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Home My WebLink About2015 Engineering Schedule 28 pay request 1 092915 Lease 2015 — Sch # 28 (Engineering Dept.) Payment Request # I 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 August 15, 2015 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. Payee: Pearson Ford, 10650 North Michigan Road Zionsville, IN 46077 Amount: $24'153.08 $19,653.08 (1,23/ L 11? $19,653.08 Description of Equipment Item Cost: 2016 Ford Escape Dated: t v i J LESSEE: City of Carmel One Civic Square Carmel,IN 032 "I By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGEI .. ...... ._.. ,i;:;?,„;Ii;.,..4;.;,„!,.::::,,., 1,,,i;,,,v.,:oifv,.,7,,:..,,A..4::""..,,,,,.0..4,•.,,,,,.,?,,,,,,,,,,*,,,''T:'::::::'1-''"?,..':'?,1.,'''''-',..t:f''''''''''"':::t1.2-',?*!t.t..''''''-:;:'!LILT'''l'i' ',•`';':.:'1',,f..%...:::::%,,V 41,1$1:: ;:::,:,Vti01%;,7,ieiNe'!-. ..'.V.1/A,";',g '':-.1.4:*,!:siili*.::;g'!1'49:0114iSli(ifPf4;Al.1 t EitriP icAttiliFiertiGliVriPO RAVE VEHICLEITTFig").:c7,-.!:4.;::2S451,,,111,,ti'7c2,-.‘'.;:'• _ :,.„.4.,..:.....,„.....:....r.i.:_,..,_..._,..::i._......:.....,_.,...._.,___ '::.,...„.71.......,....-....._. tA.,...,;,: ,., ...,.... ....,.;,..-. :./...,,k".,.:i':, ''T7f# /.: :Vaga' : ;22V'afZ ;;;-f-W:Aftggif5 ;::' . -4,,g05:- ';':ftVAR :c :'1'.':iTt14c::Alf0 :.''" 16%ft ;,7A9.1..iilitgA;; $.-t:-AgO,P-4.--,'-'4''''.'.:',441:: -,*:.,-..- :.*!,.:„:'-'2:•!IM:W,;:::',,,‘,14-1.?A4-W,. .:ii.iI-W, 1:1WrIi. '-::',VA"" - ,- t-t,,,,-.•..a\ , ,--..,,,,,..,g,:f.,;,, ,::;iiike.o.,:$7.,0.;;;fg:,igo, r•,.. ,...(,_ ,-...: !---.,---,-- 1-1.7.,lif;:,,,,,i;;Iiti:o. ;:ii,,,.?.04,itygit,; ..,,,,!,.0,,,,rap,„q f-,t,-. '''. '--• ' , .•••• ,!.:,: t...f,.:, Li::ii.,:...! ;1'. '.14.1,,,, -4,••,--qc.%. ,,:!. ..t:'',‘,V:E• '''','"P i,.., k .,,,,,,!,.......,,,,,-.0..... ::: ---.;., .,.,..x.,r;..-2,,..., -. . v.'s,.,,,,__„w4 .i.-..,..,iimaiiii w-oim NvqaI.,93---,,,,%,_----..Ninw eart, ..-... DATE INVOICE NO. ......„ ........„ iftf JULY 30,2015 .:- UA55303 0 • - !'..Vt7,','4 ........ VEHICLE IDENTIFICATION NO. , .YEAR MAKE 1FMCU9GX6GUA55303 2016 FORD : ;:-.•i::::% ; . • . •;.;;',..",..f"., ; ' BODY TYPE . - SHIPPINGWEIGHT . 105 ESCAPE SE 4WD 4DR . 3547 LBS . •.•ay., f: i:1 H P(S.A.E) G,V W. HO CYLS SERIES OR MODEL ike 15.48 4760 LBS 4 U9G7 NOMINAL TONNAGE • : 1/2 .. ,... •• .,. .fgN: . .... ... Aiit,,, ,:„.„.,.... I the undersigned authorized representative of the company v firm or corporation named beloW, hereby cer- tify that the ne.,v eh ic le described above is the property o. tke said company,firm or corporation and is: transferred on the above date and under the Invoice Number indicated to the following distributor or dealer. iitig .,.... •,i 4'0 •16 ,,' ;;;.•.:' .11:7gri 1 NAME OF DISTRIBUTOR,DEALER,ETC -.1 Milli .-:1 Pearson Ford, Inc, g ;. 10650NorthMichigan Road .. ... . 4i-. Zionsville . IN 46077 - ' .•.,..•.• ,.....„,. . e.iliV 'ff.firl 4-7F033 • - . ' ...„. It is further certified that this was the first transfer of such new motor vehicle in ordinary trade and commerce. MEMO DATA . ; B3 6 36 0150i li0 ... ....,, - FORD MOTOR COMPANY li:-q;li FINANCE SOURCE 000001 BY Ford Motor Credit Co BRADLEY m GAYT sI,SECRETARY - ,(AGENT): .....:11;...! 'Fitij1,7P.O. Box 1732; Room Atai, Dearborn MI ; DEARBORN, MICHIGAN 111 •, ,g',..; :- ; : • 48121 • -- : CITY-STATE ,,...... „.. . 6:4:..:...li ......., .1111 11111111111111111111111111111111111111111 11 11,-:if?...,i.;:-..,,,..:i•i.:.:.7::F:,:. -.....................................................................;;:::- ' .-:::-;:-ii -T:,. .,--§i7' :-/i'::::---:'-i':::--Z,-.,:, :: :: ::;;;-:.j.-:::.7,:;::iTti-:::T:..Y,-;"ii,T,.;)'!..,„ flO:A§f! 2Einsl___,,F421P.,i.igtgEOW:W4fERMo..4%42F:Rg§ o-0.))12.W. ;8e,.NP..-mP.N&i :,:;M:Mti21 n - Each undersigned selleRcertifles to the best of:his knowledge,information and belief under penalty ohlaw that the•Yehicle is new.and has not been registeredir z { • this or any state at the time.of delivery and the vehicle is not subject to any security interests other than those disclos.edhereinand warrant title to the vehicle FOR VALUER�E?CEIVEE+D I TRANSFER THE VEHICLE DESCRIBED ON THE FACE OF THIS CERTIFICATE TO:. " NAME.OF ( �Y�CY�I �•.J`w PURCHASERO. _�— w°' ADDRESS al I G � —mc— 1:�N • -{ �Q�L.+ •I•certify tot best•of my knOwle h the�d e eading is/� -�7 � No Tenths E �:w DEALER earson ��d`t ib. DLV I2� l ff mz NAME OF DEALERSHIP • DEALERS LICENSE NUMBER: Being duly sworn�at flat e:statements net y;¢'s State of forth are true and correct Subscnb rid sworn to me=" before this '-' day of •' > N A County of • '" • :_. NotaryPublic 'tee -- USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION' w PURCHASER(S) - -f "3'4:w•(13 ADDRESS ZFI certify to the best of my knowledge that:the odometer reading is : • • No Tenths ".O. ' — .�w DEALER BY. W ro 2 NAME OF DEALERSHIP DEALERS LICENSE NUMBER Being duly sworn upon oath says that the statements sett m"FZ forth are true and correct.Subscribed and sworn to me . fry- .State of .: ' • • mto before this day of -• p rn' County of _ Notary Public- • • Z G.. USENOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION - W ¢i7 'NAME OF W'w w PURCHASER(S) W ADDRESS : . O o"D z:z I certify to the.best of my knowledgethat.the odometer reading is No Tenths DEALER - • , '. ,-BY , • co p] m " • NAME OF DEALERSHIP DEALERS LICENSE NUMBER-- Being duly sworn Upon hath Says that-the statements Set' tA' State hofforth are true and correct.Subscribed and sworn tome before •CJ - this i - > -. �'� :�� daybf :: � �-. Z p to County of - Notary Public. • USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION • lL it NAME OF • F w w PURCHASER(B) - ADDRESS • Z • NO Tenths-. Z.Z I certify to the best of my knowledge that the odometer reading is W 'j . DEALER .. BY (U is NAME OF.DEALERSHIP DEALERS LICENSE NUMBER.. -'Being duly sworn upon oath says that the statements set' O' State'of forth are true and correct.Subscribed and sworn to me O N,to before this day o O pin County of :. . - Notary Public:� O (p _ . USE NOTARIZATION ONIY IF REQUIRED IN TITLING JURISDICTION.' - -Z Federal Law requires you to state the odometer mileage m connection with thetransferof ownership Failure to complete or providing a false,statement may resul H in fines and/or imprisonment ' ` I certify,to the best of my knowledge that the odometer'reading is.the actual mneage of the vehicle unless_use of the:following statements is checked Odometer yr ¢ ." Reading No Tefiths ']The mileage stated is in excess of its mechanical limits `T The odometer reading is not:the actual mileage • • .N/ARNINGOM DOETERDISCREPANCY a N J y Signature(s)of Sellers) Date•of Statement Date of Sale ' I U .Being duly sworn upon oath says that the statements set • p a Panted Name(s)of Sellers}� Dealer's No t- �'lorth arearue and correct:.Subscnbed and sworn to me { 446 r wi¢ Signature of Purchaser(S) • before this day•of r Printed Name(s)of Purchasers) - Notary Public LL p e Company Nam (If Applicable) ..._, • " State of ,._ � Address of Purchaser(s) •' County of ? USE NOTARIZATION ONLY IF REQUIRED IN TIT ING JURISDICTION `_ � "'2ridlien m favor;of `w whose address is ,„. .. /21-1 ci ... .,:',,,,......!,.,..!..'..... *.. .",fee.'1:::t..'V ...'0.:: '.VV,"4.::::::..'V..::::PIA,Y,.....!,.. .*?.10::..' ..:::::*....•.,,:',.:.?..,4n...e.1;1:...'4"..1:;:pp.,,,,,,,,.....!....!•:?........1:1:::,'T.t:' 7:!:?.:11:!;.F.-,:.: ::..,-,:i.,i .". !;'...„_._•:__. .... •;.'._:! i,T.'is'.-;:._* .1.:::•..:!—;"-1-:—:::1".17,_ :'.:::::.. ..„—. .577..‘ 11:...*,''..-;--*:7...i:: ' .;•',ji:"7:itL:..:; !:::',..7::*:!... ..,1....i'.'sifl..:....‘,',..„,'r'*:.'..,,Ii:....:,',,,:,f...‘,' -. ..,1; o::::Iw.,..7.47..A •Vg!'''!,;.V;fil. M:.":%' '',:'ii'll?.4F'fiLN .f.'ij§i'V. ; A7.:f.44t-i. .; ;N'?1.1Sk1:.M0:;i7i',Y:7t: ;;;.W*-; 7 $. 0'Z' O't7 $ Oli*F:ti.i.An7::A5.1 :iWg&7, . ..??.'6A S;.':3!-;"i'•ii..tr,'.2 '' .I2*. ':.3S'' i .1-9}.0. -;i...t.2 k -..,I.Mt3Stii'. : -:-.....!..._.:.'f.:'1 ..- ..Y2:01:::11C., 7.Xkl.', ;'31C-1 -t,..7.. .:;-t.l.t::- E ./Z :c... 2.....; AV:i**,?-i;'' '.P . ;"*;-:- ...Liti-'-2. :'':-.. --..-.---- .. '-'•-. '-'7-- -:.,......' r,,,;;iv.%,.;;;I.At ../....4.,l,!::::;.”" -4,Ti., -."4-•...,...J.-''' ..... .i.,-- - :..;,illi:;tilli;igft'.;$ttit14.4tiii. :''.. .".04,'...ie't.I'':i''''::.-:-0'''-74''''--- . - '-'-'-'-:.. -...._....-'',%\,.1,•;,..,: ..0 7:,..;.%.1t7ii:‘,..k:Oili...,ik ;66:,-iiV 1-'1(.0111:16?! :Mdri4 -':141'. 4.1 Pf:gS-- , I, 4„;''' ..,Th-it.J,,.. .";'v:'/4711i)!Zn' Nr!-",>•,,Q;;-,,,,. . - io .6: >,, .. .,,-.-._. :,.....,.....,..1,1.4.., ..• 4-'I'-'-''''. 4:iA6i .''''''''' $k ,74:7: ,,,,,,,, 4e. :: . : • : -4?:, -.:, -. . ...,..v-.--.., , • : . - .. i :: ,' . :-:::.1i:iii: .„,.., DATE . ----;.— . INVOICE NO. : 1 z.,1,:.•.• OfIii JULY 30,2015 :: : : •UA55304 .: .0 Xr'd VEHICLE IDENTIFICATION NO . YEAR• MAKE 1FMCU9GX8GUA55304 2016 FORD ..,,:. BODY TYPE : : SHIPPING WEIGHT -.....,„, q."iii7.' • 105 ESCAPE SE 4WD 4DR . 3547 :LBS. ftii ' 'Alli:ig• H P(S.A.E) G,V.W.R. NO CYLS SERIES OR MODEL ......„ .,:.'e.:...r, 15. 48 4760 LBS 4 U9G7 NOMINAL TONNAGE : . . . 1/2 . :• ' , ,::',:Eff.:i:: .....,... " ,a,J ... .. .„....: . 4iiV ' I, the undersigned authorized representative of the company,firm or corporation named below, hereby cer-. tify that the new vehicle described above is the property of the said company firm or Corporation and is lF.3-illl-g:' transferred on the above date land under the Invoice Number indicated to the following distributor or dealer. NAME OF DISTRIBUTOR DEALER,ETC . , • ,,,,.....:: --1' Pearson Ford,' Inc, zii,•.•.•,,?:;! : ' Wizz! 10650 North Michigan Road .:. ..... R* -..Zionsville '. IN 46077 Kli,k1 , J. ...—/.... . .. ' aaA'':1 'EMT: ........, 47F033 : if..7FI i It is further certified that this was the first transfer of such new motor vehicle in ordinary trade and coMmerce. ,„ . t§; MEMO DATA ' .,,,, .. .. 1 B 3 6 3 b 0 1 52 • .i,9 . AFORD MOTOR COMPANY g' „ :‘:,........9 FINANCE SOURCE 000001 .,,., ....,::,1 BY (AA. Lt "Ford Motor Motor Credit Co ' , .- - - BRADLEY M.GAYT ,SECRETARY C., ' (AGENT) P.O. Box 1732 , Room -. :luli , Dearborn ,. . MI ' DEARBORN, MICHIGAN .z.....Y!'a .• „ 48121 ......, . . . , CITY-STATE .„,....„ - . .„.. . ill'i 1 1111111111111111 11111111.111111111111111111111111111 ' ...y, w.:;, -,,: :,.,,•,,0„,:qm§- ,,ii -,,20., ,,,?4,,Ii.vg, § y,_.gt:- .2.0.0 .,,,80.,,, ,A.::fy.f2m,,, ,,,m0 ,.,:k.o.,g4,,„0 .„ •,. .... .. .,........... .....„. ,...._...., ....,, ..„.....••••.. .......... ,.......... ...._.... .,., ,............ .....,. „......•.., .•. ... ............. .,...... .• .. . . d Each undersigned seller certifies to the best•of his knowledge,information,and belief under penalty_otlaw that the iehicle is new:and,has not been registered in rE this or any state at the time,of delivery and the'vehicle is not subject to any security interests other than those disclosed herein and warrant title to the vehicle FOR VALUE RECEIVED I TRANSFER THEVEHICLE ON THE'FACE OF THIS'CERTIFICATE TO . -gat NAME OF , J•WPURCHASER(S); aT :w •ADDRESS z Z I certify to the beet of my knowledge that the odometer reading is • • • No Tenths JO w DEALER . . Y r a . • • i, BY ® - t -.-NAME OFD •L R•Hi" '.UCENSE NUMBER' Being duly sworn up oath se t the statements set.-- - 2� State of • forthare true and correct Subscn ed and sworn to me- , r -< before this.; •'.' day of • �p vt County of - f :, ' - Notary:Public • . Q • USE NOTARIZATION'ONLY IF REQUIRED IN TITLING JURISDICTION .. - •oi: NAME OF - - `' LU w PURCHASER(S) ADDRESS -z z ':I certify to the best of my kiiowtedgethat the odometer reading is Nolenths U )': 'W. DEALER <' '.' BY: - - Z -m 2 NAME OF DEALERSHIP j DEALER'S LICENSE NUMBER Being duly sworn upon oath says that the statements set:` ill _ m' F¢-OZ 'State of % >: forth are true and correct.Subscribed and sworn to me LL Co w before this day of F— in G :County of ':- • Notary Public Z, USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION LLA W 'c •NAME OF W'. U,¢ rD .w w PURCHASER(S) CC ,o ADDRESS 0' 3 3z,Z I certify to the best of my knowledge that the odometer reading is • • - No Tenths ,_' tL 01= • U -'176 DEALER BY: '` m -, • NAME OF DEALERSHIP DEALER'S UCENSE NUMBER Being duly seem,.upon oath says that the Statements netX. rn; F st Slate of •- - ,..... forth are true and,correct Subs'otcribed and:sworn to ine -: Q > .rn N. _ ,_ before this day `< Z :p co County of Notary Public CO Q. .. USE.NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION : -- LeiCrj Z o, NAME OF • • w w •PURCHASER(S) ;. - • • • ADDRESS • z z• I certify to the best of my knowledge that the odometer reading.IS No Tenths • 2 •.DEALER • • By — U • • NAME OF DEALERSHIP 'DEALERS LICENSE NUMBER'•- Being duly sworn upon oath says that the Statements set 0: U CZ7 State of • forth are true and correct Subscnbed and sworn to me 0 • before this day:of' O p to County of- • ary NotPublic CO G .' USE NOTARIZATION OND'IF-REQUIRED IN TITLING JURISDICTION . _ 2 Federal law requires you to state the odometer mileage m coenection with theetransfer of ownershipcom Failure to plete or providing a false;statement may result `� I— - In fines and/or imprisonment.'