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227462 12/17/2013
CITY OF CARMEL, INDIANA VENDOR: 241763 Page 1 of 1 ONE CIVIC SQUARE PETTY CASH CHECK AMOUNT: $141.32 CARMEL, INDIANA 46032 C/0 LISA C/0 LISA CHECK NUMBER: 227462 CHECK DATE: 12/17/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 651 5023990 121613 141 . 32 OTHER EXPENSES PETTY CASH NUM ER DATE DESCRIPTION • I • �4 N CHARGE TO ACCOUNT TOTAL Received By Approved By. -v 9672 a �►�[�l�l�'d�7:1�7�:�:1��1�1� R�7�®�I3CT� �: � Lu a c v y y Try the new Western Union Payments service for all YOLW hills in and get guaranteed pproof of payment. To learn more and to p 2 search over 10,000 Fillers, goto WesternUnionPaysMyBills.com. �p O AGT 526697 LOC 000000 DT 062013 015.00 15DQLLARS ARID I!0 GEFlTS n V WPy� ''gable to: O .A. NF AIN THIS MONEY ORDER ON BACC.IT MUST BE INCLUDED WITH ALL REFUND REOUESTE,BE SURE TO READ IMPORTANT PURCHASE AGREEMENT:You the purchaser ag ee that Western Union Financial Services Inc.(WUFSI)need not stop payment y 0 on,or replace,er refuntl a lost or stolen WUFSI Money Ortler less(t eyrvu till in the tace of the Money Ober at the nme of '^ o hose enC(2)you report the loss or theft to Western Union Me I es Inc.in wntinp i diately�and(3)Vou provide e.I WUFSI xAN Nis on nal Mon Order receipt issued by Western Union Financial Services Inc.,Englewood,Golorodo.For customer ,w aervice.p*,BDD 9-96607 4 7 1 2 4 1 8 8 0 2 * v! o v o c J 11111 milli 11111 011HI 111111 �j For your financial service needs, visit our website at www.westernunion.com Instructions Western Union Financial Services;Inc.Money Order Tracing/Refund Request For customer service, 1.This re�uest is to be completed by the urcp chaser only.A stop payment is placed on the original Money Order when refund is made to purchaser. call 1-800-999-9660. 2.The orfg nal of the Money Order receipt mu—s accompany each request.If the original of the Purchasers Copy Money Order receipt is not enclosed,your request will be delayed and may be denied. 3.Enclose a 515.00 non-refundable processing fee for each photocop�or refund request. 4.A photocopy will not be processed until the 515.00 is received.Not ce:At its discretion Western Union Financial Services.Inc.may deduct the fee from your refund if it is not enclosed with your request. MONEY ORDER DATE PURCHASED 5.Please allow 30 days for processing.All requests for refunds and photocopies must be in writing. AMOUNT M M D D v Y SEND REQUEST TO: Purchasers Name First Last Please Print Western Union Financial Services,Inc. P.O.Box 7030 Englewood,CO 801557030 Money Order was purchased at Mailing Address Please Print Money Order was Payable to: name&address Qt State Zi Code Reason for Re us I. 'To induce Western Union Financial Services,Inc.(WUFSI)to refund to me the lace amount of the above Money Order,and in consideration of that payment,I authorize WUFSI to stop payment on this Money Order, and agree to reimburse WUFSI for this refund and to hold WUFSI harmless against any and all expense and/or liability to which it may be subject by reason of this refund to me,by reason of my alleged loss of the Money Order,or by reason of the negotiation of the Money Order." PURCHASER SIGN HERE(IN INK):x BEFORE MAILING,BE SURE THAT THIS FORM HAS BEEN SIGNED IN INK. DATE PHONE NUMBER i 4.-,.= ; 'T ATE I E O INDIANA 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 A I ci ation Requirements ompleted and signed Application for Certificate of Title—State Form 44049 Original Certificate of Tale or Certificate of Origin Physical Inspection of a Vehicle or Watercraft—State Form 39530. Required for vehicles purchased outside of Indiana. Odometer Disclosure Statement—State Form 43230, if odometer statement is not completed on I Ortcertificate of title or certificate of origin.Trailers and motor vehicles over 16,000 Ibs exempt. ificate of Gross Retail or Use Tax Exemption-ST108E $15 title application fee. Fees are payable by credit card(MasterCard or Visa),check,electronic check,or money order. A$21.00 delinquent fee will be assessed on packets received 31 days after a purchase date listed on the certificate of title or certificate of origin. Re istr ion Avolication 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 N416 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. /�- d Print Name 131a: e, IMallabel — (yreLx, ; f�9err� Phone Number 17 571 2631 Emai(optional) dMwl 1a6t� ut�G4/�1/. 'm-40t/ An Equal Opportunity Employer APPLICATION FOR CERTIFICATE OF TITLE a STATE OF INDIANA o BUREAU OF MOTOR VEHICLES Stale Form 44048(R413-02) Approved by State Board of Accounts 2002 TO BE COMPLETED BYAPOLICE OFFICER,BMVOFFICIALORBMV CERTIFIED DEALER SI GNEE UWE THE UNDERSIGNED SWEAR OR AFFIRM THAT THE INFORMA- OR OUT F STATE TIlc E. I HERTtE+BY CE FTIFY THAT I PRRRSS NALLtY EXA - TION ENTERED ON THIS FORM IS CORRECT.UWE UNDERSTAND THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTI- VEHICLE IDENTIFICATION NUMBER TUTE THE CRIME OF PERJURY.FUTHERMORE,INVE AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIANA BMV FROM ANY LIABILITY ARISING FROM THIS TRANSACTION. MAKE X X DATE: The law requires Owt you apply ror Certira to of Title temin tbkty-one days tram the date of purchase of e too I BADGE,BRANCH OR 1�=Iwr wonkte.There is a delinquent rite for lagure to do so.Alta Ch Certificata of Tide assigned by eager.On sti- ed Dena must be released.SuppodhV documents surrendered with des epplkegm cannot be returned to the eppli ']n eccordanea with Federal Code 383. 1. 'SOC.SECJFEOERALI.D.NO. APPUCANTS NAME 2' 356000972 CITY OF CARMEL STREETADORESS CITY STATE LP CODE 3. 1 CIVIC SQUARE ICARMEL IIN 146032 VEHICLE I.D.NUMBER VEH.YEAR V VEH.MODELNO.VEH TYPE 4' 5L3EX3020DL001428 12013 T-MAfi yp4gZ LR FORMER TITLE NUMBER PURCHASE DATE LIEN SPEED 5' 16/7/201,q N N FIRST LIEN'S NAME OR SPECIAL MAILING ADDRESS I STREET ADDRESS B. CITY STATE Z1P CODE 7. SECOND LIEN'S NAME STREETADDRESS B. CITY STATE ZIP CODE LICENSE FORMS BNULzonmiy 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 TO7AX AMOUNT OF TAX JOEALER 7CH IPLAF EXEMPT EXEMPT t0. 'Your Social Security number/Federal I.D.number is being requested by this agency under IC 4.1.0-1.Disclosure Is mandatory and fhSs document cannot be processed without it APPLICANT RESPONSIBLE FOR ACCURACY OF INFORMATION APPLICATION FOR CERTIFICATE OF TITLE a STATE OF INDIANA a BUREAU OF MOTOR VEHICLES BUREAU -TO BE MAILED WITH TITLE REPORT IMMUCrIONS Sign and dare on top right signature line. Lim 2 Enter the name(s)('mdividuaf(s)or company)and Social Security or Federal IdedtirrAtloo Number ofthe ownet(4 Libe 3 Enter the Ind address ofthe owner(s}.The legal address Is the physical locution ofthe owner's residence or dwirms. Line 4 Enter the VIN,Year,Make.Model Number and Vehicle Type(exarbples include:2S(2 door sedans 4S(4 door sedan).CH(convertible),CP(Coupe).2W(2 door swag-N 4W(4 done wagonl VA(van},TK(truck),MC(motorrycls),TR(unUar),SE(Semi Trailer),TC(Semi Tractor).RV(recreational vehicle-including motor home and hovel trailer),MH(Mobile Home),AT(Ali Terratn�and LS(low Speed). Line 3 Enter the former title number and puxbase date.Lien YIN.If speed title is requested state)Fes'and include an additional S25 with application. Line 6&8 ladieate Hen holder fame(,)and mailing address.If there Is no lien and title should be maned to a special one time oddress include on line 6&7. Lint 10 Not required to be completed.However,appropriate tax form or payment should be included with title application. -� `r"a'�a�:s m-. r,', \ .�nv,..• - •�•�•.----• .,u,; T fir.,rprya.. ".t { f\ Tom. g, nY I y/sry3' yq.. }.i• uu:}?�y,•��':l + II•CfL e 1 i:s'• •";:. -� 1�1L (6i4aleItr"MIi •v`CJlt9g, �, ���SI /\ ,r n✓ •�- -ta- 1 .,qw- ,� `'�4�•,A4 •fi..?,].n,,�.. i /�"k •.,, ����! �� �w-•�y�3•n � ,� < a• fie: r:>. .. f.�S, ��-,�r���4 TRAILERMAN TRAILERS,iNC.0 1 ,• :kh:t DATE INVOICE NO. s.5i f JUNE 4, 2013 11643 :2 <'rl VEHICLE IDENTIFICATION N0. YEAR MAKE 5L3EX3020DL001428 2013 T-MAN . S:i3 BODY TYPE SHIPPING WEIGHT TONGUE PULL 7030 LBS ; a•, H.P.(S.A.E.) GN.W.R. NO.CYLS. SERIES OR MODEL 20000 LBS HHT8255F20 I,the undersigned authorized representative of the company,firm or corporation named below,hereby certify -�- w;^. that the new vehicle described above Is the property of the said company,firm or corporation and is transferreds ', rar. on the above date and under the Invoice Number indicated to the following distributor or dealer. t° fdfZ NAME OF DISTRIBUTOR,DEALER,ETC. TC ENTERPRISES D/BIA TC TRAILERS 437 SOUTH STATE ROAD 29: �'•, �?! MICHIGANTOWN, IN 46057 YY� �iT�J7 '�t 4 It is further certified that this was the first transfer of such new vehicle in ordinary trade and commerce. TRAILERMAN TRAILERS, INC. BY: �� •�.�� (SIGNAT E OF AUTHORIZED REPRESENTA E) (AGENT) pjY/'•'ii TTd 0026326 LOUISIANA,MO 63353 �� ,�.g,y+�pA GITYSTATE it P�'� .S; 'iel T \\ =.7 7,r � it ��ax„:� �r y°jt33 �e�..,,..-tt•i+ ,�g�� 5, ^4� �y� .._ '�S�i.i"' a� U�j�''Yt-�' 'r ���•v��q�'7�.:y;���'.�-�.SS. ��' ra,'ti'•'�-:�i�- S�+ `-,}'•� w.;;• _,,,�.�� '„"y:�-� •,,�-"�'. .�•�',\�+Y„�„- =�.� r�F. ,i,?.:1 �� �%'a9�.•.�.t,:. �i' : �' `.,.r��. Ki• ��'s, �c�i-a"� ~�'r✓�`'�j�*:�i 4l,£ Each undersigne3f seller certifies to the best of his knowledge,information and belief under penalty of law that file vehicle is nety and has not been registered In this or any statEgal the time of delivery and the vehicle Is not subject to any security interests other than disclosed herein and warrant tille to the vehicle. FOR VALUE RECEIVED I TRANSFER THE VEHICLE DESCRIBED ON THE FACE OF THIS CERTIFICATE TO: NAME OF } t�IL¢ PURCHAS£A(S� _ .�_ u� ADDRESS— �— /� � �' 1.G-i-YI+ -Vrl 1���f.-�+rp /D �- p I certify to the best of my knowledge t the udometer�leadf g is No Tenths aZ _J YZA o Ytlsfr ey By: >- ,� NA0.1E DEALERSHIP DEALERS LICENSE NUMBER to �.^ `-. UUM yon oath says that the statements set forth are m z nd corrW Subscraed,1d sworn to me �q1� F t.9 State of _____._ before Ih%c_/ day of_ 4 ar fy_�3 o0 Counr._• - Noij ubi c uf a USE NOTARIZATION ONLY IF REOUIR T'.. RI J C4 NAME OF PURCHASER(E W ADDRESS u1� - Q z I certify to the best of my knovAedge that the odometer reading is No Tenths 0 DEALER ey m .1 NAME OF DEALERSHIP DEALER'S LICENSE NUMBER Being duly sworn upon oath says that the statements set forth are y d true and correct.Subscribed and swam to me cs Slate of _ before this day of Year `NO 0 County D1 Notary Public 2 USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION x 0 NAME OF PURCHASER(S) r4 g ADDRESS _ 0 I certify to the bosrof my knowledge that the odometer reading is No Tenths O=X DEALER By: m u NAME OF DEALERSHIP DEALER's LICENSE NUMBER Being duty Sworn upon oath says that the statements set forth are we and correct.Subscribed and sworn to me f S2 State of before this day of :Year c< County of Notary Public USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION v NAME OF w It¢ PURCHASER( _ ADDRESS c j I certify to the b,' of my knowledge that the odometer reading is No Tenths 0 z D&LER By: d� NAME OF DEALERSHIP DEALER'S LICENSE NV0./BER Being duly sworn upon oath says that the statements set forth are m C 3 hue and correct.Subscribed and sworn to me ti State d before this day of Year rn(A County of x Notary Public Q 0 j USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION Federal Law regLlres you to stale the odometer mileage In connection with the transfer of ownership.Failure to complete of providing a false statement may W result In tines ar)d)or imprisonment. I certi fy to the b t of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked Odometer O'er Reading No Tenths.O The mileage stated is in excess of its mecltanICal limits.O 'odometer reading is not the actual mileage. u N WARNING ODOMETER DISCREPANCY N J Signatures)of Sellers(s) Date of Statement 'Date of sale Printed rlame(s}`At Segers(s) Dealers No. Being duly sworn upon oath says that the statements set forth are W a Signature(s)of rchaser(s) true and correct.Subscribed and swom to me U S before this Printed Names(4)of Purchaser(s) day of Year Notary Public o Company NamAif Applicable) State of 0 Address of Purcfliaser(s) County of e USE NOTARIZATION ONLY IF REOUI RED IN TITLING JURISDICTION 1st lien in favor gl whose address its °x 2nd Gen in lavor!af 2 whose address. d e Form Indiana Department of Revenue - ST-108E Certificate of Gross Retail or Use Tax State Form 48841 EXEMPTION for the Purchase of a late Motor Vehicle or Watercraft NAME OF DEALER Dealer's RRMC#(Registered ROW Merchant Certificate Number) T.C.ENTERPRISES-T.C.TRAILERS I 0003799433 015 TID#(10 digits) LOC#(3 digits) Dealer's FID#(Federal IdeMi4catbn Number.B diglta) Dealer's License Number(seven digits) 20-2272984 731 M Address of Dealer City State I Zip Code 437 S ST. RD 29 MICHIGANTOWN IN 146057 NAME OF PURCHASER(S)(PRINT OR TYPE) SSN,TiD,OR FID#(Mandatory) CITY OF CARMEL 356000972 Address of Purchaser City State I Zip Code 1 CIVIC SQUARE CARMEL IN 146032 Vehicles Identification Information of PU hase VIN#(Veldde IdenGUca m Number)or HIN#(Hun Identification Number) Year Make Model/Length 50EX3020DL001428 2013 T-MAN 30'FLATBED TRLR Calculation Of Purchase.Price Trade In Information . 1. Total Purchase Price......................... 1. 8400.00 VIN#(Venue Idemincation Number)or HIN#(Hull Identification Number) 2. Trade-Allowance (Like-kind exchanges only)................ 2. Year Make Model/Length 3. Net Purchase Price 8400.00 (Line 1 minus Line 2)......................... 3. 