the entire
application will be returned. // ,,//
Print Name lc1 0 Y
Phone Number Email(optional)
571-2431
xZZS
An Equal Opportunity Employer
APPLICATION FOR CERTIFICATE OF TITLE a STATE OF INDIANA a BUREAU OF MOTOR VEHICLES
State Form 44049(R413-02) Approved by State Board of Accounts 2002
TO BE COMPLETED BYAPOLICE OFFICER,BMV OFFICIAL OR BMV CERTIFIED DEALER S40NEE UWE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA-
FOR OUT OF STATE TITLES. I HEREBY CERTIFY THAT I PERSONALLY EXAM- TION ENTERED ON THIS FORM IS CORRECT.UWE UNDERSTAND
INED THE FOLLOWING VEHICLE AND FINO THE IDENTIFICATION NUMBER TO SEAS FOLLOWS. THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI-
VEHICLE IDENTIFICATION NUMBER TUTE THE CRIME OF PERJURY.FUTHERMORE,VINE AGREE TO
INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY
LIA�LITYARI NG F OM THIS RANSACT)ON.
im —MAKE I MODEL I TYPE I DATE X
X
D E: S-11-2013
The law requires umt you apply br Certificate of TTlo vAt*odnyona days from the dato of purcnase of a
BADGE,BRANCH OR motor verticals.Trare is a doanqusnt fes for failure to do so.Attach Candcate of Thle aselgrrod by Wier.on en.
DEALER PLATE 1, dorsed Tltks,Ens nuns be released.Supporting documonb suaanaered wart this application canal ten returned to fire eppa-
etun.9n aeewd"c*wah Fcderef Cad*3D.7.
1.
I
'SOC.SECIFEDERAL LD.NO. APPUCANT'S NAME LY
2 356000972 CITY OF CARMEL
STREETADDRESS CITY STATE ' ZIP CODE
3' 1 CIVIC SQUARE CARMEL .I /^V I 9603Z
VEHICLE I.D.NUMBER IVEH.YEAR VEH.MAKE VEH.MODEL NO.VEH TYPE METER
4' 2NKBL50X8CM309571 Zo f Z ktn�..tti T440 TK
FORMER TITLE NUMBER PURCHASE DATE U SPEED J& FR NO IRMVIIqFONIY
5. /V/q 04/23/2013 N N
FIRST LIENS NAME OR SPECIAL MAILING ADDRESS STREETADDRESS
S.
CITY
7. STATE ZIP CODE
8. SECOND LIEN'S NAME STREETADDRESS
CRY I STATE IZIPCODE IC LICENSE FORMS
9.
GROSS RETAIL&USE TAX AFFIDAVIT-VWE HEREBY CERTIFY THAT SALES OR USE TAX ON THIS VEHICLE WAS PAID AS INDICATED BELOW.
SELLING PRICE LESS TRADE-IN' AMOUNT SUBJECT TO TAX AMOUNTOFTA)( DEALER BRANCH EXEMPT IFEXEMPT
10. $ � $ PLACE P
'Your Social Security number I Federal I.D.number Is being requested by this agency under IC 4-1$1.Disclosure is manadetory and rids dommanl c mot be processed wi9tout IL
APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION
APPLICATION FOR CERTIFICATE OF TITLE o STATE OF INDIANA a BUREAU OF MOTOR VEHICLES
BUREAU -TO BE MAILED WITH TITLE REPORT
INSTRUCTIONS
Sign and dare om top right slgnanue lino
Line 2
Enter the name(s)(indivldval(s)or company)and Social Security or Federal Identification Number of tho owner's).
Line 3
Enterthe legal address e,f dfe owner's).The legoi address is the physical location of the owner's rasideda or business.
Line 4
Enter the VIN.Year,Make.Model Number and Vehicle Type(examples include:2S(2 door sedan),4S(4 door sedanX CN(convertible),CP(coupe),2W(2 door
wagoo),IW(4 door wagon),VA(van),TK(buck),MC(motorcycle),TR(sailer),SE(Semi Trwler),TC(Semi Tractor),RV(recreational vehicle.including
motor home and navel intlec).MH(Mobile Home).AT(All Terrain),and LS(Low Speed).
Line 5
Enta rife former fide number acrd purchase date.Lien Y/N.If speed fide is requested state Wand Include an additional S25 wilb application.
Lira 6&8
Indicate lien folder name(s)and mailing address.if there is no lien and title should be mailed to a special one time address include am fin 6827.
Line to
Not required to be completed.However,appropriate tax form urpaymers should be included with fide application
'fit' �,.`. .h � .� •��,f`•... ,«�c � .•"�.-`i._�`>`c ... � ---" ;� 1-'���--•"'r.� +�,��F.-•. .-- ,� �
r ,v, CERTIFICATE OF ORIGIN FORA VEHICLE` 1
\+••'� � Rf• C� � V`BM",
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KENWORTH
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1i'::` a�' ?'�"+n!•'.: C- �'�•�'. �-�`..�,�.•--�``•i�r• '� �-.�'•<�'.�`1 �4'ie?-•`5r�` "�i•�k'7'i.+�•r"�"T "�i',�.c:�''w '�^�+y�•"..�
b�F y.`'_ .�-,.-.::.�-./"..._�°.: .=.'`'<>-�.� �..:-" __...:.-��'___.�.�_�,.��• err:�� ....;'..-�'' n�.'�.... <_%7',_,.7,�-„_-�...�✓��Z�;y�
PHYSICAL INSPECTION OF A VEHICLE OR WATERCRAFT
State Form 395M(85112.11)
Approved by State Board of Accounts,2011
INDIANA BUREAU OF MOTOR VEHICLES
INSTRUCTIONS: 1. Approved Inspector must complete information In blue or black ink or print form.
2. The vehicle idenUfication number(VIN)or hull identification number(HIN)must be inspected to verify the existence and condition
of the number.An ownership document is not required to be submitted for inspection.
3. Inspections may be performed by an employee of a dealer designated by the Indiana Secretary of State,a military policeman
assigned to a military post In Indiana,a police officer,or a designated employee of a 8MV full or partial service license branch.
4. Police officers completing this form may not"charge a fee of more than$5.00 for vehicles.No fee may be collected for watercraft
Inspections.Authorized Indiana dealers and 8MV full or partial service license branches may not assess a fee.
5. Dealers may not perform watercraft inspections.
''r,:'.� >..t.:::.` :, :.. OWNERrIN FO ' ' :,.. 'a,.,.,.:`.•.r; :�. J�ti.+=: c ;,O' �1
; �-,l RMAION
Name oast first,middle Initial or company name
61t F e
Address(num r and street)
cityV#%6
5 va re
Gevmer State 23P Code
032
_
INFOR �� ,�. ,,,..,.t"• s�
r
Identification Number ❑ NONE(select!f no identification number found)
-2 1 /\/� 1AI - 370
Year Make Model Type Plate Number IState Number,th{a e
egicabon
2o12 ke�w o&,A T 4 ND Tk lvr.4 NIA
For assembled vehicles or watercraft Jncludeseria!numbers for major component parts if present:
Engine I Motor Transmission
Body Chassis Front Assembly
Rear Clip Frame
Other(specify):
'IDACS/NCIC Check(required if form Is completed by a police officer)
Date Ch*Perf (mrNddNyyy) Comments
.. ..:.. .. �:.. :. .. . ..>. ..� `.•. . :;n;•- - is 5:ic3,-HF rr C,j{�tcis'
f;swear;;o aiffrm that fyyhe'infortlatfon lKha ekenfer'eii ori`♦�,xJ'ssfo"f;is:correcti.Isun`'dei•st,ah&makJil a=false•stateme m`
'COrISt tlJf @ @t ,.CrIR1B'OF' ertU s, ;�:;tt 1; }4i; ; r _�5g .." yyyj�j�,, 15�ayn3 S
p 1: ry. r 4i:..riir., �-, +'1 F
Signaturero *s or Printed Name Title Date fm
ZL2—t- m/ddiyyyy)
a flip
Badge 1 Branch I Dealer Number Police Department/Branch I Dealership City 2A Code
a3, y GI OA _ G M
Teleplibne Number Email Address
I
i
e'sY
Form
S Form Indiana Department of Revenue
t : State Forth 48841 Certificate of Gross Retail or Use Tax
�i MIOi'P (R413-08) EXEMPTION for the Purchase of a
f�lotor Vehicle or Watercraft
NAME OF DEALER Dealer's RRMC#(Registered Retaa Merchant Cedamte Number)
JACK DOHENY SUPPLIES, INC I I U
TIDY(10 digits) LOC#(3 digits)
Dealer's FID#(Federal Ilona ication Number.9 digits) Dealer's License Number(seven digits)
38-2026979 A -00,90W
Address of Dealer City State I Zip Code
P.O. BOX 609 NORTHVILLE MI 148167
NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TID,OR FID#(Mandatory)
CITY OF CARMEL 356000972
Address of Purchaser City State 21p Code
1 CIVIC SQUARE ICARMEL IN 146032
Vehicles Identification Inform il 7KENWORTH e
VIN#(Vehicle/dent Fo20a,Number)or HIN#(Hull identficaoon Number) Year e Model/Length
2NKBL50X8CM309571 2012 T440
Calculation Of Purchase Price Trade In Information
1. Total Purchase Price......................... 1. $394,744.00 VIN#Nv Ncle Idenwicatton Number)or HIN#(Hull tdentirxation Number)
2. Trade-Allowance NIA
(Like-kind exchanges only)................ 2. $0.00 Year Make ModeULength
3. Net Purchase Price N/A N/A NIA
(Line 1 minus Line 2)......................... 3. $394,744.00
CALCULATION OF PURCHASE PRICE LINES 1,2&3 MUST BE COMPLETED FOR ALL EXEMPTED PURCHASES
NEW RESIDENT STATEMENT Must Be Completed if Exemption#8 Is claimed,see reverse side.
certify that I became a resident of INDIANA on(month&year)
My previous State of Residence was 1 hereby certify that the above statement la true and correct.
Date Signature of Owner
SALES/USE TAX WORKSHEET To be completed if Sales and/or Use Tax was paid to a state other than Indiana,Exemption#15.See reverse side.
Date of Purchase
`
I.Purchase price of property subject to sales/use tax..........................................................................1. $
2.Indiana sales/use tax due:Multiply Line 1 by sales/use tax percentage(7%)..................................2.
3.Credit for sales tax previously paid to another state..........................................................................3.
(Do not Include flat fees,local,and/or excise taxes.)In what state was the tax paid?
4.Total amount due:Subtract Line 3 from Line 2..................................................................................4. $
(Line#3 can not exceed Line#2)
DIRECT RELATIVE IDENTIFICATION EXEMPTION(Must Be Completed if Exemption#11 is claimed,see reverse side).
Name(s)on original title Relationship of above parties
Name(s)being addedideleted
PUBLIC TRANSPORTATION EXEMPTION(Must be completed if exemption#6 is claimed and you are not a school bus operator.)
USDOT#(U.S.Deoartment of Transporiation Number)
1 certify that the above vehicle or watercraft is exempt from sales/use tax under exemption# (see reverse side). I also certify
that any sales tax credit shown as paid to an out of state dealer using ex ptt 15 was aclyAlly collected by the dealer and the dealer has
not provided the buyer with a check to be paid to the BMV.I unde n at a g a fals state t on this form may constitute the crime
of perjury.
Date 5/20113
Signature of Purchaser
APPLICATION FOR NEW AND/OR TRANSFERRED BUREAU OF MOTOR VEHICLES
MUNICIPAL,ADMINISTRATIVE AND LAW ENFORCEMENT Municipal Processing
• ,e LICENSE PLATES 10o North Senate Avenue
Room N415
'•" State Form 53565(R2/8-11) Indianapolis,IN 46204
INDIANA BUREAU OF MOTOR VEHICLES
INSTRUCTIONS 1.Complete in blue or black ink or print form.
2.Complete appilcation with all Information in sections 1,2,3,and 4 as applicable and mail to the address listed above.
3.The application must be accompanied by a copy of each vehicle title,title application,or lease agreement.
4.A safety Inspection completed by the Indiana State Police must accompany all school bus requests.
I jig
OMNI
CT10C, ( 1 O 1 t
Official Name of entity that owns or leases the vehide(s) State Board of Accounts number Federal Identification Number
CITY OF CARMEL 2930323 356000972
Entilyrs Executive Officer's name and title Entity Telephone number
JAMES BRAINARD, MAYOR 317 571-2400
Entity street address(numberand sheet)
1 CIVIC SQUARE
City sta N Zip COde County Township
46032 HAMITLON CLAY
ST O' E C1Y O
OW 70 M` ON
e !1 in. a ro ea a a! n
b VEHICLE IDENTIFICATION'NUMBER:: ase enterk' 'i'esbefow' .' Purchase or lease date
2 N K B L 5 0 X 8 C M 3 0 9 5 7 1 (mm/dd/yyyy) 4/18/13
Color Type Make Model Year gross Vehicle
WHITE TK KENWORTH T440 2012 Weight(if
6600
Description of official business for which the entity will use the Basis of Financial Responsibility(Source ofself-insurance;or Insurance
vehicle Company Name and Policy number]
MUNICIPAL UTILITY TRAVELERES INSURANCE COMPANY POLICY#H8103036P64ACOF13
The application L4 for(check one) License Plate Type: check one
✓ New License Plate ✓ Municipal Sheriff School Bus
Transfer an Existing License Plate: State Owned
(plate number) City Police Administrative University
2 VEHICLE'IDENTIFiCAT:ION"NUMBER:(please entertn spaces below) Purchase or lease date
(mm/dd1nW)
Color Type Make Model Year Gross Vehicle
Weight(ff applicable)
Description of officlal business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;orinsurance
vehicle Company Name and Policy number)
The application Is for(check one) License Plate : check one
_New License Plate Municipal Sheriff School Bus
Transfer an Existing license Plate: State Owned
(plate number) City Police Administrallve University
3 VEHICi EIDEiVTiFI,CATION.NUMBER: ( se enter in spaces below Purchase or lease date
(mm/dd")
Color Type Make Model Year Gross Vehicle
j-Weight(rf applicable)
Description of official business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;orinsurance
vehicle Company Name and Policy numbet)
The application Is for(check one) License Plate Type: check one
_New License Plate Municipal Sheriff School Bus
_Transfer an Existing License Plate: State Owned
(plate number) Clty Police Administrative University
o' UTi :1UUSsi
The entity shall Indicate which one(1)of the following classifications the entity belongs,thus entitling the entity to a permanent municipal License plate.