- " - ...ownership: = •' - I a� I seriify to•the best of my knowledgethat the odometer reading is the actual mileage of the vehicle unless,one of the following statements Is checked Odometer ^ • w _Readin No Tenths The mileage stated is In excess of its rr echanicet limits The odometer,readin isnot the actual`milea e ❑ 9 g 9 ' �.: g 'WARNINGGODOMETER DISCREPANCY v N Srgnature(s)of Sellers) 'Detect Statement Date of Sale q to y ,Being duly sworn upon oath says that the statements set p a• Printed Name(s)of Seller(sj Dealers No forth are true and correct:Subscribed and seem:tome w¢ Signature Of purchaser(S)- ` before this day of Printed Names)of Purchaser(s) Notary Pubic Company Name(1f Applicable) • State of - 3u^ Address of Purchaser(s) County of •USE NOTARIZATION ONLY IF REOUIRED IN TITLING JURISDICTION tat lien In favor of _ (�_3� Q 1� -1 whose address is #s == 2nd-lien mr favor of .Z,. . 'w whose address is • • 2 cf '3 1.CERHFICA' OF QRIG1177 N)F:OF1QVEH1CLEi' ' ..... .,„.. M1i;I� A��e��li/ t!S% : : : � z::,:„:..:, ..„,. ri DATE - .. - INVOICE h10 J. .i JULY 30',2015 UA55305 0 VEHICLE IDENTIFICATION NO. - YEAR MAKE • - - - ,_ _' : ' 1FMCU9GXXGUA55305 2016 FORD I ; - BODY TYPE - SHIPPING 105 ESCAPE SE 4WD 4DR 3547 LBS. J: : H.P.(S.A E.) G.V.WR NO.CYLS SERIES OR MODEL 15.48 4760 LBS 4 U9G7 NOMINAL TONNAGE 1/2 , ft;:, r 5' I the undersigned'authorized.:representative:of.the company firm or corporation named below, hereby cer- 1. tify that the new vehicle described above is the property of the said company;firm:or corporation and is:. =.! transferred on the above date and under the Invoice Number indicated to the following distributor or dealer. \ '- NAME OF DISTRIBUTOR,'DEALER,ETC.iii Pearson Ford, Inc: NO-il :‘,'..,.:.:.,.'11.ir.i, 10650 North Michigan Road Zionsville IN. 46077 M `iiii, �. • �. .; 47F033 • It is further certified that this was the first transfer of such new motor vehicle in ordinary trade and commerce. l: B r , 1� MEMO DATA 836360154 ). r FORD MOTOR COMPANY FINANCE SOURCE . .„ , ...,, ",... ....... .. .. , 000001 /JJ'1n . . .. ,.„ .. ...., . BY • Ford Motor Credit Co BRADLEY M.GAYT d,SECRETARY (AGENT) P.0. Box 1732, Room J. Dearborn MI : DEARBORN,. MICHIGAN . 48121 CITY STATE , \ribs111111111111111111111111111111111111111111111111111111111111111 IIH VIII IIID VIII VIII III)IIII Ltii.4.1 - •*.* Nil\ :a'- is Ji- ., 1 li±P / - ti Each undersigned.seller certiflesio the best-or his knowledge,information:and belief under penalty.of law.that the-Jehicle is new and.has not-been registered-in c` this or any state at the time:of delivery and the vehicle is not subject to any security interests other than those disclosed herein and warrarit.title to the vehicle 4t FOR VALUE RECEIVED I TRANSFER THE VEHICLE:DESCRIBED ON THE FACEOF THIS CERTIFICATE TO '"` x w¢ PURCHASER(S) r•_W ADDRESS ® i. % . \ •• z Z I certify to the f of my knowledge that the odometer reading is �+ No Tenths dpi �. sW DEALER Pearson Ford nc_ t71 1 BY:rCI ' T n M. NAME OF DEALERSHIP DEALER'S LICENSE NUMBER Being duly sworn up oath:say th t the statements.set } J" ¢(, State of forth are true and correct:Subscnped and sworn to me 4V before this day of `' o in County of -• < `: - Notary Public > . C USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION " . '0 ' " ¢CSI NAME OF- I •w cc .PURCHASER(S) - J W ) 0 wa m ADDRESS 5°'Z Z I certify to the best of my knowledge that the odometer reading is 1 No Tenths: �g -0I- 4 en :D W DEALER BY ; Z C,m Z. NAME OF DEALERSHIP . DEALERS LICENSE NUMBER Being duly sworn upon oath says that the-statements set.. 2 t m..¢a State of . forth are true arid correct Subscribed and sworn to me.. • 1.:.; L y rn < _ before this --> day Of D F 0 C County of - • Notary PublicQ Z, N USEOTARIZATtON ONLY IF REQUIRED IN TITLING JURISDICTION f V t¢io NAME OF I U),J w PURCHASER(S) W ADDRESS = .