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. i certify that I became a resident of INDIANA on(month&year) My previous State of Residence was . I hereby certify that the above statement is true and correct. Date Signature of Owner SALESIUSE 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 1.Purchase price of property subject to salesfuse 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 Una 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 added/deleted PUBLIC TRANSPORTATION EXEMPTION(Must be completed if exemption#6 is claimed and you are not a school bus operator.) USDO Department of n tion Number) I certify that the above vehicle or watercraft Is exempt from sales/use tax under exemption# 1 (see reverse side). I also certify that any sales tax credit shown as paid to an out of state dealer using exemption#16 was actually collected by the dealer and the dealer has not provided the buyer with a check to be paid to the BMV.I understand that making a false statement on this form may constitute the crime of perjury. 6112113 :, )•' Date SI nature of Purchaser APPLICATION FOR NEW AND/OR TRANSFERRED BUREAU OF MOTOR VEHICLES MUNICIPAL, ADMINISTRATIVE AND LAW ENFORCEMENT Municipal Processing 100 North Senate Avenue • LICENSE PLATES Room N415 „ State Form 53565(11218-11) Indianapolis,IN 46204 INDIANA BUREAU OF MOTOR VEHICLES INSTRUCTIONS 1.Complete In blue or black Ink or print form. 2.Complete application 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,tr7le application,or lease agreement 4.A safety Inspection completed by the Indiana State Police must accompany all school bus requests. Official Name of entity that owns or leases the vehlcie(s) State Board of Accounts number Federal Identification Number CITY OF CARMEL 1 2930323 356000972 Entity's Executive Otflcer's name and We Entity Telephone number JAMES BRAINARD, MAYOR 317 571-2400 Entity street address Mumber and street) 1 CIVIC SQUARE City State Zp Code County Towmhlp CARMEL IN 46032 HAMILTON CLAY SE=QT30 ' EN[C�Etl FG Al 'ON e fo�llo. .': Jnfor`mahon• rea cle,a G . na; eets;ifinecessa 1 VEHICLE IDENTIFICATION.NUMBER::(pfeaseenter ln'spemsbelow Purchase or lease date 5 1 Lj 3 E I X 1 3 1 0 1 2 1 0 1 D I L 1 0 1 0 1 1 1 4 1 2 1 8 1 (m"Yyyy) 06/07/2013 Color Type Make Mode[ Year Gross Vehicle Weight(Jfapplicable) BLACK TRAILER T-MAN HHT8255F20 2013 1 20000 Description of official business for which the entity will use the Basis of Financial Responsibility(Source of self-insurance;or insurance vehicle Company Name and Policy number) MUNICIPAL UTILITY TRAVELERS INSURANCE COMPANY POLICY#H810303SP64ACOFI3 The application Is for(check one) License Plate T check one ✓ New License Plate ✓ Municipal Sheriff School Bus _Transfer an Existng License Plate: State Owned (plate numbed City Police Administrative University 2 VEHICLE IDENTIFICATION.NUMBER::.(please errrerin ces below),.. Purchase or lease date (mm/ddyyyy) Color Type Make Model Year T Gross Vehicle Welght(if 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 number) The application is for(check one) License Plate Typo: check one New License Plate Municipal Sheriff School Bus _Transfer an Existing License Plate: State Owned (plate number) City Police AdmWstrative University .(3)VEHICLE IDENTIFICATION NUMBER (lease enierin spaces beforij Purchase or lease date (mmlddyyyy) Color Type Make Model Year Gross Vehicle Weight(f applicable) Description of oHiclal business for which the entity will use the Basis of Financial Responsibility(Source ofseltinsurance;or Insurance vehicle Company Name and Poky number) The application Is for(check one) License Plate T e: check one New License Plate Municipal Sheriff School Bus _Transfer an E)dsdng License Plate: State Owned (plate number} City Police _administrative University 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 364-2-10)Municipal corporatlon"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 corporation(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 or ordinance(s)that establishes the authority), h)local hospital authority or corporation(Must provide a certified copy of the resolution orordinance(s)that establishes the authority), i)local airport authority(Must provide a certified copy of the resolution or ordinances)that establishes the authority), D 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 or resolution that establishes the entity) 3.A volunteer fire department(as defined in IC 36-6-12-2)(Must be listed with the Indiana State Fire Marshall or Department of Homeland Security and provide a.copy of the contract or resolution to provide 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$3,500.00.