HomeMy WebLinkAboutSIGNATURE CONSTRUCTION, LLC- 002639- 1/18/2012 CARMEL REDEVELOPMENT COMMISSION 002639
Signature Construction, LLC Check: 2639
720 3rd Ave., SW Date: 1/18/2012
Carmel, IN 46032 Vendor: SIGNATO1
Prior,
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
3-7 78.50 78.50 0.00 0.00 78.50
Hanover Square Fountain
5-5 1,304.41 1,304.41 0.00 0.00 1,304.41
Site amenities- LaFever
10-3 2,355.00 2,355.00 0.00 0.00 2,355.00
P112 Motor Court Veneer
3,737.91 3,737.91 0.00 0.00 3,737.91
.
THE KEY TO DOCUMENT SECURITY• HEAT ACTIVATED THUMB PRINT:•'ADDITIONACSECURITY FEATURES INCLUDED•SEE BACK FOR DETAILS i /
'PSt6"sic Redevelopment Commission - ' "� '
�' 30 West MainStreet REGIONS 002639
Suite 220 ,1 20.1421/740 ,
Carmel; IN 46032
' %
( 2639
DATE AMOUNT
1/18/2012 3,737.91
PAY THE SUM'OF THREE THOUSAND SEVEN HUNDRED THIRTY SEVEN DOLLARS AND 91 CENTS***
TO THE -
ORDER "
of Signature,Cohstruction, LLC
• 72o-3rd Ave., SW
4!"...k
Carmel, IN 46032 • - '1
. " 0026390 1:071,0L42L31: 0087504 LLLII'
CARMEL REDEVELOPMENT COMMISSION 002639
Signature Construction, LLC Check: 2639
720 3rd Ave., SW Date: 1/18/2012
Carmel, IN 46032 Vendor: SIGNATO1
Prior
Invoice P.O. Num. Invoice Amt Balance Retention Discount Amt. Paid
3-7 78.50 78.50 0.00 0.00 78.50
Hanover Square Fountain
5-5 1,304.41 1,304.41 0.00 0.00 1,304.41
Site amenities- LaFever
10-3 2,355.00 2,355.00 0.00 0.00 2,355.00
P112 Motor Court Veneer
3,737.91 3,737.91 0.00 0.00 3,737.91
1
IX-11-52 COMPUTEREASE FORMS DIVISION(877)577-5791 T-37228 (CA
APPLICATION AND CERTiFICATION FOR PAYMENT MA DOCUMENT 6702 PAGE ONE OF 2 PAGES .
TO OWNER CRC at City of Camsel PROJECT: Hanover Square Fountain APPLICATION NO Invoice H 7 3-7 I Distribution to:
Carmel Indiana.46032 Signature costs OWNER
ARCHITECT
CT
PERIOD TO: 1 1!251201 I X CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction Services LTC
720 3rd Avenue S.W. PROJECT NOS:
Carmel. Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT the undersiened Contractor certifies that to the best of the Contractors know ledge,
Application is made for payment,as shown below,in connection with the Contract_ information and belief the Wnrk covered by this Application for Payment has been
Continuation Sheet,AlA Document 0703=is attached_ completed in accordance with the Contract Documents,that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner,and that current payment shown herein is now due.
I. ORIGINAL CONTRACT SUM $ $$.150.00
2. Net change by Change Orders $ 0.00 CONTRACTOR:
3. CONTRACT SUM TO DATE(Line I +2) $ 33,15000
4 '1'O'I'AL COMI'LE'TED&STORED TO $ 33,130.00
use 7-Th Date. // X I //
5. RETAINAGE. homes f, -oontz,President _
a 0%of Completed Work S 0 Subs rifled and vorn to before Inc this off-/ day of ,)ad' d CJ
(Column U=E on 0703) MO+a-b, LINE �BU uANAN
b. %of Stored Material S r.
