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Home My WebLink AboutJFD DISTRIBUTOR: Office H2O .,, ourewaterpartners' eiOffice H20 9850 North Michigan Road,Suite E Carmel,IN 46032 www.officeh2o.com (866)621-6910 CUSTOMER INFORMATION BILLING INFORMATION (if different) Company Full Legal Name: Company Name: (13) s ,.0 izLI v. Z� f� i 6_ Contact Phone #: 4 Contact: Phone #: t p (l 7,"c%. 8 f,z - 16445 2-61/45" Equipment Loca ion Address: Address: 40?6Li E )6 6 c_ "69 oil 6 City, S„ tate, Zip: City, State, Zip I JG a >_ u,g--V i'_Ln r) 17iJô Email: TIN#: Email: P.O.#: J fo/c0 rey,7fG,/loh ae3/.2o?cj'0 We Org Type: ❑ Corp ❑ LLC ❑ Partnership ❑ Other State incorporated/organized: ------- RENTAL TERM MONTHLY PAYMENT BILLING FREQ./TYPE SPECIAL INSTRUCTIONS Quarterly payments save you (7� time and money! bU Quarterly ❑Check 60 months $I! (plus taxes) E Monthly ❑ ACH EQUIPMENT SCHEDULE ACCOUNT SETUP FEES Installation Fee $ / Unit = $ Other Fees* = $ ❑ See attached equipment schedule (if applicable). * ACH INSTRUCTIONS By providing the bank account information herein, I (we), as the account holder(s), authorize the Distributor or its assignee and our or its financial institution to debit our account for the amounts due or to become due under the terms of this Rental Agreement. This authorization will remain in effect until written notification of termination is received by the Distributor or its assignee. Routing #: Account#: Account Name: Authorized Signer: Agreed and Acce to y: Customer: _ 1 V A/,'":ek.. "24/ , AJthorizei-Sibn ure Name Printed V I-ierio,vvi4[ Ale Z./-"i17 ' - 16— ) Title Date Distri • , a,,, / Signa Title t Date stomer acknowlediii, . having read and understood all of the terms of this Rental Agreement, including page 2 hereof, and agrees to be bound by all of the terms herein upon execution of this Rental Agreement. Reference Number (for internal use only) page 1 of 2 Customer 40 office H 0 Sastisfaction 2 Guarantee Provided customer uses the equipment to manufacturer's specifications, the equipment is guaranteed to perform for the entire term of the rental period. If repairs cannot be made, Office H2O, will replace the equipment with another model of equal or greater capabilities at no additional cost to the customer. In the event that the customer becomes aware that the • equipment does not meet minimum performance standards, customer agrees to notify Office H2O in - writing within ten (10) business days of first knowledge of unsatisfactory performance, Office H2O shall have five (5) business days to correct the specified problem. In the event the specified problem is not corrected as provided herein, customer shall be issued a check from Office H2O equal to the amount of one month's rental payment per non-performing system and for each month of non-performance commencing with the date of first receipt of written notification of non-performance. Agreed By: •-•') ) 1� � �r -Cn/i n/J 012- 10- I/3 6ffi'ce H2O A co i nt Excutive Date )14/51t_wil �V; L1.0 /.1-1 t 21) 61)4 Q►�-t��t Custo Contact Date Office H2O's Statement of Assurance Office H2O is committed to providing its customer's quality equipment, quality service and quality drinking water. If for any reason you are not satisfied with the performance of your equipment please contact Office H2O directly for prompt assistance. Service@officeh2o.com DISTRIBUTOR: I' Office H2O a ourewateraartners" Off ice E120 9850 North Michigan Road,Suite E Carmel,IN 46032 www.officeh2o.com (866)621-6910 Customer Name: I1 Ji IAA_f LLL, +.0 A q()111S6 DELIVERY AND ACCEPTANCE CERTIFICATE Customer and Distributor certify that all Equipment described in the Rental Agreement has been delivered and properly installed according to the Rental Agreement. Customer acknowledges that the Equipment is in good condition and is performing satisfactorily. Customer hereby accepts the equipment unconditionally and irrevocably in accordance with the Rental Agreement and understands that invoicing will commence upon receipt of this Certificate showing execution by Customer. Distributor acknowledges its obligation to provide maintenance services in accordance with any maintenance agreement separately entered into between Distributor and Customer. Customer: Do not sign this Certificate until you have actually received, installed, inspected and accepted all of the Equipment described in the Rental Agreement. lek: ��G� c)? A} Customer(Authorized Signature) Name(Print) Title Date ail 7 c Qr 1 -- .6/010L� {Distributor(Authori d Signature) Name(P int) Title L ate MODEL SERIAL # ev - /c ? Ikytis Cvi"/of4ls Cr 1,t.)e l/,syS /1 Sys Cv Sys ❑ See attached equipment schedule (if applicable). Statement of Assurance Distributor is committed to providing you with quality equipment,quality service and quality drinking water. If for any reason you are not satisfied with the performance of your equipment or the level of service provided, please contact us directly for prompt assistance. Reference Number (for internal use only) Form ST-105 Indiana Department of Revenue Stae Form(R5i16--17)49065 General Sales Tax Exemption Certificate Indiana registered retail merchants and businesses located outside Indiana may use this certificate.The claimed exemption must be allowed by Indiana code. Exemption statutes of other states are not valid for purchases from Indiana vendors.This exemption certificate can not be issued for the purchase of Utilities, Vehicles, Watercraft,or Aircraft. Purchaser must be registered with the Department of Revenue or the appropriate taxing authority of the purchaser's state of residence. Sales tax must be charged unless all information in each section is fully completed by the purchaser.Purchasers not able to provide all required information must pay the tax and may file a claim for refund(Form GA-110L)directly with the Department of Revenue.A valid certificate also serves as an exemption certificate for(1)county innkeeper's tax and(2)local food and beverage tax. Name of Purchaser:Cityof Jeffersonville i, Business Address: 500 Quartermaster City: Jeffersonville State:IN ZIP Code: 47130 ° Purchaser must provide minimum of one ID number below? •. Provide your Indiana Registered Retail Merchant's Certificate TID and LOC Number as shown on your Certificate. o'. TID Number(10 digits):0031209530 -LOC Number(3 digits): 010 g If not registered with the Indiana DOR,provide your State Tax ID Number from another State m *See instructions on the reverse side if you do not have either number. State ID Number: 1356001067 State of Issue:INDIANA cv o Is this a EI blanket purchase exemption request or a C single purchase exemption request? (check one) Description of items to be purchased: co Purchaser must indicate the type of exemption being claimed for this purchase.(check one or explain) Sales to a retailer,wholesaler,or manufacturer for resale only. C Sale of manufacturing machinery,tools,and equipment to be used directly in direct production. C Sales to nonprofit organizations claiming exemption pursuant to Sales Tax Information Bulletin#10.(May not be used for personal hotel rooms and meals.) C Sales of tangible personal property predominately used(greater then 50 percent)in providing public transportation-provide USDOT Number.A person or corporation who is hauling under someone else's motor carrier authority,or has a contract as a school bus operator,must provide their SSN or FID Number in lieu of a State ID Number in Section 1. USDOT Number: Sales to persons,occupationally engaged as farmers,to be used directly in production of agricultural products for sale. Note:A farmer not possessing a State Business License Number may enter a FID Number or a SSN in lieu of a State ID Number in Section 1. ES Sales to a contractor for exempt projects(such as public schools,government,or nonprofits). C Sales to Indiana Governmental Units(agencies,cities,towns, municipalities,public schools,and state universities). E Sales to the United States Federal Government-show agency name. Note:A U.S.Government agency should enter its Federal Identification Number(FID)in Section 1 in lieu of a State ID Number. 0 Other-explain. I hereby certify under the penalties of perjury that the property purchased by the use of this exemption certificate is to be used for an exempt purpose pursuant to the State Gross Retail Sales Tax Act,Indiana Code 6-2.5,and the item purchased is not a utility, vehicle,watercraft,or aircraft. O I confirm my understanding that misuse,(either negligent or intentional),and/or fraudulent use of this certificate may subject both V, me personally and/or the business entity I represent to the im+osition of tax, interest,and civil and/or criminal penalties. rn Signature of Purchaser: rw' Date: 1/2/2018 Printed Name: Heather Metcalf Title:City Controller The Indiana Department of Revenue may request verification of registration in another state if you are an out-of-state purchaser. Seller must keep this certificate on file to support exempt sales.