(Must be registered as a Volunteer Emergency Ambulance Service with the Indiana Emergency Medcal 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.) 8.A community action agency(IC 12-14-23)(Must be designated by the Governor or 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!n-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 entitles pursuant to IC 9-18-3-6): (Must provide official Idenfification showing the representative Is employed with the entity.) 9.The Indiana State Police Department 10.The Indiana Department of Natural Resources 11.A county police department 12.A city or town polic e department fflWW"MOffAM*W1A'd� E_ The authorized representative submitting this application swears or alums under the penalty of perjury that the answers and Information contained in this application are true and correct,that the entity for which this application is made owns or leases the above listed vehicle(s)and uses it for official 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 acco►dance with iC 9-18-3-4. Date(month,day,year) Signature of authorized entity representative Typed or printed name of entity representative 6/12/13 JOE FAUCETT Typed or printed title of entity representative Office telephone number of entity representative COLLECTIONS SYSTEM MANAGER (317) 671-2634 X 216 PETTY CASH NUMBS 'jso6 DATE DESCRIPTION OFITEM/SERVICE PURCHASED A a. CHARGE TO ACCO NT TOTAL Received By Appro d By 9672 PETTY CASH NUMBER DATE s • • • -w v e CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 PETTY CASH NUMB R DATE DESCRIPTION/ OF e 7777,Tmmm CHARGE TO ACCOUNT TOTAL Received By Approved B 9672 PETTY CASH NUMBERD DESCRIPTION OF • PNP/ CHARGE TO AAC UNT TOTAL ljI '7, Received By Approved By 9672 ap PETTY CASH NUMBER O O DATE 10 DESCRIPTION • e L. CHARGE TO ACCOUNT TOTAL Gl Received By Approved By--�% 9672 PETTY CASH NUMBE��R pp E DAT / G V'• Qo2 ✓ DESCRIPTION OF e CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 PETTY CASH NUMBER DATE P o ail! 5, vN _ °tip 5 CHARGE TO ACCOUNT TOTAL Received Approved By 9672 PETTY CASH NUMBER rDATE O . 7S0).0 �o DESCRIPTION OF IfEM/SERVICE PURCHASED aP/` CHARGE TO ACCOUNT TOTAL Received By Approved By 9672 14EYGRAM PAYMENT SYSTEMS,INC.DRAWER t P.O.BOX 9476 MINNEAPOLIS,MN 55480 PLEASE READ REVERSE SIDE www.monoygrom.com/moneyordor DATE/AMOUNT O a� 20 522"2e f�iSQ 3�� E �,lk-/0 71j 2Q13 �o o°o�� a� 123 NN $15.00 f i1C1-22 00. o OIL 36474'2'- a 3 8 1 46 . ., a. 8 2 0 5 2 2 2 6 6 5 0 3® 698(12/12)EMPLOYE M 71362-U v VDFTACH HFRF V v O PURCHASER'S AGREEMENT: Pou,the putt a—(r b filling to th.front. completo chid Money Order d r ddl In the Arent of the Money Order,sf"`i fed O d,r bin it m the your heirs.or loans of this Morley Orden bind you,your heirs.or others whf roceive this Mfnoy Order from you Purchaser's Proof of Purchase It is the purchaser's responsibility to keep a copy,of this stub for their records.A Claim Card is REQUIRED to process a refund or a claim on a lost or stolen money order.Claim Cards may be downloaded from our web site at yrwer.moneygram.comlmoneyorder or from the location where the money order was pur. chased or any MtoneyGram money order agent.Com- plete the enbre form and mail it with a copy of this stub to the address oo the claim card. For additional questions,please call 1-800-542-3590. Para recibir esta informacibn en aspanol, por favor Ilamar at 1-800-542-3590. MONEYGRAM PAYMENT SYSTEMS,INC.DRAWER _ P.O.BOX 9476 MINNEAPOLIS,MN 55480 r PLEASE READ REVERSE SIDE www.moneyf#Cm.COm/moneyorder DATE/AMOUNT AA L 2pS222bbb7 � 11705/2013 `,;;X00; .. _....084Jy..:gj� 15a 06 �Q< o - --- �0u 4 A, aom 364742Z681-22 13 13 LLF� W � W ® EMPLOYEE 698(12/12)500/5000 820522266657 " M 71362-U Y VDFTACH HFRF V v PURCHASER'S AGREEMENT: You,tFe purowa-Ser,aqoe talmmodlntely complete this Money Ortler by filling in the front of the Money Order,signing,and eddroeslng it at the bottom.The terms of this Money Ortler bind you.your heirs,or others who recoNe this Money Order from you. Purchaser's Proof of Purchase It is the purchaser's responsibi!ity,to keep a copy of this stub for their records.A Claim Card is REGU AED to process a refund or a claim on a lost or stolen money order.Claim Ca us may be downloaded from our web site at www,h neygram.comlmoneyorder of from the location whemithe money ofoer was pur- chased or any non money order agent.Com- plete the entire form and mail it with a ropy of this stub to the address on the claim card. For additional questions,please all 1.800.542-3590. Para recibir esta infonmaci6n an espanol, por favor Ilarnar al 1-500-542-3590. MONEYGRAM PAYMENT SYSTEMS,INC.DRAWER P.O.BOX 9476 `MINNEAPOLIS,MN 55480 CV PLEASE READ REVERSE SIDE vjww.monaygrom.com/moneyordarDATI/AMOUNT 0 L .2c.d1J.2ii663CSO,,,.,,,° s [A2705J>li0_13 `°aN N (384 T $15.00 $oio + 36474r 23' 8123`68 13 a R 2 0 5 2 2 2 6 6 6 5 8 n 696(1ti,2;50'0;5000 M 71362-U v vnFTArH HFRFV v PURCHASER'S AGREEMENT: moo.IFe purcTiaser.agree ro tmmetllelcly complete this Money Older by tilting In the front of the Money Order,signing,and addressing it at the bottom.The terms of this Money Order bind yeu,your heirs,or others who receive thie Money Older troth you. Purchaser's Proof of Purchase It is the purchases s reisponslbil),to keep a copy of this stUG for their records.AClaim Card is REQUIRED to process a refund or a don,or,a lost or stolen money cider.Cieim Cares may be oov;n!oaded from our;veb site at www.moneygram.comlmoneyorder or from the loca!ion where the money order was pur- chased or any tdoneyGiam money order agent.Com- plete[he entire form and mall it with a copy of this stub to the address on the claim card. For additional questions.please call 1.800,542-3590. Para recibir esta intormaci6n on espanoi, por favor flamer ai 1-800-542-3590. f i i d Sale C S,Lt" U CLUB ta'.fWiflGFR RYnN SiMPSON (317) F.SS-;619 INDIAN.1POLTS, TN Visit Samf !uh.t:on 09/02/13 i 4:i S ;aI< '?i r',8.0990 9(190. HANK Y01-1144' '189341 V I NEGAR. N TOT VL 3.58 mci fip !'CND 3,c8 k)9/03/,- ,1.1 .II 66 V "t : :;oit' "tai: ti:4 1,. 43;f `.1Laa 'iiVi. �5 'fig" tl- !TF a .q 'Abi 1 ;tt J 0'79 8;"':• s,.tJ x tti-v t) 75=ii ' IE ip �:t�• t�qE € CtP 7 a iidfl�t 1��I I����Ij-� t�i� i j� .alt.�..rt;,,,:1 , ,.•prig„, � . , - IPF+ ; tu1�Lt'!;'' !1If�Sr`.vt '�1,,7;;;itEEli)^7tt't ,aVfc, EPJf %Fi; F ;+U1 f;r, ,t lil4 G,?CL t .•jpe<i!.Rt2;)5 P...t-� :.. 7'.a....tic. t ':! •_ t a trr,:ia HI t rf.:: ,ft _.!rtr PC 1,. v=.W N,:t11.'• 1- rx:. C ±r t:1t'ol;It rti, ri r r t t i I It 1-;n.. . .4...:.+e 1 Ni -a1 i.1 •ml:•l-i'lP. i t•, ,ay.e;!tr�.u. .,y.s:;:a:.IrESa..xnnt / - .r..: +,�:Ic:ar•r.:?e it r. .:p fire.; I:.IoS1H;:mrt:v,11w of it ',[tl t!.ao, L,r. ..�:.�Soii f:,-E9t LtiiPP lili S d:-i C:t.tnrje..I.A[ !d I it i l tS 110 Savi nss Sif3ri up r.d :tlt: xn/email 09/o2/is 14.;'0,31 MEMBER ROPY / �A��#�SR����� �G���� � . � �� � . �~�\� � . � . ������� i�i�V _ i . '' OFFICE DEF'OT1; 539 12917 N. Meridian St. Carmel, IM 96032 .�' (317)571-1300 11/15/20-1-3 ��1.3�9.7 � 9:96 AM STR 539��EG 1<� ,�TRN�:9017 t=t'IF;�333�19��© SALE Product TD Description Total 525698 B?(,Cl_PBRD,STOR 19.99 S Subtotal : �-�� i 9.99 `-' ��SS�iv� � ��s' �-O�CU90 Cash: �?0.00 CHANGE: (0.01 ) Taz .Exempaion Number 86102.185 ' Shoe rrnline at www.officedepot.com is?o � � s� � ������ ����o :E3E*#*�F***jE#*�c***�(�*ii***�i 3f 9t iE iE iE*3F 3f jE 9E*di*�*%iE** WE WANT TO HEf1R FROM YOU! Participate in uur online customer survey and receive a co�.rpon for $10 off dour next yuat'if�yi'ns��ru chasre�oPs$50_or rnor_e on l l i i°� � � -fit S'o'��ii`�' of f i ce�supp hies; furrnl=tur-e�and�raore-:o (Excludes Technology. Limlt 1 couPOn Per household/butriness. ) Uisit www.offlcedePOt.com/feedbac4; and enter the survey code be Cow. � , K3S4 BB�F 8ESN " _".. � - � IILI_II III II .I;IIIILIII IIIIIIIIIIIIIIIIIIIIIIIIII 22TTRQPPR535YMBRB ' r• 1 and In their original,unopened cononion,may oe exchanged or returned for a tun refund within 30 days of purchase. Ink&Toner,Including Office Depot®Brand and all national brands;with their Original Receipt and in their original,unopened condition,may be exchanged or returned with a full refund within 30 days of purchase. Technology and consumer electronic products may be exchanged or returned with their Original Receipt and in their original packaging with UPC code within 14 days of purchase.A 15%Restocking Fee will be applied if any components are missing.Opened software may be exchanged for the same Item only.Please remember to remove all personal data from exchanged/retumed products.Office Depot is not responsible for any personal data left In or on an exchanged/returned product. Furniture may only be exchanged or returned with Original Receipt and in new condition, unassembled,in original packaging with UPC code within 14 days of purchase. Refund Method for Returns with Original Receipt :If you aid with: Your refund will be:'- Cash or check written more than 10 days ago Cash - Check less than 10 days ago or Office Depot Office Depot Gift Card Merchandise Card Credit Card or Debit Card - - Same Card Refund Methods for Returns without an Original geceip_t All Ink,toner and supplies being returned without an Original Receipt require valid government Identification.Items still active in our computer system will be refunded in the form of an Office Depot Merchandise Card in an amount equal to the lowest retail price during the preceding 90 days.If that amount Is under$10,we will refund in cash. Office Depot reserves the right to request Identification or deny any exchange or return. Catalog and Web Purchases may be returned/exchanged in accordance with this policy by contacting 1-800-GO-DEPOT(1-800-463-3768)or in any store. Non-Refundable:Special Order/Custom Items and Manufacturer Direct items cannot be returned or exchanged unless damaged upon receipt.Pre-Paid Cards such as Gift Cards and Phone Cards are non-refundable,and cannot be returned or used to purchase other gift cards.Special terms and conditions are Included with each card. See Tech Depot"Services Terms and Conditions for separate return policy. Office Depot reserves the right to amend these terms at any time and to make exceptions on case-by-case basis. 100% Satisfaction Guarantee Refund.Methods for Returns with Original Receipt,packing slip.or order confirmation("Original Receipt") Our Brand Promise—Office Depot®Brand products(excluding Office Depot® Brand Ink and Toner)may be returned at any time for any reason.With Original Receipt, you will receive a full refund. Office supplies(excluding Office Depot Brand products);with their Original Receipt and in their original,unopened condition,may be exchanged or returned for a full refund within 30 days of purchase. Ink&Toner,including Office Depot'Brand and all national brands,with their Original Receipt and in their original,unopened condition,may be exchanged or returned with a full refund within 30 days of purchase. Technology and consumer electronic products may be exchanged or returned with their Original Receipt and In their original packaging with UPC code within 14 days of purchase.A 15%Restocking Fee will be applied if any components are missing.Opened software may be exchanged for the same Item only.Please remember to remove all personal data from exchanged/returned products.Office Depot is not responsible for any personal data left in or on an exchanged/returned product. Furniture may only be exchanged or returned with Original Receipt and in new condition, unassembled,in original packaging with UPC code within 14 days of purchase. Refund Method for Returns with Original Receipt: If you paid with! - -Your refund will be: Cash or check written more than 10 days ago' Cash - Check less than 10 days ago or Office Depot Office Depot*Gift Card Merchandise Card Credit Card or Debit Card Same Card Refund Methods for Returns without an Original.Receiot All Ink,toner and supplies being returned without an Original Receipt require valid government Identification.Items still active in our computer system will be refunded in the form of an Office Depot Merchandise Card in an amount equal to the lowest retail price during the preceding 90 days.If that amount Is under$10,we will refund In cash. Office Depot reserves the right to request identification or deny any exchange or return. Catalog and Web Purchases may be returned/exchanged in accordance with this policy by contacting 1-800-GO-DEPOT(1-800-463-3766)or in any store. - Nnn-Refnmriahl-Snacial Order/Custom Items and Manufacturer Direct items cannc I r® er - Great food . - -b' -prices . 150 WEST 161ST STREET' 317 7-6314 YO KROGER(( US_C� O�R t � 1-i; 33 19790—'�HOMECITY ICE/ C_5 ,FF MONSTER ENRG PC 1 .25 T SC KROGER SAVINGS 0.94 MONSTER ENRG PC 1 .25 T Sc KROGER SAVINGS 0.94 MONSTER ENRG PC 1 .25 T SC KROGER SAVINGS 0.94 MUNSTER ENRG PC 1 .25 T SC KROGER SAVINGS 0.94 TAX 0,35 33** BALANCE 9.94 CASH 20.00 CHANGE 10.06 TOTAL NUMBER OF ITEMS SOLD = 5 * * ** KROGER SAVINGS 333333133333 KROGER SAVINGS $ 3.76 TOTAL SAVINGS (28 r7 $ 3.76 * 33 3333 KROGER SAVINGS ** * 10/02/13 07:09am 970 82 7 999 SEPT FUEL POINTS REMAINING - 362 THESE POINTS EXPIRE 10/31/13. EACH MONTH IS A SEPARAFE ACCUMULATION PERIOD. POINTS DO NOT COMBINE. HIGHEST UNREDEEMED DISCOUNT FROM SEPT OR CURP111T MONTH OFFERED AT THE PUMP. 33333�1:� fr3333E333333*33%333333333333t OCTOBER FUEL POINTS da REDEEM IOOPTS TO SAVE .10 PER GAL. ON ONE PURCHASE OF UP TO 35 GAL. SAVE UP TO $1 PER GAL AT KROGER OR .10 PER GAL AT SHELL ON 1 FILL-UP. --------------------------------------- FUEL POINTS THIS ORDER o 10 FUEL POINTS THIS MONTH = 11 THIS MONTHS POINTS EXPIRE 11/30/13. VISIT WWW.KROGER.COM/FUEL, FOR DETRILS 3333333#333333333'34..33 33);.3'31i3113133333 You Saved $3 . 