226861 12/03/2013 ,.F CITY OF CARMEL, INDIANA VENDOR: 367782 Page 1 of 1
ONE CIVIC SQUARE WEST 96TH ST REAL ESTATE LLC
CARMEL, INDIANA 46032 ATTN:MAILOU HUMPHRIES CHECK AMOUNT: $29,480.00
�� 3940 W 93TH ST CHECK NUMBER: 226861
°" INDIANAPOLIS IN 46268
CHECK DATE: 12/3/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
610 5023990 EASEMENT 29, 480 . 00 EASEMENT
t
I BY
4
Prior Deed References:
Instrument No. 9709737634 in
Dic-til Recorder's Office for
Hamilton County, Indiana
WATER LINE EASEMENT AGREEMENT
This Water Line Easement Agreement (the "Agreement") is made and entered
into this day of 2013, by and between West 96`" St. Real Estate,
L.L.C., an Indiana limited liability company ("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 I attached hereto
and incorporated herein.
B. Grantee, in connection with Grantee's improvement/construction of the
Michigan Road Water Main Installation — 96°i 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.
-NTC)W THEREFORE fnr and in consirulP15itinn of the Ebrerrninrr rPnitalc Sarhioh 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
Grantor's 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. Continuous Access. Except for emergencies involving the public health,
safety or welfare, in the event that any construction work which is the subject of this
Agreement requires a temporary blockage of access to Grantor's Property, Grantee, or its
specified contractor, shall notify Grantor at least ten (10) days prior to commencement of
the anticipated work. In addition, any such work shall be undertaken in a manner to
minimize the limitation on ingress and egress to the balance of Grantor's Property. Except
for emergencies involving the public health, saftety or welfare, one-half of the driveway
located on the Easement Property and on Grantor's Property shall remain open at all
times in order to assure appropriate circulation for the overall site. During instances of
temporary blockage, Grantee shall place temporary signage reasonably acceptable to
Grantor in order to redirect invitees of Grantor to another entrance to Grantor's Property.
'l. Construction Schedule.. Except for emergencies involving the public
health, safety or welfare in which case Grantee shall notify Grantor as soon as reasonable
practicable. Grantor and Grantee shall establish a construction schedule that accomodates
the Project and minimizes work on the Easement Property that interferes with access to
the Easement Property.
5. 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, without Grantee's
written consent, which consent shall not be unreasonably vvitI-ilield but may be
conditioned upon the Grantor's future improvements not interferring with the
improvements and Grantee not being responsible for replacement or repair of Grantor's
future improvements. Any such improvements and related work shall be at Grantor's
sole expense, in accordance will all applicable codes, ordinances; laws and regualtions
and shall require Grantor to obtain all necessary approvals of the City of Carmel, its Plan
Commission and any other municipal body or entity entitled to review such construction
or related work. 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.
6. 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.
7. 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 atrreements 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).
S. Environmental Matters. Grantor covenants and represents that to the best
of its l.no\vledge, 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.
9. 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.
10. Other Obliaatiorns. 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.
11. Waiver. Waiver by either party of any one default hereunder Nvill 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.
12. 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.
13. 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
si_,ned by the parties, and no agreement or consent of any other persons shall be necessary
ivr such tciiliinatiorn, modification, or amendment.
14. GoverninLy Law. This Agreement will be governed by and construed in
accordance with the laws of the State of Indiana.
15. Notice. Any and all notices, demands, requests, submissions, approvals,
consents, or other communications or documents required to be (Yiven, 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 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, hldiana 46032
Attn: Carmel City Attorney
With a Copy to: City of Carmel
One Civic Square
Carmel, Indiana 46032
Attn: Director of Utilities
If to Grantor: '144 hI Ma '► 1 o cam. LL vu h r i e S
41£5T %±t, S'T. KEAL r S�L L-c
3'1yo Gc/• 96 jA !izgz 'T
Any such notice"nll be effective three days after the notice has been deposited in the United
States mail, as provided above, or if earlier upon receipt.
16. 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.
17. Authority. The person executing this instrument on behalf of Grantor hereby
represents that he/she has the authority to bind Grantor to the tern-is 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.
