31661 Hylant Groupof Carmel
ONE CIVIC SQUARE
CARMEL, INDIANA 46032 -2584
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997
INDIANA RETAIL TAX EXEMPT
CERTIFICATE NO. 003120155 002 0
FEDERAL EXCISE TAX EXEMPT
35- 60000972
PAGE 1 Jl
PURCHASE ORDER NUMBER
3)11,4
THIS NUMBER MUST APPEAR ON INVOICES, NP
VOUCHER, DELIVERY MEMO, PACKING SLIPS,
SHIPPING LABELS AND ANY CORRESPONDENCE.
'URCHASE ORDER DATE
DATE REQUIRED
REQUISITION NO.
VENDOR NO.
DESCRIPTION
VENDOR 1"v,a iaC111..i7) Set.
SHIP
TO
CONFIRMATION
BLANKET
CONTRACT
PAYMENT TERMS
FREIGHT
QUANTITY
UNIT OF MEASURE
��
Send Invoice To:
GQ-,\ L.c
DESCRIPTION
UNIT PRICE
EXTENSION
- }U 63.5311„1 11 �`J.bTTL
_ ZLS' 10E7 LZu 33
PLEASE INVOICE IN DUPLICATE
u5) 9247. 5k)
a'
DEPARTMENT
I ZU5
ACCOUNT
PROJECT
PROJECT ACCOUNT
AMOUNT
`!`<5
SHIPPING INSTRUCTIONS
• SHIP REPAID
-
• C.O.D. SHIPMENTS CANNOT BE ACCEPTED.
• PURCHASE ORDER NUMBER MUST APPEAR ON ALL
SHIPPING LABELS.
• THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99. ACTS 1945
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO.
ORDERED BY
TITLE
PAYMENT
• A/P 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.
I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
THIS APPROP`(RRI/IIA'ROON'SUFFICIENTTO PAY FOR THHEEEAABOVE ORDER.
q CLERK - TREASURER
DOCUMENT CONTROL NO. 31661 A.P.V. COPY - SIGN AND RETURN TO CLERK'S OFFICE
HYLANT
A GROUP
301 Pennsylvania Parkway, Suite 201
Indianapolis, IN 46280 -0925
Phone: 317- 817 -5000
To: City of Cannel
Attn: Steve Engelking
One Civic Square
Carmel, IN 46032
r
INVOICE 1Page 1
ACCOUNT# CSR I DATE
CARMELO -02 79 1219/2014
PRODUCER
W. Michael Wells
EFFECTIVE
BALANCE DUE ON
!EXPIRATION
1/1/2015 1/1/2016
1/1/2015
Amount Due
$ 3,280
$196,433.00
INVOICE FOR:
CRC, 4CDC, CGDC AND CRA
Invoice # Trans Policy # Description Company Amount
66199 REN H630581M4076TIL Property /IM Travelers $148,174.00
66201 REN ZLP14T62033 Genl Liab Travelers $32,806.00
66202 REN H8103036P64ACOF Auto Travelers $0.00
66198 REN XC00000374 Umbrella National Casualty Co. $15,453.00
Amount Due
PREMIUM ALLOCATIONS
Prop /IM
Gen! Liab
Auto
Umb
Total
4CDC
$ 8,028
$ 3,280
$ 1,545
$ 12,853
CGDC
$ 8,028
$ 3,280
$ 1,545
$ 12,853
CRA
$ 96,337
$ 13,123
$ 6,181
$ 115,641
CRC
$ 35,781
$ 13,123
$ 6,182
$ 55,086
TOTALS
$ 148,174
$ 32,806
$ 15,453
$ 196,433
301 Pennsylvania Parkway, Suite 201, Indianapolis, IN 46280
Toll Free: 800- 678 -0361 Local: 317 - 817 -5000 Fax: 317- 817 -5151
$196,433.00