76 with our New Low - Prices . BY USING YOUR KROGER*PLUS CARD,YOUR ANNUAL SAVINGS TO DATE IS $1,158.87 THANK YOU FOR SHOPPING KROGER CUSTOMER SERVICE IS EVERYONE'S JOB. LET ME KNOW HOW WE ARE DOING. DAWN BURDINE, MANAGER v �' � , i I i � � 1 .. � �' i i r Thanks for shopping our friendly store. White ' s Ace Hardware ' CarMe L 731 S Rangetine Rd Carmel, IN .16032 317-846-2311 CASH SALE ITEM OTY SALE/REG EXT 5954 2.00 1.98 .3.96 EACH IKEY SINGLE CV;' 7A-, -- 2.00 0.20 0.40• EACH 500.00 ••Fastners SUBTOTAL S 4.36 TOTAL $ CASH 21.00 L-2:HANGE 15.33 EMPLOYEE TERM INV# TIME DATE 2000015 11114 2519802 08:06 09-Oct-13 Your receipt guarantees your no-hassle• return. We're your source for let Spring, Summer, Winter and Fall for a l l Your hardiq.are needs. \j i IN V I CE -- CARMEL RETAIL STORE CARMEL, Indiana 460329998 1740350814-0094 11/25/2013 (800)2.75-8777 02:21 :20 PM _— Sales Receipt =-- Product Sale Unit Final Description Qty Price Price CARMEL IN 46032 Zone-O $0.46 First-Class Mail Letter 0,90 oz. Scheduled Delivery Day: Tue 11/26/13 Return Rcpt (Green $2.55 Card) @@ Certified $3.10 Label 0: 701210100010218358427 Issue PVI: $6,11' " Total : $6.11 Paid by: ,- Cash $6.11 @@ For tracking or inquiries go to USPS.com or call 1-800-222-•181,1 *#*4*********-k****04*0 BRIGHTEN SOMEONE'S MAILBOX. Greeting cards available for purchase at select Post Offices, In a hurry? Self-service kiosks offer quick and easy check-out:. Any Retail Associate car* show you how. .. . Order stamps at usps.com/shop or call 1-800-Stamp24. Go to usps.com/clickriship to print shipping labels with postage. For other information call ' 1-8004:1)K-USPS. Get your mail when and where you want it with a_secure Post Office Box. Sign up for a box online at: usps.com/poboxes. Bi110:1000601766941 Clerk:04 All sales final on stamps and postage Refunds for guaranteed services only Thank you for your bUSinE:SS HELP US SERVE YOU BETTER Go to: https://postalexperiencE:.com/Pos TELL US ABOUT YOUR RECENT POSTAL EXPERIENCE: YOUR OPINION COUNTS Customer Copy Hamilton County Recorder Mary L. Clark 10./18/2013 11:57:04A Trans #: 000535279 Business Uate: 10.-18/2013 Rey_ By: SAG 2013064450 RELEASE 11:57:04A Subtotal: $12.00 2013064451 RELEASE 11:57:04A Subtotal: $12.00 2013064452 RELEASE 11:57:04A Subtotal: $12.00 2013064453 RELEASE 11:57:04A Subtotal: $12.00 2013064454 RELEASE 11:57:04A Subtotal. $12.00 2013064455 RELEASE 11:57:04A Subtotal: $12.00 2013064456 RELEASE 11:57:04A Subtotal: $12.00 2013064457 RELEASE 11:57:04A Subtotal: 312.00 2013064418 RELEASE 11:57:04A Subtotal: '$12.00 2013064459 RELEASE 11:57:04A Subtotal: $12.00 2013064460 RELEASE 11:57:04A Subtotal: $12.00 2013064461 RELEASE 11:57:04A Subtotal: $12.00 2013064462 RELEASE 11:57:04A Subtotal: $12.00 2013064463 RELEASE 11:57:04A Subtotal: $12.00 2013064464 RELEASE 11:57:04A Subtotal: $12.00 2013064465 RELEASE 11:57:04A subtotal: $12.00 2013064466 RELEASE 11:57:04A Subtotal: $12.00 2013064467 RELEASE 11:57:04A SUbtotal: $12.00 2013064468 RELEASE 11:57:04A Subtotal: $12.00 2013064469 RELEASE 11:57:04A Subtotal: $12.00 2013064470 RELEASE 11:57:04A Subtotal: $12.00 2013064471 RELEASE 11:57:04A Subtotal: $12.00 2013064472 RELEASE 11:57:04A Subtotal: $12.00 2013064473 RELEASE 11:57:04A Subtotal: $12.00 2013064474 RELEASE 11:57:04A Subtotal: $12.00 Receipt Total: $300.00 Paid By Amount Ref # Check $259.00 0000004912 CARREL UTILITIES Gash, $41.00 LISA KEMPA Good Day Sunshine! VOUCHER # 137008 WARRANT # ALLOWED 241763 IN SUM OF $ PETTY CASH - ADMIN C/O LISA Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR – —-- - -- Board members PO# INV# ACCT# AMOUNT Audit Trail Code 121613 01-7200-02 $19.99 121613 01-7202-05 $4.59 121613 01-7202-06 $4.36 121613 01-7200-08 $3.58 121613 01-7360-02 $6.31 121613 01-7502-06 $61.49 121613 01-7750-08 $41.00 Voucher Total $141.32 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 241763 PETTY CASH -ADMIN Purchase Order No. C/O LISA Terms Due Date 12/10/2013 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 12/10/201: 121613 $141.32 ti i f hereby certify that the attached invoice(s), or bill(s) is (are) true and i ;orrect and I have audited same in accordance with IC 5-11-10-1.6 - c Date Officer r