--. - O • i 3 z,Z I certify to thebest of my knowledge that the odometer reading is • - No Tenths =: C7 til. DP:w DEALER 6Y: J I m o 2 ... NAME OF DEALERSHIP DEALERS LICENSE NUMBER Being duly sworn upon path says that the statements set • U) �(Z,ry State of forth are true and corredt Subscribed and Sworn to:me 0 I ' . .-.before this : : Z a< County of Notary Public .m I USE.NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION - w 1 H, w w _PURCHASER(S) I , w ADDRESS r. O_o _W. ZZ Z•• I certify to the best of my knowledge that the odometer reading is No:Tenths cI- 1 W mow. :DEALER Bl 0 209 Z' NAME OF DEALERSHIP 'DEALERS LICENSE NUMBER Being duly sworn upon oath says that the Statements set ;O, 0''¢C7 State of forth are true and correct Subscnbed and sworn to me O y rn - :; ; before this <- day of • l ,Q O o rn- County of - Notary Public O Cn ,G ' -•USE NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION • .' • x, I Federal Law requires you to'state the odometer mileage in_connection with;the-transfer of ownership.Failure to complete or providing a false;statement may result sFrB H in fines and/or imprisonment r - �'y='' I certify to the best of my knowledge that the odometer reading is the actual mileage of the vehicle unless one of the following statements is checked.Odometer �,,�,, 1 W • Reading • No Tenths ]The mileage stated is In excess of Its mechanical m ID The odometer reading is not the actual mileage m}, vh .WARNING ODOMETER DISCREPANCY .,o a Q „7:v Signature(s)of Seller(s) —Date of Date of Sale •1�t�-�� 1 -a :.Being duly sworn upon oath says that the statements set ' 0 a Printed Names)of Seller(s) Dealer's No .,H : • forthi are true and correct Subscribed and sworn to me s:w'¢ Signature of;Purchaser(s)• r before this day of - --- S OLLOPrinted Names)of Purchaser(s) ` Notary.Pub(c 7 ' -0 Company Name(If Applicable) '- State of - - { i fir.. 'Address of Purchaser(s) County of USE'NOTARIZATION ONLY IF REQUIRED IN TITLING JURISDICTION .',,'., W. t.1st lien in favor of'' he- �LtL� Ke QpQ1f r K ' O whose address is . � 6 { •' � 1a- _Q _202 0 �Z' 2ndlieninfavorof - ``W W �iF whose address is 3 EL "VEHICLE ORDER AGREEMENT-, ' Date: 8/31/2015 Pearson Ford, Inc. Name: City of Carmel Attention: Kate Lustig 10650 North Michigan Road Address: 0 INVOICE Zionsville, Indiana 46077 City: Carmel, In 46032 317.873.3333 www.pearsonford.net Phone: 317-571-2432 Fax: - VEHICLEfORDER INFORMATION ;.,r MSRP/Selling Price $ $24,153.08 n New Used ❑Demo Optional Accessories: Year: 02016 Make: 2016 Ford Escape 1. 0 $ 0.00 Model: 0 Color: White 2. 0 $ 0.00 Stock#: 24900 Salesperson: P. Lennen 3. 0 $ 0.00 VIN #: 1 FMCU9GX6GUA55303 4 0 $ 0.00 MILEAGE: Actual/Not Actual 5 0 $ 0.00 *NOTES: 6 $ 0.00 Sub-total $ 24,153.08 TRADE ALLOWANCE: (-) $ : !'-i'''''.,'''''''''''''':''' Fleet Discount 0.00 THE INFORMATION YOU SEE ONTHE WINDOW FORM FOR�THIS VEHICLE IS PRT OF (-) $ THIS CONTRACT INFORMATION ONTHEWIND"OW FORM OVER RIDES ANY-4-.-- Fleet Incentive: (-) $ 0.00 CONTGRARY-PROVISIONS IN THE VEHICLE ORDER AGREEMENT •:---0e.:7.'-''f: ..