QPA Proposal - Gametime - New Surface at Potawatomi Park Playground

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F lipm ST I05 Indiana Department of Revenue Stile Fomt4e1165 R4I8-05 General Sales Tax Exemption Certificate Indiana registered retail merchant I%unit businesses located oil [Side Iruliana may use (his certificate. Tie claimed exemption must be allowed by Iuliamr code. f3xcmption sluttas of other stales are not valid for purchases from Indian([ vendors. This exemption certificate can not be issued for the purchase of Ulililies, Whiclec, I9r re •errs r, or An crn f Purchaser must be registered with the Depot anent ref Revenue or the appropriate basing owhority of the purchaser's suite of residence. Sales Ins must be charged unless !it-[ Information in each section is fully completed by the pmrcl asen Purchasers not able to provide all required infurntalirm must pay (he lax tad may rile it claim for refund (Form GA.I I OL) dhrctly with the Department of Revonme. Name of Purchaser City of South Bend ness Address 227. W Jefferson Blvd Ctly South Bend Slate IN hoser trust provide tininuun of one 1D another bdow.e ide your Indiana Registered Retail Merchant's Certificate 0003122131 and LOC Number os shown on your Cwiilicale ............ .................•. TIDN On dulls) If noungistered with the Indiana DOR, provide your Slue Tax IDNumber from :mother State ............................................... •.......,,.... •.. *-See instructions on the reverse side if you do not have either number, Slate )])it ate. Is (his a 0 blanket purchase exemption request or a ❑single purchase exemption regueO (check one) 0 Description cal items to be purchased. Purchaser toast indicate the type of exemption facing claitucd for this purchase. (cheek one nr explain) ] Sales In a relailer, who)csoler, at, manufacturer for resale only. :1 Sale of manufacturing machinery. mots, unit equipment to be used directly in direct production, a Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin #10. (May not he used for persomd hotel reams and teals.) Zip 46601 001 LOCP 13 digik) Stile of Isere Sales or totgible personal properly predominately used (greater (bell 50 percent) In providing public transportation - provide USDOTtI A person nr corporation who is hauling antler someone else s motor can9cr authority. or has a contract as a school has operator, must provide their SSO or FIDH in Kett of n Stale IDfk in Section ill • USDOTN Stiles to pelsous, occupationally engaged as fornlas, to be used directly in production orngricttlturnl product, for %;de. Note: A Tumor not possessing at Slate Business Licetseft any enter it FIDII or it SS# iu lieu of a Slatc ID4 in Section it 1, Stairs to a contractor for excnnpt projects (such as public schools, guvernmcn4 or nonprofits). Sales to Indiana Coveramental Units (agencies, cities, lowns, municipalil ics, public schools. tad slate universities) Shies ionic United.Stntcs Federal GoVornment-showageucy name, -- Note: A U.S. Government agency should cater its Federal Identification Number tP1Dfi) in Section III in lieu all a Slate ID/t. Otlier - explain. Vim 1 hereby certify under lire penullics of perjuy that file properly ptteclmsed by the use of this exemption certificate Is to be used for all exempt purpose pursuant m the State Gross Retail Sules'fax Act. Indiana Code 6-25, laid the item purchased is nil a utility, vehicle, woercrtdl, or uil'crn0. ��i wnfinn my nnderstuntling that misuse (rit/ernegfigrnr nr lnrrnrinn<d), and/or frnutlulem axe of this rrrtificate may subjnl both me pclsnnnily mud/or the business corky I rc +r snot to the ["Past Oil of us, interest. unit civil anthill criminal pcutdlies. Signn(ureol•Purchaser 4-X116r;." ' 'T.�t1.� Date 1/5/2015 Prined None Sh�nnon Fredline Till, AP Supervisor The Indiana Depnrtment of Revenue only request verification of re&istmtion it, another state Irvin are an oul-or-same purchasm Seller musthctp ibis certificate on rile tosupport exempt sales.