223206 08/13/2013 CITY OF CARMEL, INDIANA VENDOR: 00350511 Page 1 of 1
ONE CIVIC SQUARE SMOCK FANSLER CORP
i; CARMEL, INDIANA 46032 2910 W MINNESOTA ST CHECK AMOUNT: $20,115.00
INDIANAPOLIS IN 46241
CHECK NUMBER: 223206
CHECK DATE: 8/1312013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
2201 R4239034 26317 1119 20, 115 . 00 106TH/GRAY ROAD
Smock Fansler Corporation- INVOICE
2910 W. Minnesota Street
Indianapolis IN 46241-
Invoice No:1119
(317) 248-8371 Date:7/26/2013
Bill To: Due Date:8/25/2013
CITY OF CARMEL STREET DEPT.
3400 W 131 ST ST Job No:12196
Description: CARMEL ROUNDABOUT REPAIR
WESTFIELD IN 46074 PO #:
Quantity Description Unit Price Extended Price
CARMEL ROUNDABOUT REPAIR @ 106TH & GRAY
COMPLETED TO DATE 100 %
1.00 TOTALAMOUNT DUE 20,115.00 20,115.00
Thank You For Your Business! Amount Now Due: 20,115.00
Terms:Net 30 Days
AFFIDAVIT AND WAIVER OF LIEN
[X] Final [ ] Partial [X] Payment to Follow
State of Indiana
County of Marion
T. M. Fansler, being duly sworn states that he is the CEO of SMOCK FANSLER CORP.
having contracted with: City of Carmel Street Dent. to furnish certain labor, materials, and/or services
as follows: Misc. Construction for a project known as: SFC 412-196 Carmel Roundabout Repair
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($21,115.00)
Twentv One Thousand One Hundred Fifteen Dollars and No/100
[ ] 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 waiver_.
SMOCK FANSLER CORP. By ✓X) ,Title CEO
T. M. Fansler
cn o 0 oasRY iP U
WITNESS MY HAND AND NOTARIAL SEAL, this 26 day of July ,2013. \,,o� ocP..- 41,
AI
��
Melissa J. Bish p Nota Public
My commission expires_November 30, 2016 Residing in_Morgan_County
VOUCHER NO. WARRANT NO.
ALLOWED 20
Smock Fansler Corporation
IN SUM OF $
2910 W. Minnesota Street
Indianapolis, IN 46241-4541
$20,115.00
ON ACCOUNT OF APPROPRIATION FOR
Carmel Street Department
PO#/Dept. INVOICE NO. ACCT#/TITLE AMOUNT Board Members
26317 1 1119 1 42-390.341 $20,115.00 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
VF da t 013
SR'�e�fl(t�rn9Pri�84#A61�r
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund
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
Purchase Order No.
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
07/26/13 1119 $20,115.00
1 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
, 20
Clerk-Treasurer