& .,�. • .... Other (-) $ 0.00 TRADE-IN VEHICLE INFORMATION TOTAL SELLING PRICE $ 24,153.08 (1)Year: Make: 7% Sales Tax: (+) $ Model: Color: TRADE PAYOFF (+) $ VIN#: Service Contract (+) $ Mileage: Tire Tax (+) $ Amount of Lien: Luxury Tax (+) $ Lienholder: Capped Acq Fee: (+) $ 0.00_ Address: Other Amounts Owed (+) $ Total amount due (_) $ 24,153.08 Phone: Down payment/ Deposit (-) $ 0.00 Stock#: Rebate (-) $ 0.00 (2) Year: Make: $ Model: Color: AMOUNT DUE AT DELIVERY $ 24,153.08 VIN#: MILEAGE: Actual/Not Actual Amount of Lien: By signing this "Vehicle Order Agreement" I /We Lienholder: agree to the terms and conditions herein: Address: Company Name: Oil Y OF COLI - et Phone X .g Authorized Signature: VI� � L`j'�� CuTRADE;IN CERTIFICATION stomer agrees to deliver to DeadP` ler good and marketable titie(s) to the-trade-in vehicle(s)has part of�the consideration{for,=the vehicle,ordered at the-:time of;`delivery. Customer warrants that the trade in'vehicle(s)are owned"only by customer-and arefree"and: clear:of all hens and encumbrances except aas otherwise"stated::in writing:herein:`Customer certifie0hat the:airbags;,safety and emissions equipment in the trade in"vehicle(s)"has/have never;-been and is/are not required to be titled,:m;any"state as defective rebuild salvage flood;, lemon or buy back vehicle and have never been damaged ^ ' :.:4 ',`S ES VEHICLE ORDER AGREEMENT. Date: 8/31/2015 •Pearson Ford,Inc. Name: City of Carmel Attention: Kate Lustig 10650 North Michigan Road Address: 0 INVOICE Zionsville, Indiana 46077 City: Carmel, In 46032 317.873.3333 www.pearsonford.net Phone: 317-571-2432 Fax: - VEHICLE''ORDER INFORMATION K ,I MSRP/Selling Price $ $24,153.08 n New Used ❑Demo Optional Accessories: Year: 02016 Make: 2016 Ford Escape 1. 0 $ 0.00 Model: 0 Color: White 2. 0 $ 0.00 Stock#: 24902 Salesperson: P. Lennen 3. 0 $ 0.00 VIN#: 1 FMCU9GX8GUA55304 4 0 $ 0.00_ MILEAGE: Actual/Not Actual 5 0 $ 0.00 *NOTES: 6 $ 0.00 Sub-total $ 24,153.08 TRADE ALLOWANCE: (-) $ 4,500.00 ''f Fleet Discount THE INFORMATION YOU SEE ON THE WINDOW FORM FOR-THIS VEHICLE b,PART•OF, O $ 0.00 THIS CONTRACT INFORMATION ON'THE WINDOW FORMOVER-RIDES ANY`: Fleet Incentive: (-) $ 0,00 .coNTGR/ARr PROVISIONS IN THE VEHICLE ORDER AGREEMENT f. Other (-) $ 0.00 4_ _-, �_. . .. _z . -: s �, TRADE-IN VEHICLE INFORMATION TOTAL SELLING PRICE $ 19,653.08 (1)Year: Make: 7% Sales Tax: (+) $ Model: Color: TRADE PAYOFF (+) $ VIN#: Service Contract (+) $ Mileage: Tire Tax (+) $ Amount of Lien: Luxury Tax (+) $ Lienholder: Capped Acq Fee: (+) $ 0.00 Address: Other Amounts Owed (+) $ Total amount due (=) $ 19,653.08 Phone: Down payment/Deposit (-) $ 0.00 Stock#: Rebate (-) $ 0.00 (2) Year: Make: $ Model: Color: AMOUNT DUE AT DELIVERY $ 19,653.08 VIN#: MILEAGE: Actual/Not Actual Amount of Lien: By signing this "Vehicle Order Agreement" I /We Lienholder: agree to the terms and conditions herein: Address: Company Name: G+y of ccjrrnel Phone �t (� Authorized Signature: t k4 a ;TRADE IN CERTIFICTION n Customer agrees to deliver tosDealer good clear and marketable title(.) to•the-trade in vehicle(.) as part of the consideration for"the vehicle ordered at the)time.of.delivery." Customer warrants that the trade-in vehicles)are owned only;by customer and are`free.and clear=of all"liens and encumbrances except � � EA 2 c 992 .,VEHICLE ORDER AGREEMENT Date: 8/31/2015 Pearson Ford,Inc. Name: City of Carmel Attention: Kate Lustig 10650 North Michigan Road Address: 0 INVOICE Zionsville, Indiana 46077 City: Carmel, In 46032 317.873.3333 www.pearsonford.net Phone: 317-571-2432 Fax: - VEHICLE ORDER INFORMATION MSRP/Sellin Price _ g $ $24,153.08 n New Used (Demo Optional Accessories: Year: 02016 Make: 2016 Ford Escape 1. 