HomeMy WebLinkAbout221862 07/17/2013 CITY OF CARMEL, INDIANA VENDOR: 367266 Page 1 of 1
ONE CIVIC SQUARE A&A DEVELOPMENT CORP CHECK AMOUNT: $75,000.00
CARMEL, INDIANA 46032 9699 N MICHIGAN ROAD
o� CARMEL IN 46032 CHECK NUMBER: 221862
CHECK DATE: 7/17/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
610 5023990 75, 000 . 00 OTHER EXPENSES
Z*1
Prior Deed References: Instrument No.23311 in
Book 326, Page 379 and Instrument No.22514 in
Book 330, Page 466 in Recorder's Office for
Hamilton County, Indiana
WATER LINE EASEMENT AGREEMENT �cfs
This Water Lime Easement Agreement (the "Agreement") is made and entered into this day
of , 2014 by and between A & A Development Corporation ("Grantor") and the City of
Carmel, Indiana ("Grantee").
RECITALS:
A. Grantor is the owners of certain real property located in Hamilton County, Indiana
("Grantor's Property") more particularly described in Exhibit 1 attached hereto and incorporated herein.
B. Grantee, in connection with Grantee's improvement/construction of the Michigan Road
Water Main Installation — 96t1i Street to Retail Parkway (the "Project") requires a permanent, exclusive
easement over, through, under, upon and across that portion of Grantor's Property more particularly
described and depicted on Exhibit A and Exhibit B attached hereto and incorporated herein, (the
"Easement Property") to provide for the laying, installing, constructing, maintaining, operating,
inspecting, altering, repairing, replacing and removing water utility lines, and all associated valves,
pumps, fittings, meters, accessories and equipment on, over, and across the Easement Property.
NOW, THEREFORE, for and in consideration of the foregoing recitals which are incorporated
herein by reference and the mutual covenants and agreements hereinafter set forth and other good and
valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as
follows:
1. Grant of Easement. Grantor hereby grants and conveys to Grantee an exclusive, perpetual
easement for the purpose of laying, installing, constructing, maintaining, operating, inspecting, altering,
reparing, replacing and removing water utility lines, and all associated valves, pumps, fittings, meters,
accessories and equipment (the "Improvements") on, over, through, under, upon and across the Easement
Property. Grantee shall have the right to: (a) subject to Section 2, remove from the Easement Property
any fences, structures, asphalt or concrete paving, curbing or other improvements, trees, bushes, earth
berming, landscaping and other structures that exist prior to, at the time of, or after Grantee's acquisition
of such easement: and (b) make such alterations and improvements to the Easement Property as Grantee
deems may be necessary or useful in the exercise of Grantee's rights hereunder. If the Improvements are
installed in good faith in a location other than the location that is described and depicted in Exhibit A and
Exhibit B then, and in that event, the Easement Property defined herein shall be revised to include that
strip of land that is centered on the line or equipment as installed, and in such an event; Grantor and
Grantee, shall join in the execution and acceptance of an appropriate substitute easement instrument if
either Grantor or Grantee shall deliver to the other a written request for such a substitute easement
instrument. Grantee shall also have the right of ingress and egress over, under. upon and across the
1646963_4. ]
Grantors Property for purposes of access to the Easement Property. The easement also includes the rights
and privileges to temporarily use, from time to time, additional space on the Grantor's Property, where
available and necessary, for equipment and materials necessary for the installation, repair and maintenance
of the Improvements located in, under, upon, over, and/or across the Easement Property, to do all acts and
things requisite and necessary for the full enjoyment of the easement hereby granted, and for nearby
property owners, their grantees, successors, agents, or employees, to connect the premises of such nearby
property owners by service pipes to the Improvements installed by Grantee within the Easement Property,
provided such nearby property owners, their grantees, successors, agents, or employees restore the portion
of the Grantor's Property disturbed by their work to a condition that is as near the condition that existed
just prior to the time the portion was distrubed by them as is practicable.
2. Obligations of Grantee. To the extent practical and within acceptable construction
practices, Grantee shall utilize directional boring for the initial installation of the water utility lines that
are a part of the Improvements. Open cutting or ditches shall be utilized to install service lines, taps,
hydrants, valves or similar items; as needed as part of the directional boring process; where two water
lines intersect or connect; or if problems arise with the directional boring process. Grantee shall not be
required to use directional boring for any future repair, maintencnace, replacement, reconstruction,
relocation of the Improvements. Grantee shall maintain, repair, replace and service the Improvments.
Notwithstanding anything in this Agreement to the contrary, Grantee shall restore the Easement Property
and Grantor's Property, to the extent practicable, to the condition as existed prior to the commencement of
the Project, including driveways thereon. This obligation to restore the driveways shall apply to all future
work, including repair, replacement or relocation of the Improvements.
3. Rights Retained by Grantor. Grantor shall retain unto itself the right to use the Easement
Property for any and all purposes and uses not inconsistent with the foregoing easement. Subject to
Grantee's rights and obligations in Sections 1 and 2 with respect to the Easement Property, Grantor shall
be entitled to maintain all improvements on the Grantor's Property in existence as of the date of this
Agreement. With the exception of those Improvements in existence on the date of this Agreement,
Grantor shall not erect or maintain any permanent structures, obstructions, or other improvements under
and/or upon the surface of or over the Easement Property. Grantor shall not perform any act which would
impair or interfere with Grantee's use and enjoyment of the Easement Property or the easement herein
granted. The immediately preceding sentence prohibits (among the other prohibitions effected by it) the
erecting or maintaining in the Easement Property of any earthen mound or series or system of earthen
mounds.
4. Obligations of Grantor. Grantor shall keep the Easement Property free of any fence,
structure, asphalt, Gravel, plants, concrete or other improvements (other than those installed by Grantee).
Grantor shall mow and care for the grass located within the Easement Property and shall maintain all other
parts of the Easement Property in good condition. Grantor shall not block, impede or interfere with the
Improvements or Grantee's access to or use of the Easement Property.
5. Easement and Covenants Appurtenant. The easement granted, created and made herein,
together with the benefits thereof, shall run with the Grantor's Property and the Easement Property, inure
to the benefit of Grantee and its grantees, successors and assigns and shall bind Grantor and its grantees,
successors and assigns. All covenants and agreements hereunder may be enforced by an action for
specific performance. and in the event that a party breaches any such covenant or agreement, the other
party may exercise any remedy available hereunder, at law or in equity, and recover from the breaching
party all amounts expended in connection with exercising any such remedy (including without limitation.
court costs and attorneys' fees).
6. Environmental Matters. Grantor covenants and represents that to the best of its knowledge,
neither the Grantor's Property nor the Easement Property is not presently the subject of, nor is there the
threat of any federal, state or states, or local environmentally related lien, proceeding, claim, liability or
action. Grantor agrees that between Grantor and Grantee, the acceptance of this Agreement by Grantee
shall not increase the liability of Grantee for environmentally related claims arising from or related to (1)
conditions on the Grantor's Property or the Easement Property prior to the acceptance of this
Agreement; (ii) acts of Grantor or any other third party; or (iii) conditions on the Grantor's Property or the
Easement Property not created by Grantee.
7. Jurisdiction. Grantor and Grantee agree that any litigation associated with or arising from
this indenture shall be filed with a court of competent jurisdiction within the State of Indiana.
8. Other Obligations. Grantor agrees that this Agreement shall not transfer to Grantee any
past, present, or future obligation(s) of Grantor to be responsible for, or to pay, any tax, assessment, or fee
associated with or related to the Grantor's Property or Easement Property.
9. Waiver. Waiver by either party of any one default hereunder will not be deemed to be a
waiver of any other default under this Agreement. Any remedy or election under this Agreement will not
be deemed exclusive, but instead, whenever legally permissible, will be cumulative with all other
remedies at law or in equity.
10. Amendment. Grantor and Grantee agree that this Agreement shall only be modified or
released by the express, written consent of both Grantor and Grantee. Said consent, when duly recorded,
shall run with the Grantor's Property and the Easement Property.
11. Entire Agreement. This Agreement contains the entire agreement of the parties with respect
to the subject matter hereof, and all prior agreements, communications and negotiations between the parties,
either verbal or written, are hereby merged into this Agreement. This Agreement may be terminated,
modified, or amended only by a writing signed by the parties, and no agreement or consent of any other
persons shall be necessary for such termination,modification,or amendment.
12. Govenming Law. This Agreement will be governed by and construed in accordance with the
laws of the State of Indiana.
13. Notice. Any and all notices, demands, requests. submissions, approvals, consents, or other
communications or documents required to be given, delivered or served or which may be given, delivered
or served under or by the terms and provisons of this Agreement or pursuant to law or otherwise, shall be
in writing. All notices shall be either (a) sent by overnight delivery using a nationally recognized
overnight courier, in which case notice shall be deemed delivered one business day after deposit with such
courier. (b) sent by certified or regular U.S. mail, postage prepaid, in which case notice shall be deemed
delivered two business days after deposit in such mails, or (c) sent by personal delivery, in which case
164696 d. 3
notice shall be deemed delivered upon receipt or refusal of delivery. All notices shall be addressed to the
respective parties as follows:
If to Grantee: City of Carmel '
One Civic Square
Carmel, Indiana 46032
Attn: Carmel City Attorney
With a Copy to: City of Carmel
One Civic Square
Carmel, Indiana 460')2
Attn: Director of Utilities
If to Grantor: A n n J-an A e
A -+ A 1.)VJ10faw"0b- A-Cpora+ZSn
tT N M --h,!A(,n : A
Any such notice will be effective three days after the notice has been deposited in the United States mail, as
provided above, or if earlier upon receipt.
14. Severability. If any term, covenant, condition or provision of this Agreement or the
application thereof to any person or circumstance, shall at any time or to any extent be held invalid or
unenforceable, the remainder of this Agreement, or the application of such term or provision to persons or
circumstances other than those as to which it is held invalid or unenforceable, shall not be affected
thereby, and each such term, covenant, condition and provision of this Agreement shall continue to be
valid, binding and enforceable to the fullest extent permitted by law.
15. Authority. The person executing this instrument on behalf of Grantor hereby represents that
he/she has the authority to bind Grantor to the teens and conditions set forth herein and that all necessary
action therefore has been taken. Grantor further represents and warrants to Grantee that Grantor is the fee
simple owner of the Easement Property; that Grantor has the right to grant this easement; that Grantor
guarantees the quiet possession of the Easement Property to the Grantee; that the Easement Property is
free of any liens or encumbrances, except the lien of current taxes and any other lien or encumbrance that,
as of the date of execution hereof; appears of public record; and that, subject to the foregoing. Grantor will
warrant and defend Grantee's title to the easement granted hereby against all claims thereon.
16. Attorneys' Fees. In the event of any action or proceeding brought by either party against
the other under this Agreement, the prevailing party shall be entitled to recover all costs and expenses.
including reasonable attorneys' fees.
IN WITNESS WHEREOF, the parties hereto have executed this Water- Line Easement Agreement
as of the day and year first above Na-ritten.
16.16963_}. 4
GRAN'T'OR:
BY: rl�� 7�
Ann Lande
President
&1.L, o
Date
16469634
GRANTEE:
THE CITY OF CARMEL
By and through its Board of Public Works and Safety
By:_ /
James Brainard, Presiding Officer
Date:
By 1 ,
: Q�i
M y Aug Burke, Member
Date: —j
By:
Lori W n, Member
Date: 5 /(
ATTEST:
I� na L. Cordray, I C, Cl •k-Treasurer
((Date:
1646963_x. 6
STATE OF INDIANA )
SS:
COUNTY OF HAMILTON )
Personally appeared before me this day James Brainard, Mary Ann Burke, and Lori Watson, who having
been duly sworn/affirmed, state(s) that they are members of the City of Carmel's Board of Public Works
and Safety and have executed the foregoing Water Line Easement Agreement on behalf of such entity.
WITNESS my hand and notarial seal, this J aay of , 2017
My Commission Expires: U��(� Signed Name:
P b
My County of Residence: Printed Name:
1646963_4. 7
STATE OF INDIANA )
SS:
COUNTY OF F-) vj I L TO j' )
Before me, a Notary Public in and for the State of Indiana, personally appeared Ann Lande, by me
known to be the President of Grantor, who acknowledged the execution of the foregoing Water Line
Easement Agreement for and on behalf of said Grantor.
Witness my hand and Notarial seal this day of 2012.
My Commission Expires:
;c; Notary Public
My County of Residence:
[Prii ted]
This instrument was prepared by and after recording return to: Douglas C. Haney, City of Carmel, One
Civic Square, Carmel, IN 46032.
I affirm, under the penalties for perjury, that I have taken reasonable care to redact each Social Security
number in this document, unless required by law. Douglas C. Haney
a
ka
EXHIBIT 1
Grantor's Property
Lot Number Eleven(11) in North Augusta Re-sub.,a re-subdivision of lots numbered it and 12 in North Augusta, an
addition in Hamilton County, State of Indiana, as per plat thereof recorded in Deed Record 134, Page 521, in the Office of
the Recorder of Hamilton County, Indiana. EXCEPTING therefrom, a part of said real estate described as beginning at the
Southwest corner of said Lot Number 11; thence 131 feet Northwesterly along the Easterly right of way line of U.S.
Highway No. 421; thence Northeasterly on a line parallel with the Northerly line of said Lot Number 11 to a point due
North of a point on the South line of said Lot Number 11, 105.60 feet East of the Southwest corner of said lot; thence
South to a point on the South line of said Lot Number 11, 105.60 feet East of a point of beginning; thence West on the
South line of said Lot Number 11, being also in the North right of way line of 96th Street, 105.6 feet to the place of
beginning.
EXCEPTING a part of Lot 11 in North Augusta Re-Subdivision; a re-subdivision of Lots 11 and 12 in North Augusta,an
addition in Hamilton County, Indiana, the plat of which is recorded in Deed Record 134, Page 521, in the Office of the
Recorder of Hamilton County, Indiana, described as follows: Beginning at the Northwest corner of said lot; (I)thence
Northwesterly 40.24 feet along the Northwestern line of said lot; (2)thence South 20 degrees 225 minutes 55 seconds
East 85.00 feet to the Southeastern Line of said lot: (3)thence Southwesterly 40.10 feet along said Southeastern line to
the Southwestern line of said Lot; (4)thence Northwesterly 85.00 feet along said Southwestern line to the point of
beginning.
ALSO:
Part of Lot Eleven (11) in North Augusta Re-subdivision,a re-subdivision of Lots 11 and 12 in North Augusta, an addition
in Hamilton County, Indiana, as per plat thereof recorded in Deed Record 134, Page 521 in the Office of the Recorder of
Hamilton County, Indiana, described as beginning at the Southwest corner of said Lot Number 11; thence 131 feet
Northwesterly along the Easterly right of way line of U.S. Highway No. 421; thence Northeasterly on a line parallel with
the Northerly line of said Lot Number 11 to a point due North of a point on the South line of said Lot Number 11, 105.60
feet East of the Southwest corner of said lot; thence South to a point on the South line of said Lot Numbered 11, 105.60
feet East of a point of beginning; thence West on the South line of said Lot Number 11, being also the North'right of way
line of 96th Street, 105.60 feet to the place of beginning.
EXCEPT from caption:A part of Lot 11 in North Augusta Re-subdivision, a Re-subdivision of Lots 11 and 12 in the North
Augusta, an addition in Hamilton County,Indiana, the plat of said Re-subdivision being recorded in Deed Record 134,
Page 521, in the Office of the Recorder of Hamilton county, Indiana described as follows: Beginning at the Southwest
corner of Lot 11 in said North Augusta re-subdivision; (1)thence Northwesterly 131.00 feet along the Southwestern line
of Lot 11 in said North Augusta Re-subdivision to the West corner of the Owner's Land; (2)thence Northeasterly 100.10
feet along the Northwestern line of the Owner's Land; (3) thence South 20 degrees 18 minutes 12 seconds East 166.66
feet to the Southeast corner of the Owner's Land which is on the South line of Lot 11 of said North Augusta Re-
subdivision; (4)thence South 88 degrees 56 minutes 05 seconds West 105.60 feet along said South line to the point of
beginning.
ALSO:
A part of Lot 11 in North Augusta Re-subdivision, a re-subdivision of Lots 11 and 11 in the North Augusta Addition, an
addition in Hamilton County, Indiana, the plat of said re-subdivision being recorded in Deed Record 134, Page 521in the
Office of the Recorder of Hamilton County, described as follows:
Commencing at the Southeast corner of Lot 11 in said North Augusta Re-subdivision: thence South 88 degrees 56
minutes 05 seconds West 100.00 feet along the South line of said Lot to the point of beginning of this description; thence
North 74 degrees 52 minutes 31 seconds West 73.29 feet to the East right-of-way of US 421; thence North 20 degrees 25
minutes 55 seconds West 124.04 feet along said East right-of-way; thence North 69 degrees 34 minutes 05 seconds East
60.00 feet; thence South 20 degrees 18 minutes 12 seconds East 166.66 feet to the point of beginning and containing in
all 8,698 square feet or 0.200 acres more or less
EXCEPTING THEREFROM:
A part of Lot 11 in the North Augusta Resubdivision of Lots 11 and 12, an addition to Hamilton County,Indiana,the plat
of said Resubdivision recorded in Plat Book 134, Page 521, in the Office of the Recorder of Hamilton County, Indiana, and
being that part of the owner's land lying within the right of way lines depicted on the attached right of way parcel Plat of
Parcel 99, described as follows: commencing at the Southeast corner of said Lot 11 in said Resubdivision; thence North 1
degree 04 minutes 09 seconds West 6,096 meters(20.00 feet)along the East line of said Lot to the North boundary of
West 96th Street; thence South 88 degrees 55 minutes 51 seconds West 30.480 meters (100.00 feet)along the boundary
of said West 96th Street; thence South 88 degrees 57 minutes 16 seconds West 11.192 meters(36.72 feet) along said
boundary to the point of beginning of this description, also being point#252 designated on said plat; thence continuing
South 88 degrees 57 minutes 16 seconds West 10.222 meters (33.54 feet) along said boundary to where said boundary
of meets the Eastern Boundary of U.S.R. 421; thence along the boundary of said U.S.R. 421 Northwesterly 54.805 meters
(179.81 feet)along an arc to the left and having a radius of 51,985.71 meters(170,556.79 feet)and subtended by a long
chord having a bearing of North 20 degrees 34 minutes 02 seconds West and a length of 54.805 meters(179.81 feet)to
a point#199 designated on said plat; thence South 26 degrees 04 minutes 26 seconds East 48.688 meters(159.74 feet)
to point#253 designated on said plat; thence South 47 degrees 31 minutes 14 seconds East 10.947 meters(35.92 feet)
to the point of beginning and containing 166.3 square meters(1,790 square feet), more or less.
EXHIBIT "A"
EASEMENT
A PART OF LOT 11 IN THE'NORTH AUGUSTA RESUBDIVISION OF LOTS 11 AND 12,RECORDED IN PLAT BOOK 134,
PAGE 521 IN THE OFFICE OF THE RECORDER OF HAMILTON COUNTY, INDIANA, AND BEING IN THE SOUTHEAST
QUARTER OF SECTION 7, TOWNSHIP 17 NORTH, RANGE 3 EAST OF THE SECOND PRINCIPAL MERIDIAN,
HAMILTON COUNTY,INDIANA,MORE PARTICULARLY DESCRIBED AS FOLLOWS:
Commencing at the Southeast corner of said Lot 11 in said Resubdivision; thence North 01 degree 04
minutes 09 seconds West, along the East line of said Lot 11, a distance of 20.00 feet to the existing
right—of—way of 96th Street per Instrument Number 9103565 and the PLACE OF BEGINNING; thence South
88 degrees 55 minutes 51 seconds West, along said existing right—of—way, a distance of 100.00 feet;
thence South 88 degrees 57 minutes 16 seconds West, along said existing right—of—way, a distance of
36.72 feet to the existing right—of—way per Instrument Number 200000038782; the following two calls are
along said existing right—of—way per Instrument Number 200000038782: 1) thence North 47 degrees 31
minutes 14 seconds West, a distance of 35.92 feet; 2) thence North 26 degrees 04 minutes 26 seconds
West, a distance of 54.70 feet; thence South 47 degrees 31 minutes 14 seconds East, a distance of 86.10
feet; thence North 88 degrees 57 minutes 16 seconds East, a distance of 23.47 feet; thence North 88
degrees 55 minutes 51 seconds East, a distance of 100.00 feet to the East line of said Lot 11; thence
South 01 degree 04 minutes 09 seconds East, a distance of 15.00 feet to the PLACE OF BEGINNING,
CONTAINING 0.073 ACRES(3172 SO.FT.)MORE OR LESS.
I, Trent E. Newport, a Registered Land Surveyor in the State of Indiana, do hereby certify that this
description was prepared from information obtained from Instrument Number 200000038782, as recorded in
the Hamilton County Recorder's Office. No fieldwork was performed and therefore, this description is
subject to any overlaps, gaps or inconsistencies that a field survey might reveal.'
OESTE Fpp0�
l
M/ 2-14-12
No. 29600021 Trent E. Newport Date
Reg. Land Surveyor No. 29600021
STATE OF State of Indiana
AND I Atk
qN� S U RN Ey
PREPARED BY:
Transportation S
Development Consultants
.un XM m BUa GM H 9107 pin 7W-!s5
ROAD: MICHIGAN ROAD r 99 DRAWN BY : CJL 11-22-11
PROJECT: MICHIGAN ROAD FDR MAIN REVISED BY : CAW 02-14-12
96th ST.-106th ST, CHECKED BY : TEN
COUNTY: HAMILTON EASEMENT EXHIBIT SCALE : 1" = 100'
SECTION: 7
TOWNSHIP: 17 NORTH ' OWNER: A & A DEVEOPMENT CORP.
RANGE: 3 EAST RECORD DOCUMENTS: CORPORATE WARRANTY DEED, BK. 326 PG. 379
100 0 100 100
HATCHED AREA IS THE
APPROXIMATE EASEMENT
NQRTH
g701 STREo p9 i
A & A DEVELOPMENT CORP. \j
BOOK 326 PAGE 379
\
APP. R/W PER I
INST.#200000038782 NORTH AUGUSTA
RESUBDIVISION
moo\ \ P.B. 134, PG. 521 / 1
6 � LOT 10
N NORTH AUGUSTA JI
IJNE TABLE �, / RESUBDIV1S10N �j L,�
P.B. 134, PG. 521 ��(39 49
L1 NOt'04'D9"W 20.00' \� LOT 11
L2 S88'55'S1"W 100.00' r
L3 S88'S7'16"W 36.72' \ �,
VN26*04'26"W 4"W 35.92' d �` A & A DEVELOPMENT CORP. I
26"W 54.70` BOOK 326 PAGE 379 p 4"E 86.1 0' co
6"E 23.47'1"E 100.00'9"E 15.00' \ L8 r
PLACE OF BEGINNING
APP. R/W PER
HAMILTON COUNTY 205'60 INST.#9103565
7 7 96th STREET
818 ° MARION COUNTY S. LINE, SE 1/4 SEC. 7-17N-3E
E. Nt No fieldwork was performed and therefore, this description is subject to PREPARED BY:
G1S7ERfo p� any overlaps, gaps or inconsistencies that a field survey might reveal. N
This plot was prepared from information obtained from Instrument Number
200000038782, as recorded in the Hamilton County Recorder's Office.
No. 29600021 _
STATE OF _ 4-
!4 AND I ANA y�� Trent E. Newport Date t t;
S U R`1 F' Reg. Land Surveyor No. 29600021 Transportation&
State of Indiana Development Consultants
3111 vGW OR BM cans a ww Pn)W-Ism
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ACCEPTANCE OF ADMINISTRATIVE SETTLEMENT
A & A Development Corporation, landowner of the property or interest in property
described in the attached Exhibit A and Exhibit B. hereby accepts the administrative
settlement of$75,000.00 made by the City of Carmel on this day of
2012.
A & A Development Corporatio
BY I le,
v�� -�� ---
Ann Lan e
President
NOTARY'S CERTIFICATE
STATE OF INDIANA )
)SS:
COUNTY OF r4.rj H 1 L T6 J)
Subscribed and sworn to before me this day of S�n few lam¢r- . 2012
My commission expires: (y-1 ots
i
County of residence:;� -
Sionature
17 Ll
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Printed
3 cl E
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Forn- W-9 Request for Taxpayer Give Form to the
(Rev.December 2011) requester.Do not
Department of the Treasury Identification Number and Certification Send to the IRS.
Internal Revenue Service
Name(as shown on your income tax return)
A&A Development Corporation
Business name/disregarded entity name,if different from above
N
N
Ql
ti
c- Check appropriate box for federal tax classification:
C
° ❑ Individual/soie proprietor ❑ C Corporation S Corporation ❑ Partnership ❑ Trust/estate
N
T ❑Exempt payee
o ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)►
O
C N
- C
a ❑ Other(see instructions)►
— Address(number,street,and apt.or suit Requester's name and address(optional)
CL
9
co
City,state,and ZIP code f
`� 2 (D�ciZ-
Lis account number(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on the"Name"line Social security number
to avoid backup withholding.For individuals,this is your social security number(SSN).However,fora MI -m -
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Employer identification number
number to enter.
Certification
Under penalties of perjury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or 1 am waiting for a number to be issued to me),and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined below).
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and d!!yidends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 4.
Sign Signature of `
Here U.S.person i' Date► a A-r�/-?✓
General Instructio Note.If a requester gives you a form other than Form W-9 to request
your TIN,you must use the requester's form if it is substantially similar
Section references are to the Internal Revenue Code unless otherwise to this Form W-9.
noted.
Definition of a U.S.person.For federal tax purposes,you are
Purpose of Form considered a U.S.person if you are:
A person who is required to file an information return with the IRS must •An individual who is a U.S.citizen or U.S.resident alien,
obtain your correct taxpayer identification number(TIN)to report,for •A partnership,corporation,company,or association created or
example,income paid to you,real estate transactions,mortgage interest organized in the United States or under the laws of the United States,
you paid,acquisition or abandonment of secured property,cancellation .An estate(other than a foreign estate),or
of debt,or contributions you made to an IRA.
•A domestic trust(as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S.person(including a resident
alien),to provide your correct TIN to the person requesting it(the Special rules for partnerships.Partnerships that conduct a trade
requester)and,when applicable,to: business in the United States are generally required to pay a withholding
tax on any foreign partners'share of income from such business.
1.Certify that the TIN you are giving is correct(or you are waiting for a Further,in certain cases where a Form W-9 has not been received,a
number to be issued), partnership is required to presume that a partner is a foreign person,
2.Certify that you are not subject to backup withholding,or and pay the withholding tax.Therefore,if you are a U.S.person that is a
3.Claim exemption from backup withholding if you are a U.S.exempt partner in a partnership conducting a trade or business in the United
payee.If applicable,you are also certifying that as a U.S.person,your States,provide Form W-9 to the partnership to establish your U.S.
allocable share of any partnership income from a U.S.trade or business status and avoid withholding on your share of partnership income.
is not subject to the withholding tax on foreign partners'share of
effectively connected income.
Cat.No.10231X Form W-9(Rev.12-2011)
/ n
Prescribed by State Board of Accounts
Form No.301(Rev.1995) ACCOUNTS PAYABLE VOUCHER
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.
191
Officer Title
Voucher No. Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
MUNICIPAL WATER DEPT. ACCT.
NO.
CARMEL, INDIANA
Favor ue/0? 02�
Total) Amount of Voucher $
�G •JOSDedu ti ns
Amount of Warrant
Month of 19
VOUCHER RECORD Acct.
No.
Source of Supply
Water Treatment
Transmission and Dist.
Customer Accounts
Administrative and General
Operation-Maintenance
s
Utility Plant in Service
Constr.Work in Progress
Materials and Supplies
Customers Deposits
Total
Allowed
Board of Control
Filed
Official Title
�'\ BOYCE FORMS•SYSTEMS 1-800-382-8702 325