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2014 Police department schedule 17 pay request 1 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-01 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 February 14, 2013 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: Don Hinds Ford, Inc. Amount: $25,913.00 Description of Equipment Item Cost: 2014 Ford F150 Truck Dated: April 14, 2014 LESSEE: City of Carmel One Civic Square Carmel,IN +032 By: . Name: t,fa'�G {, �_ Title: Clerk re,:- fr (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Don Hinds Ford, Inc. 12610 Ford Drive Fishers, In 46038 PAGE 1 J l ® DATE(MM/DD/YYYY) AW ° CERTIFICATE OF LIABILITY INSURANCE 3/25/2013 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). CONTACT PRODUCER NAME: MarianrleUban Hylant Group Inc-Indianapolis 301 Pennsylvania Parkway,#201 E-MAILo.Exti:317 817 5136 I ialc,No):317-817 5151 Indianapolis IN 46280 ADDRESS:marianne.uban a( hylant.com INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARM E8O INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1271512319 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 IADDLTSUBRI I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYYI (MMIDDIYYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2013 1/1/2014 EACH OCCURRENCE 52,000,000 DAMAGE TO RENTED © COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) 850,000 ■■ CLAIMS-MADE X OCCUR MED EXP(Any one person) SExcluded ■ PERSONAL&ADV INJURY S2,000,000 ■ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG {$2,000,000 POLICY JECOT LOC I $ A AUTOMOBILE LIABILITY H8103036P64ACOF13 1/1/2013 1/1/2014 COMBINED SINGLE LIMI (Ea accident) 1 82,000,000 ® ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS PROPERTY DAMAGE ■ HIRED AUTOS AUTOS ED (Per accident) X Comp X Coll Comp/Coll Ded I $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY I YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE_$ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S 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 Re: Various Police Equipment/Vehicles 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&its assignors and ACCORDANCE WITH THE POLICY PROVISIONS. assignees c/o American Lease Insurance AUTHORIZED REPRESENTATIVE 654 Amherst Rd., Ste. 335 Sunderland MA 01375 C921416 &41-1.44(__,) ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 0 %A. l P i.3 dr OneKind To Be Titled INVOICE City of Carmel Stock Date Address No. FT1484 4/9/2014 1 Civic Square Miles Del. 35 Date 4/10/2014 City/State Carmel, IN Zip 46032 � Serial No. Telephone 317-571-2600 1F TFVVI1EF 6 E F B 4 8 5 9 0 Home Work Year 2014 Make Ford Model F150 Type XL CREW Color GRAY Purchase Federal ID# 35-60000972 Order# Factory Installed Equipment Trade Ins: Insurance Co.Name Price $ 25,911.75 Agent's Name Trade In Agent's Address Agent's Phone Policy# Trading Difference $ 25,911.75 Year Make Model Color 7%Sales Tax EXEMPT 0 2-DR ® 4-DR Tire Tax of of tires 5 $ 1.25 Delivery Cost Serial No. ' A/C ri Auto n Cyls Total Cash Difference $ 25,913.00 . Mileage Balance Owed on Used Vehicle $ - Total Balance Due $ 25,913.00 Balance Lein Date Less Cash Rec Owed Holder - Unpaid Balance of Cash Price $ 25,913.00 Salesman Aproved Customer . Date by DON HINDS FORD, INC. 12610 Ford Drive Phone (317)849-9000 x1290 Fishers, IN 46038 Toll Free (800)644-4637 x1290 john @donhindsford.com Direct Phone&Fax 317-813-1319