The entity must also submit the following requested written documentation or meet the requirements that establish that the entity meets the classification
for which It qualifies for a municipal or law enforcement license plate.Please check one(1):
1. The State of Indiana
a)a state agency,
b)a state university,or
c)other state entity
2. A municipal corporation(as defined in IC 36-1-2-10)Municipal corporation"means any of the following:
✓ a)a county,city,town,or township,
b)school corporation(Must be listed as a school corporation with the Indiana Board of Education),
c)library district(Must be listed as a library with the Indiana State Library),
d)local housing authority(Must provide a certified copy of the ordinances)that establishes the authority),
e)fire protection district(Must be listed with the Indiana State Fire Marshall or Indiana Department of Homeland Security),
Q public transportation corporatlon(Must provide a certified copy of the ordinance(s)that establishes the corporation),
g)local building authority(Must provide a certified copy of the resolution orordinance(s)that establishes the authority),
h)local hospital authority or corporation(Must provide a certified copy of the resolution or ordinance(s)that establishes the authority),
focal airport authority(Must provide a certified copy of the resolution or ordfnance(s)that establshes the authority),
p special service district(Must provide a certified copy of the resolution or ordinance(s)that establishes the district),
k)other separate local governmental entity that may sue and be sued(Must provide a certified copy of the statute,ordinance orresolution that
establishes the entity)
3.A volunteer fire department(as defined in iC 36-8-12-2)(Must be listed with the Indiana State Fire Marshall or oepartinent of Homeland
Security and provide a copy of the contract or resolution to pro vide firefighting services for a county,city,town,or township.)
4.A volunteer emergency ambulance service that meets the requirements of IC 16-31 and has only members that serve for no
compensation or a nominal annual compensation of not more than$5,500.00.(Must be registered as a Volunteer Emergency Ambulance Service
with the Indiana Emergency Medical Services and provide an official letter from the Indiana Emergency Medical Services Commission.)
5.A rehabilitation center funded under IC 12-12(Must be listed as a rehabilitation center with the Indiana Rehabilitation Bureau and provide a
letter from the Indiana Rehabilitation Bureau of the FSSA.)
6.A community action agency(IC 12-14.23)(Must be designated by the Govemoror under Federal law as a community action agency.)
7.An area agency of aging and the aged(IC 12-10-1-6)and a county council on aging that is funded through an area agency(Must
provide a copy of the contract with the Bureau of Aging and In-Home Services.)
8.A community mental health center(IC 12-29-2)(Must provide a copy of the Division of Mental Health and Addictions certificate to operate In
Indiana as a community mental health center.)
For Law Enforcement License Plate(only available to these entities pursuant to IC 9-18-3-6):
(Must provide official Identification showing the representative Is employed with the entity.)
8.The Indiana State Police Department
10.The Indiana Department of Natural Resources
11.A county police department
12.A ci or town Police department
�'Q b SlGNA
The authorized representative submitting this application swears or affirms under the penalty of perjury that the answers and Informatfon contained in this
application are true and correct,that the entity for which this application Is made owns orleases the above listed vehicle(s)and uses it forof icial
business pursuant to iC 9-18-3-1.A municipal license plate Issued to a vehicle shall be permanently attached to the vehicle listed in this application in
accordance with IC 9-18-3-4.
Date(month,day,year) S1g ure oriz repr entalive Typed or printed name of entity representative
4/23/13 entity JOE FAUCETT
Typed or printed title of entity representative Office telephone number of entity representative
COLLECTIONS SY EM MANAGER (317) 571-2634 X 216
Form Prescribed 301 State Board of Accounts ACCOUNTS PAYABLE VOUCHER
Form No.301-S(Rev.1995)
TO
ADDRESS
Invoice Date Invoice Number Item Amount
I 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
119
Signature Title
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. 119 — /, ///,
f i er Title
Voucher No. Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
SANITATION DEPARTMENT ACCT.
I
CARMEL, INDIANA NO.
6A / Favor Of
X00 /Vv5
a,v 4 49/(,j .1-N ;go t
Total Amount of Voucher $
Deductions
5aa 3
l 7502.v6 n(
r
f
Amount of Warrant $ 6 Q
Month of 19
Acct.
VOUCHER RECORD No.
Collection System
Operation
Plant
i
Commercial
General
Undistributed
i
I
Construction
Depreciation Reserve
Stock Accounts-Merchandise
Total
Allowed
Board Members
Filed
BOYCE FORMS•SYSTEMS 7.800-382-8702 325