18. Attornevs' 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 written.
GRANTOR:
Signature Yv
Pnnted4,
P�.esfcQ
Title
l e 21 2y
Date
GRANTEE:
THE CITY OF CARMEL
By and through its Board of Public Works
and Safety
By: '7W M:�O�
James Brainard; Presiding Officer
Date: ��
Bv:
Ma Ann Burke, Member
Date:
By:
Lori WafsVn, Member
Date: ✓ iv ,
Sandra M.Johnson,
ATTEST: Deputy Clerk foir
Di, na L. Cordray, hk-MC, Clerk-Treasurer
Date: �'l 3
STATE OF INDIANA )
SS:
COUNTY OF HAMILTON )
Personally appeared before me this day James Brainard, Mary Arm Burke, and Lori
Watson, who having been duty 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 Acyreenient on behalf of such entity.
WITNESS my hand and notarial seal, this day of �? ;
2013.
My Commission Expires: Signed Name:
My County of Residence: yv�//ti%yxj Printed Name:
STATE OF / )
) SS:
COUNTY OF ot) 1
Before me a Notary Public in�ad for the State of N �. personally
appeared OPr ft-at-n A . Rik- I'Mm 6d) me known to be the 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 thisa� day of , 2013.
f x .
My C mmission Expires: A ALI
r-s
l L� Notary Public '7;
_ a -
F
My County of Residence:
L+nA [Printed]
STATE OF )
SS:
COUNTY OF )
Before me, a Notary Public in and for the State of personally
appeared Robert P. Johnson, by me known to be the General Partner 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 2013.
My Commission Expires:
Notary Public
My County of Residence:
[Printed]
This instrument Nvas prepared by and after recording return to: Douglas C. Hare} City of
Carmel, One Civic Square. Carmel, IN 460')?
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
EXHIBIT I
Grantor's Property
Part or'the Southeast Quarter:- of Section. 7, Township. 17
north, Range TEast; Clay Township, Ramilton County, Indiana,.
more fully.descrioed by:
Commencing at the Southeast corn er of said Southeast ar;
thence along the. South line..thernof, South,88°55'35°'West '
1829.25 feet;,thence.North.;81104'25" West.25.00 Peet to the - -
- Point of Beginni ;: thencs.along the Westerly lire'or said -
Lot 13A, .North 0104'25" Vest 298.83 .feet'to the ,NOrt23vest
corns; of said Lot 1' ;.thence: along the Northerly,line of
said Lot IIA.and Lot:1Z, North 74°04'44" East 706.91 fee.alot fo.
the No1rtheast corner of said. tot 12; thence ng the:
Easterly line of said Lot 1T, South ol'04'25^ East. '251.85
feet, thengerSouth.e8°55135^West 200.00 feet to the Point of
Beginning, containing 1,0346 Acres, more or.;.less.
.. - 7armarly 3aova.as: Lot 11R and 11 in NorlLx Augusta R421bd vision, ,
the,plat of which is recorded' In:Dead Hook 134, page 521 and 522
in'the Office of.the Recorder.of ttamilton County, Indiana_
EXHIBIT "A"
EASEMENT
APART OF LOT 11A 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, MORE PARTICULARLY
DESCRIBED AS FOLLOWS:
Commencing at the Southwest corner of said Lot 11A; thence North 01 degree 04 minutes 25 seconds
West, along the West line of said Lot 11A, a distance of 20.01 feet to the existing right—of—way of 96th
Street per Instrument Number 200400069569 and the PLACE OF BEGINNING; thence North 01 degree 04
minutes 25 seconds West, along West line of said Lot 11A, a distance of 15.00 feet; thence North 88
degrees 55 minutes 35 seconds East, a distance of 16.70 feet; 'thence North 83 degrees 42 minutes 39
seconds East, a distance of 83.65 feet to the East line of said Lot 11A; thence South 01 degree 04
minutes 25 seconds East along said East line, a distance of 15.06 feet, to the existing right—of—way of
96th Street per Instrument Number 200400069569; the following two calls are along said existing
right—of—way. 1) thence South 83 degrees 42 minutes 39 seconds West, a distance of 82.97 feet; 2)
thence South 88 degrees 55 minutes 35 seconds West, a distance of 17.38 feet to the PLACE OF
BEGINNING, CONTAINING 0.035 ACRES(1505 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 Numbers 9709737634 and
200400069569, 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.
oES T ER�p0��
2-14-12
No. 29600021 Trent E. Newport Date
Reg. Land Surveyor No. 29600021
STATE OF State of Indiana
<' IND 10 )
�N� S
PREPARED BY:
1'ransportation S
Development Consultants
vr,SI}L LF,MCI. w,m(3v)m-m5 .