0 $ 0.00_ Model: 0 Color: White 2. 0 $ 0.00 Stock if: 24946 Salesperson: P. Lennen 3. 0 $ 0.00 VIN #: 1 FMCU9GXXGUA55305 4 0 $ 0.00 MILEAGE: Actual/Not Actual 5 0 $ 0.00 *NOTES: 6 $ 0.00 Sub-total $ 24,153.08 TRADE ALLOWANCE: (-) $ 4,500.00 Fleet Discount THE.INFORMATION YOU SEE ON THE WINDOW FORM FORETHIS VEHICLE IS PART of () $ 0.00 •THIS CONTRACT INFORMATION ON THE WINDOW FORM OVERjRIDES ANY: Fleet Incentive: (-) $ 0,00 CONTGRARY.PROVISIONS IN THE VEHICLE ORDER AGREEMENT Y Other O $ 0.00 TRADE-IN VEHICLE INFORMATION TOTAL SELLING PRICE $ 19,653.08. (1)Year: Make: 7% Sales Tax: (+) $ Model: Color: TRADE PAYOFF (+) $ VIN#: Service Contract (+) $ Mileage: Tire Tax (+) $ Amount of Lien: Luxury Tax (+) $ Lienholder: Capped Acq Fee: (+) $ 0.00 Address: Other Amounts Owed (+) $ Total amount due (=) $ 19,653.08 Phone: Down payment/Deposit (-) $ 0.00 Stock #: Rebate (-) $ 0.00 (2) Year: Make: $ Model: Color: AMOUNT DUE AT DELIVERY $ 19,653.08 VIN#: MILEAGE: Actual/Not Actual Amount of Lien: By signing this "Vehicle Order Agreement" I /We Lienholder: agree to the terms and conditions herein: Address: Company Name: City ol- Can--el Phone Authorized Signature: Y ;i �3 ni :$ z� �� 0-RADE'IN CERTIFICATION Customag er rees to deliver to Dealer good; clear and marketable title,(s) to the,'trade m vehicle(s) as "partof the consideration for•tthe vehicle'ordered ats the time of delivery Customer warrants that the trade in••vehicle(s);are w aned only by,cum stoer'and are-free and. clear.;of all liens,and encumbrances except as otherwise stated;;in writing herein:'.,Customer; certifies that the airbags safety and;emissions equipment in the trade in,ve'hicle(s)has/have I never and is/are not required to be titled;in any state as defective rebuild salvage flood, i lemon or buy back vehicle and have.never been damaged r I i ..kf f I 1 ACO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 9/25/2015 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(ies)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 CONTANAME: Marianne Uban Hylant Group (n/CC.NNo.Ext1:317-817-5136 FAX No):317 817 5151 301 Pennsylvania Parkway,#201 DRI Indianapolis IN 46280 nESS:marianne.uban AboNEss:marianne.uban@hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:735580928 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTRINSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) A GENERAL LIABILITY ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $0 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 7 POLICY PFCT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 COMBINED SINGLE LIMI1 (Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) _ X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If 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(CNO1) Cincinnati OH 45202 AUTHORIZED REPRESENTATIVE I /SRL ©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#: ARD ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED Hylant Group City of Carmel POLICY NUMBER One Civic Square 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 #1 FVHG5CY5FHGS0907,2015 Freightliner Trk #1 FVHG5CY7FHGS0908, 2015 Freightliner Trk#1 FVHG5CY9FHGS0909(Street Dept.) 2015 Ford F-250 VIN#1 FTBF2B6OFEC46708 2016 FORD ESCAPE 1 FMCU9GX6GUA55303 2016 FORD ESCAPE 1 FMCU9GX8GUA55304 2016 FORD ESCAPE 1 FMCU9GXXGUA55305 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD