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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 1 ' t-P:7.4.4, 6 ve;:"‘. '''' { A►1 . fir ?: S e0 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 I /° //4t 4i6 ? �r 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 frbwdsrta•Gosh 3.4201l MaBm4w171 Svcs m® ma.r ass IDI tcLmpn lm M ern/ /1111/40 I j 31\10\J . 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. 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