Max
ROAD: MICHIGAN ROAD DRAWN BY : CAW 02-14-12
PROJECT: MICHIGAN ROAD FDP MAIN EXHIBIT REVISED BY :
96th ST.-106th ST. CHECKED BY : TEN
COUNTY: HAMILTON EASEMENT EXHIBIT SCALE : 1" = 100'
SECTION: 7
TOWNSHIP: 17 NORTH OWNER: WEST 96TH ST. REAL ESTATE, LLC
RANGE: 3 EAST RECORD DOCUMENTS: WARRANTY DEED, INSTR. #9709737634
too o too too
SCAI.�'I' HATCHED AREA IS THE
APPROXIMATE EASEMENT
NORTH
LINE TABLE
L1 N01'04'25"W 20.01'
L2 NOt'04'25'W 15.00'
L3 N88'55'35"E 16.70'
L4 N83'42'39"E 83.65'
L5 S01'04'25"E 15.06'
L6 I S83'42'39"W 82.97' / �\
L7 S8855'35"W 17.38' / N
I �
/ ?
LOT 11 i i NORTH AUGUSTA co
R SUBDIVISION I I N
IP.B. 134, PG. 521
co
I I LOT 11A LOT 12
N II
v WEST 96TH ST I o
(REAL ESTATE LLC I I Cn
�\ ° III INSTR. NO.
y °z i 9709737634
L4
d PLACE OF BEGIN I1-3 / � --- ---
7 7 HAMILTON COUNTY "— ��t
7 8
8 8 MARION COUNTY S. LINE, SE 1/4 SEC. 7-17N-3E 8 7
96th STREET
PP. R/W PER
NST.
No fieldwork was performed and therefore, this description is subject to PREPARED BY:
�G1STE'? A0 any overlaps, gaps or inconsistencies that a field survey might reveal.
R ,0 A This plot was prepared from information obtained from Instrument ~
Numbers 9709737634 and 200400069569, as recorded in the Hamilton
No. 29600021 County Recorder's Office.
STATE OF
l9 AND I ANP y0� Trent E. Newport Date ,T-. U
Reg. Land Surveyor No. 29600021 1'ransportation&
State of Indiana Development Consultants
X1 snr a.QZCH=c f,�6m I3171 1&'1.W
Form Wain Request for Taxpayer Give Form to the
{Rev.Deromber2+7t1) requester.Do not
(Rev. ecem cr2011) Identification Number and Certification send to the IRS.
Internal Revenue Service
Name(as shown on your home tax return)
n Business name disregarded entty name,if different from above
w
? Check appropriate boa for federal tax classification:
° ❑Individu=l!sola Proprietor ❑ C Corporation ❑S Corporation E] Partasrsh;o ❑Trus estate
N '
Ef �'
'0. p Exempt y e
L ° Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership}►
0 i
N
r 0
�` to ❑ Other(see instructions)
Address(number,street,and apt.or suite no.) Rc-quzster's Hume and address(aptional)
' city,state,and ZJP code
-v
1L
List account nuinber(s)here(optional)
Taxpayer Identification Number(TIN)
Enter your TiN in the appropriate box.The TIN provided most match the name given on the"Name"hoe soc,a!security number _
re avant backup withholding.proprietor,For individuals,this is your he al security number n page However,.For fora � _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(Ellq).If you do not have a number,see How to get a
771J on page 3.
Note.If the account is in more than one name,see the chart on page 4 for guidelines on whose Ernployar id=ratification number
number to enter, i5l F/M7 Cel 61 /Certification
Under penalties of pe-jury,I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me),and
2. 1 am not subject to backup withholding because:(a)I am exerai`L from backup v.!ithholding,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 ail interest or dividends,or(c.)th-1F.S has nctiried m-that!am
no longer subject to backup withholding,and
3. 1 am a U.S.citizen or other U.S.person(defined bolo-w).