(Column P on 0701) ,.�rN�. My Commission Expitea
a:�` August 20,2019
(Coal Rctainn 701)sis+Sh or .f;i:
Total in Column !of 6703) $ 0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT
6. TOTAL EARNED LESS RETAtNAGE S 3360.00 In accordance with the Contract Documents,based on on-site observations and the data '
(Line 4 Less Line 5 Total) comprising the application,the Architect certilics to the Owner that to the best of the
7. LESS PREVIOUS CIERI IFICA I RS FOR Architect's knowledge, information and belief the Work has progressed as indre ted_
PAYMISN[(Line 5 from prior Certificate) S 33,071 50 the quality of the Work is in accordance with the Contract Documents;and the Contractor
8. CURRENT PAYMENT DUE $ 7850 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH,INCLUDING RETAINAGE $ 0.00 7 }R,^
(Line 3 less Line 6) AMOUNT CERTIFIED S !v [Nr�
�fCHANCE ORDER SUMMARY ADD1710N5 DEL7[1C'fi(7N5 (Attach explanation jfmnonnl certifier(differsframlhe amount applied Initial all figure)on this 4
'I oral changes approved Application and onlhe i ruanmt Sheer that are changed to conform 1vath the aria certified 1
in previous months by Owner ARCHITECT. v
Total approved this Month By: �'q�q Date: \1111 11
'TOTALS $0.00 $0.00 'this Certificate is n't`negotiabye, 'the AMOUNT CERTIFIED is payahlp only/n the
Contractor named Si em issuance,payment ana acceptance 01 payment,re wn out
NE CHANCES by Change Order 50.00 prejudice to any. .
E I its of the Owner or Contractor under this Contract
Ala DOCUMENT 0702-APPLICATION AND CERTIFICATION FOR PAYMENT-1992 EDITION-nIA 01952 THE AMERICAN INSTITUTE OF ARCHITECTS.1735 NEWYORK AVE.,NW.,WASHINGTON,DC 20005-5292
Users may obtain validation of this document by requesting a completed AIA Document D401 -Certification of DOic ment's Authenticity from the Licensee.
Aro CA.—--1/2,
/212333//
■
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA )
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and / or labor as
follows. Construction Management Services for a project known as
Hanover Square Fountain, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of
seventy-eight dollars and fifty cents ($75.50) the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
T
----f
hom s E. ntz, President
Subscribed and sworn to before me this: gad, a r, ?off
Notary Public, i-ci'f,f// t ,&.
:g"'''`"t;;; LINDA G.ouCHANAN
- Henoock County
^;;.o q r My commission Expires
.. August 20,20/0
•
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 7
11/25/11
Hanover Square Fountain
Carmel, Indiana
WORK COMPLETED MATERIALS TOTAL I BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORK VALUE APPLICATIONS PERIOD STORED STORED TO DATE % FINISH Cost
General Requirements:
Site Supervision 16,575.00 16,575.00 0.00 0.00 16,575.00 100% 0.00 16,575.00
Construction Management Fee 16,575.00 16,496.50 78.50 0.00 16,575.00 1005 0.00 16,575.00
33,150.00 33,071.50 75.50 0.00 33,150.00 100% 0.00 1 33,150.00
Date: 11/21/2011 Const Mgt Projects-Signature Page: 1
Time: 1.46:51PM CASH REQUIREMENTS REPORT
Invoice Description Invoice Due Invoice Retention Discount Workers' Paid Payment
Date Date Comp to Date
Vendor: 2808 -SIGNATURE CONSTRUCTION
7/HANOVER SIGNATURE CONSTRUCT! 11121/2011 1273012011 78.50 0.00 0,00 0.00 0.00 78.50
Vendor Total 75.50 0.00 0.00 0.00 0.00 78.50
Vendor: 3325-SMOCK FENSLER CORP.
7/HANOVER SMOCK FENSLER CORP. 11/1812011 1213072011 1,570.00 157.00 0.00 0.00 0.00 1,413.00
Vendor Total 1,570.00 157.00 0.00 0.00 0.00 1,413.00
Number of Checks 2
Company Totals 1,648.50 157.00 0.00 0.00 0.00 1.49150
GENERAL LEDGER ACCOUNT TOTALS
Account Description Debit Credit
CASH 0 00 1,491.50
2010 ACCOUNTS PAYABLE 1,491.50 0.00
f_icersal n c 1; . r C...0,--S`.''4r.tivn Inc AP( :R,. 1 r^=
APPLICATION AND CERTIFICATION FOR PAYMENT AIf1 DOCUMENT G702 PAGE ONE OF 2 PAGES2 -
TO OWNER CRC at City of Cannel PROJECT:she Ameuilies APPLICATION NO Invoice 5.-5 Distribution Lo: • .
