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INDIANA DEPARTMENT OF HIGHWAYS — LAND ACQUISITION -- CLAIM VOUCIJER <br />1pl11,-%'cd by star hoard <br />if Accounts — 1986 STATE AGENCY FILL ]N <br />COUNTY <br />PROJECT <br />PARCF'L NO. <br />This form may be used only for <br />claims chargeable to Purchase of Right of Way. <br />City O SOUtl1 Bend Account Number: <br />State Agency: Department of Highways 800 <br />County -City Building Appr. Name: <br />227 West Jefferson Ave. State Share: $ <br />South Bend, IN 46601 <br />Federal Share: $ <br />Total Amt. of Chcck; $ <br />St. Joseph Doc.I.D: PV 800 <br />ST-226-7 (A) Date: <br />30 Parcel: <br />5T.ATE AGENCY FILL IN <br />L I Invoice <br />r,, rt...,,t, Fund I Appr <br />GI <br />02 <br />03 <br />04 <br />05 <br />Purpose Of This Statement: <br />Vendor Code: <br />ACCOUNTING LINE DISTRIBUTION <br />Loc. Func. Object Cost Pro'ect <br />Acct. Prefix Mrrt,Fiar r Part Contract <br />To Purchase Provisional Right of Way <br />Check Delivery Instructions: Yes 0 (See reverse side) <br />CLAIMANTS <br />Pursuant to the provisions and penalties of Indiana Code 5-1 I-10-1 <br />1 hereby ccriify that the foregoing account is just and correct, that the <br />amount claimed is legally due, after allowing all just credits, and that no <br />hart of the same has been paid. 1 also authorize payment to be made as <br />indicated above. <br />X City of ' South Bend <br />Date (If a rm or corporate give name) <br />s93tX uyx <br />�66;h <br />l Signature Title <br />x <br />E. Kernan Mayor <br />--)ate Signature if individu <br />��[eo X Atte s t ' • � /,-- /�- �- , --�-� <br />Datd XiNxxxRk 9xdQ9x <br />x Irene K. Gammon, City Clerk <br />Date Signature if individual <br />X <br />Date Signature if individual <br />Recommend Approval: <br />Originator <br />Approved Division of Land Acquisition: <br />DIVISION CHIEF <br />Date <br />,31 :VICES MANAGER <br />Date <br />Send when ready <br />Amount <br />LIENHOLDERS <br />I hereby sign this claim voucher as a lienholder and only certify to the <br />extent of my interest therein and authorize payment to be made as indicated <br />above: <br />X <br />Ua 'te Of a firm or corporation, give name <br />X By <br />Date Personal Signature Title <br />instrument Approved as to Form, prrliminary only, Excepting Real <br />Estate Description. <br />Deputy Attorney General Date <br />Payment Approved as to Account No. and Funds Available. <br />ID OH Division of Accounting and Control Date <br />Approved, Indiana Department of Highways. <br />DIRECTOR 11 Date <br />DEPUTY DIRECTOR L.__I <br />DIVISION CHIEF 11 <br />I <br />