Certification instructions.You must cross out item 2 above if you have been notified by the iRS that you are currently subject to backup with
because you'have failed to report ail 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 dividends,you are not required to sign the cerfifrcation,but you must provide your correct TIN.See the
instructions on page 4.
Sign Signature of
Here U.S.person► Ji 3' ' /t� a ��
{.�(,ti,il.,. 'C��" ��,, ;'J1 _� Date► ,' "t:2.<.. '7G GC.7j,
General Instructions Note.If a requester gives you a form other than Form VV-9 to request
your TIN,you roust use the requester's form if it is substantially similar
Section references are to the Internal Revenue Code unless othenvise to this Form 1N-9.
noted. Definition of a U.S.person.For iederat tai:purposes,you are
Put-pose of Porn 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 carrect taxpayer identification number(TH)to report,for •A partnership,corporation,company,or association created or
example,income paid to you,real estate transactions,mortgage interest organized in ii}e United States or under the laves of the United S'Mfcs,
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(2s defined in Regulations section 301.7701-7).
Use Form Vi'-9 only if you are a U.S.person(including a resident conduct
alien):to provide your correct TIN to the person requesting it(the Special runes for partnerships.Partnerships quirt dtnduct a trade l
)• p � "r� business in the United States as aeneraity required to pay a withholding
requester)and, when applicable,to tax on any foreign partners'share of income from such business,
A.Certify that the TiN you are giving is correct(ar you are waiting for a Further,in certain cases v,!here a Form VV-9 has not been receive',2
number to be!ssued), P=rtnership is required to presume that a partner is a foreign person,
2.Certify that you are not subiect to backup v itflirold a,or and say the withholding tax.Therefore,if you are a U.S.person that is a
nrtner in a �artr;-rsiii conducting a trade u business is qi�e United
3.Claim exemption fru n backup vviihhoiding if you are a U.S.ex opt p` partnership
Slates,provide Form Vil-9 to the partnership to esia`,lish your U.S.
pay&e.If applicable,you are also certifvinc that as a U.S.person,your and h „f rir
a.110--able share of any partn<%ship income from a U.S.trade cr business
tatus an avoid ydit.hot i .on your share_ pa. eanip income.
is not subject to the withholding ta:on foreign p.'Utners'share Gen
effeciiveiv ccnnec;ed incoms. _
Cat.1,10.10? iX Dram W-g(Hai 12- 01 f)
ACCEPTANC12 Oh ADIVIINISTfZNTIVE SE�I"1 LE��ENT
West 9b��� St. Real Estate, L.I_.C., lando���ner of the above-described property or interest in
property described in Exhibit A and Exhibit B. which are attached hereto and incorporated
herein, hereby accepts the administrative settlement of 29,450.00 made by the City of Carmel
on this Andav of' _ 2U 13.
West 96"' St. Real Estate. L.L.C.
13 y
Si011ature
Printed
r�
Title
NOTARY'S CERTIFICATE
STATE OF I NCI �� )
')SS:
COUN"l Y 01" �k v�(�-(Ut•J)
Subscribed and sworn to bel-ore me this��� day of'_ 'O1
NI), Commission explres:-;�b—q f o`-o L
COLMt\ of residence: �,Cht �'�T1/� —_� Q �--' �a Tr f
Si�n�lttne - ,-
Printed
VOUCHER # 133010 WARRANT # ALLOWED
T673 IN SUM OF $
WEST 96TH ST REAL ESTATE LLC
ATTN: Mailou Humphries
3940 W 96th St
Indianapolis, IN 46268
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
AMo�00
100713 06-1052-06 -__$25;80.0.,00
Availability
�q, yaG 06
Voucher Total _-$2-5;80-0.00
Cost distribution ledger classification if
claim paid under 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 of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
T673
WEST 96TH ST REAL ESTATE LLC Purchase Order No.
ATTN: Mailou Humphries Terms
3940 W 96th St Due Date 10/7/2013
Indianapolis, IN 46268
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
10/7/2013 100713 $25,800.00
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 icer