Carmel Indiana 46032 [Allover Signature cows OWNER
ARCHITECT
PERIOD TO: 12/20/201 I X CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT:Pedcor Design I
Signature Construction Services LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel, Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge,
Application is made for payment,as shown below,in connection with the Contract information and belief the Work covered by this Application for Payment has been
Continuation Sheet.A1.4 Document 0703,is attached. completed in accordance with the Contract Documents,that all amounts have been paid by
the Contractor for Work for which previous Certificates for Payment were issued and
payments received from the Owner,and that current payment shown herein is now due.
I. ORIGINAL CONTRACT SUM S 28_,290.00
2, Net change by Change Orders 5 0.00 CON'TRAC'TOR
3. CONTRACT SUM'TO DATii(Line 1±2) S 28,290.00
4. TOTAL COMPLE-TED&STORED TO $ 27,140,37 -
Hy - Date: tiAr ,.
5. RETAINAGE: Thomas V Koomz,President '
a- 0 %of Completed Work S 0 Subscribed ail/sworn to before me this day of Dec. 3041
(Column D+E on 0703) 3 - .. - -
h. %of Stored Material $ ;,4;;; ' LINDA O,BUCHANAN
(Column I'on 0703) -,- Hancock COUnty
Total Retainagc(Lines 5a+ib or :■,.% ac. ;. My Commission Expires
Total in Column 1 of G70.3) S 0.00 ARCHITECTS CERTIFICATE FOR P A teo'ee c
_L f-
6. TOTAL EARNED LESS RE AINAGF S 27,140.37 In accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less Line 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge,information and belief the Work has progressed as indicated,
PAYMENT(Line 6 from prior Certificate) S 25,835.96 the quality of the Work is in accordance with the Contract Documents,and the Contractor
8- CURRENT PAYMENT DUE $ 1,304.4] is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH,) INCLUDING RE CNNAGE S 1.149.63
line
(Line 3 less line 6) AMOUNT CERTIFIED... . ..... .S
CHANGE ORDER SUMMARY ADDITIONS USDUCIION'S (lunch explanation if amount certified differs from the amount applied.Initial all figures or this
'Iotal changes approved Applieofiml and or:the( .-c i1 alreet that are changed to conform with the amount certified.)
in previous months by Owner ARCHITECT: IP 0
'Total approved this Month Ry: io Date: 112/ �/(`9/
TOTALS $0.00 SO 00 This Cer--scale is not negotiable- The AMOUNT CERTIFIED is payable ly tp the
Contractor a -ern.Issuance,payment and acceptance at payment arc wm- ut
NET CHANGES by Change Order $000 prejudice to any rights of the Owner or Contractor under this Contract.
AEA TS]CUMENTG]D2•APPLICATION AND CERTIFICATION FOR PLYMENr-1942 EDITION-AIA 53992 INC AMERICAN INSTI IF OF ARCHITECTS,1735 NEWYORK AVE..N W.WASHINGTON,DC Yacce52s2
Users may obtain validation of this document by requesting a completed AIA Document D401 -Certifi of Document's Authenticity from the Licensee.
um�
� 12723/1/
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 5
12/20/11
P112 Site Amenities - Lefever
Carmel , Indiana
WORT( COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORE VALUE APPLICATIONS PERIOD STORED STORED TO DATE I FINISH Cost
General Requirements:
Site Supervision 13,145.00 13,145.00 0.00 0.00 13,145.00 100% 0.00 13,145.00
Meetings 1,000.00 270.62 291.75 0.00 570.37 57% 429.63 570.37
Construction Management Fee 14,145.00 12,412.34 1,012.56 0.00 13,425.00 95% 720.00 13,425.00
28,290.00 25,035.96 1,304.41 0.00 27,140.37 96% 1,149.63 27,140.37
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA )
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and /or labor as
follows: Construction Management Services for a project known as
Site Amenities, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of one thousand
three hundred four dollars and forty-one cents ($1,304.41) the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment.
