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Home My WebLink About2014 Street Department schedule 22 pay request 3 042315 Lease 2014 — Soh # 22 (Street Dept.) Payment Request # EXHIBIT A PAYMENT REQUEST FORM/ACCEPTANCE CERTIFICATE The Escrow Agent is hereby requested to pay from the Acquisition Fund established by the Escrow Agreement dated as of October 1, 2014 by and among the Escrow Agent, the Lessee and Lessor, to the person or corporation designated below as Payee, the sum set forth below in payment(of all/of a portion)of the Acquisition Costs described below. The amount shown below is due and payable under a purchase order or contract with respect to the Equipment described below and has not formed the basis of any prior request for payment. In addition,the undersigned acknowledges delivery,installation and receipt in good condition,and hereby accepts the Equipment described on the attached invoices.„ 1 Payee: 7� �t+� �� ` {fit"1(, 111 _. Amount: )' Description of Equipment Item Cost: (��y (' .1...3 Dated: LESSEE: City of Carmel One Civic Square Carmel, IN 46()32 N By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE E TRUCK COUNTRY - INDIANAPOLIS taagaM jea 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 FR lCIITLlNER-9IIA1ITY Tt ltf8 Phone;(8130)899-1.533 DIVISION Of ;l i ,ion; Fax: (317)7814387 Vehicle Invoice/Bill Of Sale Sold Ins Deal Number V�1301000645 CITY OF CARMEL -STREET Invoice Date: 4122/15 1 CIVIC SQ. Cis Id 116233 CARMEL,IN 46032 Cash Price Vehicle: 811760,00 Added Equipment: 0.00 Registration Fee: 0.00 Sales Tax: 0.00 Excise Tax: 0.00 Service Contracts: 0.00 Title Fee: 0.00 Loan Filing Fee: 0.00 License Fee: 0.00 Counter Service Fee 0.00 Doc Fee: 0.00 Doe Fee Discount: 0.00 Total Price: 811760.00 Trade Allowance: 0.00 Payoff on Trade: 0.00 Equity in Trade: 0.00 Payment with Order Cash 0.00 Rebates 0,00 Total Down: 0.00 Amount Due: 811760.00 Lien Holder: *Please see attached addendum for the list of vehicles* Sales Person Signature: Customer Signature: Page 1 of 2 TRUCK COUNTRY- INDIANAPOLIS gate:001P.M 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 fA'E16NIUMfMN-DUALITY INAIOER Phone:(800)899-1533 U.VISION Of NA ' fff_I' Fax:(317) 781-4376 miry ruvbsraMa ADDENDUM Sold To: CITY OF CARMEL-STREET Deal# VM301000645 I CIVIC SQ. CARMEL,IN 46032 Description of Purchased Vehicle(s): UnUd ModeIYear VI ;'1akg Model Wine Price 395469 15 I FVHG5CYI FHOS0905 FTL 108SD 162,352.00 395470 15 IFVHG5CY3FHGS0906 FIL 108SD 162,352.00 395471 15 I FVHG5CY5FI1GS0907 I'L'L 108SD 162,352.00 395472 15 I FVFIG5CY7FI IGS0908 FTL 108SD 162,352.00 397890 15 IFVHG5CY9F1-IGS0909 FTL 108SD 162,352.00 TOTAL 817,760.00 Sales Person Signature: Customer Signature: nature:g Page 2of2 filet dba � itli 1851 Sfoo� Thompsas Freghr�Rd.ner �� /ndiana�olis;tN 4fi2fi7 800-899-1533 (317) 782-4037 fax FAMILY OWNED SINCE 195$ Re: Wire Instructions - Equipment Funding BANK NAME: FIFTH THIRD BANK 251 N. ILLINOIS STREET, SUITE 1200 INDIANAPOLIS, IN 46204 Sharon Chandler, 317-383-5317 ROUTING NO: 042000314 Wires 074908594 ACH ACCOUNT NO: 7653181417 ACCOUNT NAME: TRUCK COUNTRY OF INDIANA, INC. OBI: PLEASE INCLUDE LAST 6 OF THE VEHICLE ID NUMBER AND CUSTOMER NAME IN THE OTHER BENEFICIARY INFORMATION If you have questions please contact your sales representative A RD CERTIFICATE OF LIABILITY INSURANCE 4/23/2015 D/YYTY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Marianne Uban ._._.____.._.._...._....._.._............ Hylant Group (Alc°.No.an:317-817-5136 �,__ (ac,.Not 3_1..7_-$1 :5.1.61___. 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADD RESS;trtarianne.,uba_ta yia.aLcQm ( INSURER(S)AFFORDING COVERAGE I NAIC a _._.._.........._._._.__._.._. INSURER A:Charter Oalt_Eice..in...u.ran.ce....Co...........................................__.._._...._...15615 INSUREDCARME80 INSURER B.................._..°--_-- _._...__.._..._.....__........._.._............................- City of Carmel INSURER C: One Civic Square INSURER 0: Carmel, IN 46032 __.___ ._._._._......_.............._.___ ....... INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1721923242 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ('� ';AbDL SUBRj ----""'- -� POLICY EFF i POLICY EXP INSR LTR 1 TYPE OF INSURANCE I INSR_MD! POLICY NUMBER I/MM/DD/YYYYI i(MMIDDIYYYY), LIMITS A f GENERAL LIABILITY ZLP14T82033 (U1/2015 111;2016 iEACH OCCURRENCE ' $2,000,000 . i I t)urA"o'E 1.O RENTED X COMMERCIAL GENERAL_L.IABILIIY � _P ....$_ErkoccL r e lce__ SS ,00 0 1 CLAIMS-MADE X 1 OCCUR ! MED EXP AAny one person) i SO , PERSONAL&ADV INJURY $2,000.000 —. • !GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER I PRODUCTS-COMPIOP AGO ;$2,000,000 I. I PRO- ' $ POLICY JFCT I .LOC ' .(:OMHINtU ylNtalh LIMIT 1 1/112016 A AUTOMOBILE LIABILITY H8103036P64ACOF15 /112015 ,SEa accident)_ $2,000,000 i X ANY AUTO BODILY INJURY(Per person) S ALL OWNED I -1 SCHEDULED I 1 BODILY INJURY(Per accident) $ AUTOS i AUTOS ON-O PROPERTY DAMAGE '-1 NON-OWNED (Per accident) I HIRED AUTOS I — AUTUT AUTOS ....___......_.....:$_. .'__.................. X Comp IX Coll i ;Comp/CollOed 52,500 .__.,.. UMBRELLA LIAR 1 _ OCCUR j E , EACH OCCURRENCE $ I i � 1 EXCESS LIAB i .CLAIMS-MADE � ! AGGREGATE f$ ,___ DED RETENTION$ ; S I I WC TATU- OTH-1 1 AND EMPLOYERS'LIABILITY Y r N COMPENSATION ? I _ZQ.....LIMITS...._...__.I__EH_)_-----.._..............._.. 1 AND EMPLOYERS'LIABILITY Y)N _ h E 1. EACH ACCIDENT' $ ANY PROPRIETOPJFARTNER/EXECUTIVE N l A 1 OFFICER/MEMBER EXCLUDED/ (Mandatory In NH) j E L.DISEASE.EA EMPLOYEE, $ ll es,describe under E.L DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS below 1 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,It more space Is required) ADDITIONAL NAMED INSUREDS: CARMEL CLAY PARKS BUILDING CORPORATION; CARMEL CLAY BOARD OF PARKS& RECREATION;CARMEL REDEVELOPMENT COMMISSION;CARMEL REDEVELOPMENT AUTHORITY;CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION Certificate Holder is named as Loss Payee Re:2015 Ford F250#40970 and 2015 Ford F250#40967, 2015 Ford F250#0969,2015 Ford F250#0968 (City of Carmel Street Dept.) Re:2015 Subaru Forester#4258,2015 Subaru Forester#6408,2015 Subaru Forester#6484,2015 Subaru Forester#7856 (Community See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Huntington National Bank ACCORDANCE WITH THE POLICY PROVISIONS. 105 East 4th Street(CND1) Cincinnati OH 45202 AUTHORIZED REPRESENTATIVE fr{1.2.i' t' I l� U 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CARME80 LOC#: `� GD ACORD ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Hylant Group City of Carmel One Civic Square POUCY NUMBER Carmel, IN 46032 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Services-Bldg Inspectors) Re: 2014 Ford F150#5094,2014 Ford F150#5093(DOC) Re:2015 Freightliner Trk#1 FVHG5CY1 FHGS0905,2015 Freightliner Trk#1 FVHG5CY3FHGS0906, 2015 Freightliner Trk #1FVHG5CY5FHGS0907,2015 Freightliner Trk #1FVHG5CY7FHGS0908, 2015 Freightliner Trk#1FVHG5CY9FHGS0909(Street Dept.) • ACORD 101 (2008101) CO 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD