30307 Traveler's Insurance INDIANA RETAIL TAX EXEMPT PAGE
16 II Carmel T�`� rL� F CERTIFICATE N0- 00312D155 002 0 PURCHASE ORDER NUMBER
y �T 1L \ASS// lW-j� J61L.IL 1Li d FEDERAL EXCISE TAX EXEMPT 30307
35-60000972
ONE CIVIC SQUARE THIS NUMBER MUST APPEAR ON INVOICES, AM
CARMEL, INDIANA 46032 2584 VOUCHER. DELIVERY MEMO. PACKING SUPS,
SNIPPING LABELS AND ANY CORRESPONDENCE.
FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL 1997
PURCHASE ORDER DATE DATE REQUIRED REOUISITION NO. VENDOR NO. DESCRIPTION
12/20/11 N/A 3149316 John Paul Pack Tort Claim Settlement
Traveler's Insurance AO
13c0o1 COI lectiGYs eenterDr: SHIP 1
VENDOR
I I I_ eaCe3 TO DEC 20.1
CONTWMATION BLANKET CONTRACT PAYMENT TERMS FREIGHT
QUANTITY JUNIT OF MEASURE DESCRIPTION UNIT PRICE 1 EXTENSION
1 EA Claim #CES9536 John Paul Pack Tort $5,000.00 $5,000.00
4I 1 I ti
F i
1
Send Invoice To 1
$5,000.00
PLEASE INVOICE IN DUPLICATE
DEPARTMENT I ACCOUNT 1 PROJECT I PROJECT ACCOUNT 1 AMOUNT
1125 -1- 4358400- Refunds, Awards Indemnifications PAYMENT
Am VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O.
NUMBER 15 MADE A PMT OF THE WUCHER AND EVERY INVOICE AND
VOUCHER IIAS THE PROPER SWORI AFFIDAVIT ATTACHED
SHIPPING INSTRUCTIONS !HEREBY CERTIFY THAT THERE I5 P4 UNDSLIGATED BALANCE IN
•SHIP REPAID. THIS APPROPRIATION SUFFICIENT A PAY FOR THE ABOVE ORDER.
C.O.D. SHIPMENTS CANNOT BE ACCEPTED. Michael Klitzing DK 12A L LI 11
PURCHASE ORDER NUMBER MUST APPEAR ON ALL ORDERED BY
SHIPPING LABELS.
THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99. ACTS 1945 TITLE 1 J L, 1
AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO
30307 CLERK TREASURER
DOCUMENT CONTROL NO. VENDOR COPY