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2013 Fire department schedule 16 pay request 1 Lease 2013 — Sch # 16 (Fire Dept.) Payment Request # 1 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 2, 2013 by and among the Escrow Agent, the Lessee and Lessor,to the person or corporation designated below as Payee,the sung 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: Gbn qa, I -66453 er, SEIV■ 6 .5 r �� � Amount: ,� '1� Description of Equipment Item Cost: .---7 (knq 11/1U+ -eCt/ 3 - Dated: LESSEE: City of Carmel One Civic Square Carmel, IN 46032 By: / W a:it• � fA Name: 01. a or Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE 1 MES - Indiana Telephone (888)322-8402 6975 Hillsdale Court Fax 317-596-'1701 Indianapolis, IN 46250 Mt IfiltIPAt EMERPENCY SWIM,at.0 Ship To: Invoice CARMEL FD 2 CARMEL CIVIC SQUARE Number PB_496716 cARMEL, IN 46032 Date 2i20/2014 Page .1 of 1 Contact: Sales order Phone' Requisition Your ref. Our ref. kschulthei Bill To: CARMEL. FD Payment Net 30 2 CARMEL CIVIC SQUARE Sales Rep kschulthei CARMEL, IN 46032 Terms of delivery Supplier Pays Freight . . .. . Item number Description Size Color Quantity Unit Unit price Amount INCARM00100 I'104173 Tails Black 69.00 EA 1,308.88 90,312.72 INCARtv100100 LT0417• Tails Black Zipper 82.00 EA 1,294,93 106,184.26 Closure iNCAR M0099 LTO41Z3PB pants Black 151.00 FA 867.76 131,031 76 LT04173 Ref SO 405890 and 427039 ;ales balance Total discount S&H Sales tax TOial 327,528 74 0 00 0.00 0.00 327,528.74 USD 411 returns must be processed within 30 days of receipt and require a return authorization number and are subject to a restocking lee. ACOO DATE{MMIDDlYYYY) R CERTIFICATE OF LIABILITY INSURANCE 3/7/2014 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 NAME: Marianne Uban Hylant Group IA//c°.N o Ext):317-817-5136 Farc,N e):317 817 5151 301 Pennsylvania Parkway,#201 ADDREan @h/lant.com Indianapolis IN 46280 SS:marianne.ub 1NSURER(S)AFFORDING COVERAGE L NAIC 0 INSURER A:Charter Oak Fire Insurance Co 5615 INSURED CARME80 INSURER B: City of Carmel SEE NOTE PAD FOR INSURER C: - I SEE PROPERTY SCHEDULE INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATEp414jUBER: 7761279 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 LTR INSR END POLICY NUMBER I(MMIDOIYYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2014 1/1/2015 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES{Ea occurrence) $50,000 CLAIMS-MADE IX I OCCUR MED EXP(Any one person) $Excluded I PERSONAL BADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 ' GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,000,000 -POLICY ,,IIF� P1 LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 COMHINLU SINGLE LIMII (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 AUUTOS TOS (Per acciderl) _ ,� X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB 1�--{�CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION VVC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY_LIM(LS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE I N!A E,L,EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE$ If yes,describe under DESCRIPTION OF OPERATIONS below EL,DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS 1 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 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MES-Indiana ACCORDANCE WITH THE POLICY PROVISIONS. 6975 Hillsdale Ct Indianapolis IN 46250 AUTHORIZED REPRESENTATIVE az,,,,,..y....t, I ©1988-2010 ACORD CORPORATION. All rights reserved. ■ ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD