HomeMy WebLinkAbout31621 Xerox City O ty of f Carmel INDIANA RETAIL TAX EXEMPT 155 00 PAGE
Ili/ll1}111 ISIS,/ CERTIFICATE NO.003120155 002 0
PURCHASE ORDER NUMBER
'K IT mg(1-1--
-F F i a � FEDERAL EXCISE TAX EXEMPT 3 / I
L 1 1 i (.�-r L 35-60000972 J (f/
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES,NP
CARMEL, INDIANA 46032-2584 VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL- 1997
PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION
19li &8
Xi(10X
SHIP
VENDOR TO
CONFIRMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION
Lop')0( tgas.e P( SPA4ackedi 1 g 1913 - la
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t-P:7.4.4, 6 ve;:"‘. ''''
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Send Invoice To: ° .,!- `=' "" G di
2O /3 Encumbrance
PLEASE INVOICE IN DUPLICATE
(�
DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT
90 9 a (9((a l 435s004/ PAYMENT 8: ZD IS Z
Cod • NP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND
VOUCHER HAS THE PROPER SWORN AFFIDAVIT ATTACHED.
SHIPPING INSTRUCTIONS • I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
�THIS-APPROP• a ION SUFFICIENT TO PAY FOR THE ABOVE ORDER.
•SHIP RSHAID. _�
•C.O.D.SHIPMENTS CANNOT BE ACCEPTED. ORDERED BY
•PURCHASE ORDER NUMBER MUST APPEAR ON ALL
SHIPPING LABELS.
•THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99,ACTS 1945 TITLE
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
CLERK-TREASURER
DOCUMENT CONTROL NO. 31621 OFFICE COPY
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Xerox e /Rpm O p
Legal Department-2011 �•�
p)/k� /Lr/fato
Appropriation#430-53004; P.O.#16719 L1hjtt L,z_ /�.&C�L
Contract Not To Exceed$484.17/per month
ADDITIONAL SERVICES AMENDMENT TO
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES
THIS AMENDMENT TO THE GOODS AND SERVICES AGREEMENT (°Agreement) entered into by and
between the City of Carmel and Xerox (the 'Vendor'), as City Contact number 10.17.07,04 shall amend the terms of
the Agreement by adding the additional services to be provided by Vendor consistent with the Scope of Work
attached hereto and incorporated herein as Exhibit 11A". Furthermore, the terms of the Agreement shall be amended
to include the E-verity requirement as stated in Indiana Code § 22-5-1.7 et seq., which is attached hereto and
incorporated herein as Exhibit`B`, as well as the required E-verify Affidavit attached hereto and incorporated herein
as Exhibit'C'..Also, pursuant to I.C. § 5-22-16.5, Xerox shalt certify that in signing this document, it does not engage
In investment activities within the Country of Iran. The terms and conditions of the Agreement shall not otherwise be
affected by this Additional Services Amendment and shall remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have made and executed this Amendment as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
By: By:
714e70-0, ZeVit{"
ames Brainard, Presiding Officer Authorized Signature
Date. —C • / "/
'/ / /lCC�t7 ( t//f1t i/
L/ ! Printed Name
M. An :urke,Me ber •
Date: — Inangyeie-
/ Title
(J -
Lori S.Watson;Clem er FID/TIN:
Date: " t11 1 3
Last Four of SSN if Sole Proprietor
ATTEST:
Date: L24/AL/
aria Cordray, IAMC,Clerk-Treasurer
Oats: (-'6/-/_3 - - _ wee a.reitvent. Y 12
NOTARY PUBLIC STATE OF NEW YORK
Regiseeacc Na 01M0J4t62411
. -
Qualified in Monroe County
Cammissim Wins JunJ�eJ 16,2011
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.
Xerox
Legal Department-2012
Appropriation 1$430-53004; P.O. t1 26719
Contract Not To Exceed 3484.17/per month
Exhibit°C
�� E-Verify Affidavit
Ei'F,e n (IA-h ;k 1/ ,being first duly sworn,deposes and says that
he/she is familiar with and has personal knowledge of the facts herein and, if called as a witness in this
matter, could testify as follows:
I. I am over eighteen (I 8) years of age and am competent to testify to the facts contained
herein.
2. I am now and at all times relevant herein have been employed by Xerox (the"Vendor") in
the position of Ne /ripp,a c-titer
U
3. I am familiar with the employment policies, practices, and procedures of the Vendor and
have the authority to act on behalf of the Vendor.
4. The Vendor is enrolled and participates in the federal E-Verify program. Documentation of
this enrollment and participation is stated in the Addendum, "Exhibit B," to the original
City Contract#0723992001, and is incorporated herein.
5. The Vendor does not knowingly employ any unauthorized aliens.
6. To the best of my information and belief, the Vendor does not currently employ any
unauthorized aliens.
7. FURTHER AFFIANT SAYETH NOT.
EXECUTED on the :6 day of P-tC 2ct_ 20 IR .
Printed: Ole e tilt/4/
I certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
Printed: tile-en 0.4411/
r , 5G. •J
NOTARY PUBLIC,Stat OF NEW YORK
R<0;.xne00 Na 0424164862471
1 in Mover Caloy -
Commission Expires Jane 14 7014
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