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
f
T roma7koontz, President
Subscribed and sworn to before me this. ...269 1110, Poi
Notary Public/2'1.4_14 -io _Cz_r
„�..I. LINDA G.BUCHANAN
=p er, Hancock Douro'ices
.•l sue. ;' My Commission Exp
nor r: August 26,2019
APPLICATION AND CERTIFICATION FOR PAYMENT ,41.4 DOCUMENT 6702 PACE ONE OF 2 PAGES2 •
TO OWNER CRC at City of Carmel PROJECT:P112 Motor Coup APPLICATION NO invoicg T3 Distribution to: •
Carmel Indiana 46032 vr,,e-:r Signature costs [ ]OWNER
ARCI4fTEC1-
PERIOD TO: 12/20/2011 X CONTRACTOR
FROM CONTRACTOR: VIA ARCHITECT: Pedcor Design
Signature Construction Services LLC
720 3rd Avenue S.W. PROJECT NOS:
Carmel_ Indiana 46032
CONTRACT FOR: CONTRACT DATE:
CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of Contractors knowledge,
Application is made for payment,as shown below,in connection with the Contract information and belief the Work covered by this Application for Payment has been
Continuation Shea,AIA Document 6703,is attached_ completed in accordance with the Contract Documents,that all amounts have been paid by
the Contractor for Work for which previous Cenirieates for Payment were issued and
payments received from the Owner,and that eon-cot payment shown herein is now due.
1. ORIGINAL CONTRACT SUM $ 49,100 00
2. Nut change by Change Orders $ 0.00 CONTRACTOR:
3. CONTRACT SUM'10 DATE(pine I±2) $ 49,100.00
4, TOTAL COMPLETED&STORED TO $ 19,555,32
Br, f Date: 4,12_a ! I
5 RETAINAGE: //////���171anas anti.President !,. ____
a. 0 %of Completed Work S. 0 Sub f ribed and nm to before me this day of 9� r,,
(Column D+ Eon 6703) ,�;;a*'=L4;.., LINDA 6.BUCHANAN
b. %of Stored Material $ "er.�°4 Hancock Count'
(Column F on G703) _ . a ' ` My Commission Expires
Total Retainage(Lines So+Sh or _„..,,.. August 20,2016
'Fetal in Column]of 6703) S 0.00 ARCHITECT'S CERTIFICATE FOR PAYM;RT
6- TOTAL EARNED LESS RE'rA1NAGE 5 19.555 32 In accordance with the Contract Documents,based on on-site observations and the data
(Line 4 Less tine 5 Total) comprising the application,the Architect certifies to the Owner that to the best of the
7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge.information and belief the Work has progressed as indicated,
PAYMENT(Line 6 front prior Certificate) $ 17,200.32 the quality of the Work is in accordance with the Contract Documents,and the Contractor
8. CURRENT PAYMENT DUE $ 2.355.00 is entitled to payment of the AMOUNT CERTIFIED.
9. BALANCE TO FINISH.INCLUDING RFTAINAGE 5 29,544-68
(Line 3 less Line 6) AMOUNT CERTIFIED. . ....,-..s r925 O\lr
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Anach explanation ifa rte ire certified d�ersfromn rlrs amount applied. Initial all fgurna on this C
Total changes approved Application and or -oration Sheet char are changed to conform with the amount cerii ied.J
in previous months by Owner ARCHI FECT: 1 1
Total approved this Month By: i Date 1 `�/ A,
•
'TOTALS $0.00 $0.00 This rtifrcate is ,of legrt. .1e. The AMOUNT CERTIFIED is pavabl onlyryothc
Cnntrac r mimeo t erect-Issuance,payment and acceptance 01 payment a ski! OUI
NET CHANGES by Change Order 50.00 prejudice to any rights of the Owner or Contractor under this Contract
PIA DOCUMENT 0702 APPLIC4PON AND CERTIFIKATION MR PAYM=NT,1992 EDITION-AlA -001992 THE AMERICAN INS UTE OF ARCHITECTS, 5735 NEW YORK AVC,N.W.,WASHINGTON,[Sc 20006-5292
Users may obtain validation of this document by requesting a completed AIA Document 0401 -Certif. of ents Authenticity from the Licensee.
dir /2/nj!
SIGNATURE CONSTRUCTION LLC
720 3rd Avenue, S. W.
Carmel, Indiana 46032
Invoice # 3
12/20/11
P112 Motor Court Veneer - 12036
Carmel, Indiana
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF SCHEDULED FROM PREVIOUS THIS PRESENTLY COMPLETED AND TO Committed
NO. WORK _ VALUE APPLICATIONS PERIOD STORED STORED TO DATE R FINISH Cost
General Requirements!
Site Supervision 10,500.00 9,602.02 0.00 0.00 9,602.82 91% 897.18 9,602.82
Site Supervision Alt 1 s 5 14,050.00 0.00 0.00 0.00 0.00 0% 14,050.00 0.00
Construction Management Fee 10,500.00 7,597.50 0.00 0.00 7,597.50 72% 2,902.50 7,597.50
Construction Management Fee Alt i6 5 14,050.00 0.00 2,355.00 0.00 2,355.00 17% 11,695.00 2,355.00
49,100.00 17,200.32 0.00 0.00 19,555.32 40% 17,849.68 17,200.32
CONDITIONAL AFFIDAVIT AND WAIVER OF LIEN
STATE OF INDIANA )
COUNTY OF HAMILTON )
Thomas E. Koontz being duly sworn states that he is the President of Signature
Construction, LLC having contract to furnish certain materials and /or labor as
follows: Construction Management Services for a project known as
P112 Motor Court Veneer, located at Carmel, Indiana and owned by the
Carmel Redevelopment Commission and does state:
CONDITIONAL WAIVER:
that the balance due from the owner is the sum of two thousand
three hundred fifty-five dolllars and zero cents ($2,355,00)the
payment of which has been promised as the sole consideration for this Affidavit
and Conditional Waiver of Lien which is given to and for said amount, effective
upon receipt of such cash payment,
THEREFORE, the undersigned waives and releases unto the Owner of said premises any
and all line or claim whatsoever on the above-described property and improvements
thereon on account of labor or material or both, furnished by the undersigned thereto, and
further certifies that no other party has any claim or right to a lien on account of any
work perform or material furnished to the undersigned for the said project, and within the
scope of this affidavit and waiver.
SIGNATURE CONSTRUCTION, LLC
T oma .,Koontz, President
Subscribed and sworn to before me this', ,420 a a.3oy
Notary Public . ,,
L
'' tit•. LINDA a BUCHANAN
w.uI. Hanco Co unt
\....s My Commission ck Expires
Augus120,2C19
Prescribed by State 60anlui Accounts „
ACCOUNTS PAYABLE VOUCHER
City Form No..oHa�.,�95,
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
5-; q vir C or,S L2Z2 Purchase Order No.
720 ii'4e,rt , 5-16,- Terms
/1 y er,3: Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
1z/2 /8— 3 /7/2 Pe-lJdr Cov, 7' VP✓/Pwi- 2 35 5-030
n
Total 235500
I hereby •certify that the attached invoice(s), or bill(s), is (are) true and correct and I -. :, e in accordance
with IC 5-11-10-1.6.
I "It. , 20 tZ
- reasurer
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
S'S-,e./ire Coo,fwc 71-7o% LL L Purchase Order No.
720 arc/ 42i.voa� 5 - lt! Terms
Ceerwe/, //c2 S/6 32- Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
i2/ao//7 S—S /5 5;7r /, 77g--.,,'74; / y1//
r
1'
3
C'
Total /�994/. 9/ ,,
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance r.
with IC 5-11-10-1.6.
I —lB , 20tZ
surer
Prescribed by Stale Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Pee.1995)
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
S,6</r , fr0c1-).1,<,- Sfi �i IFS,LLC Purchase Order No.
720 3,-d /%A<,vw 5w
6.4.r-<nri- bnJ /6032 Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
///25/x' 3 -7 "75'-5,J
•
ii
.i�
r
? it,
Total 73-56 ; ci)
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance r
with IC 5-11-10-1.6.
1-1 B , 2017-- M
easurer