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2014 Police Schedule 17 pay request 2 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-02 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: Dell Marketing L.P. Amount: $8,823.06 Description of Equipment Item Cost: Microsoft Office Pro License x 27 Dated: April 16, 2014 LESSEE: City of Carmel One Civic Square Carmel,IN •6032 By: r`/ f .•x 7 L Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Dell Marketing L.P. C/O Dell USA L.P. PO Box 802816 Chicago, IL 606802816 i'AGF I This is your INVOICE Page 1 01 1 DOLL FID Number: 74-2616805 Customer Number: 98574231 Invoice Number: XJCXT4RT8 Sales Rep: Brenda Wade Purchase Order: 31926 For Sales: (800)981-3355 Order Number: 590169005 Invoice Date: 03/28/14 Sales Fax: (800)433-9527 Order Date: 03/27/14 Payment Terms: NET DUE 30 DAYS Customer Service: (800)981-3355 Due Date: 04/27/14 Technical Support: (800)822-8965 83 01 0 01 00 N Shipped Via: STANDARD GROUND Dell Online: www.dell.com Waybill Number: MS-VIRTUAL SOLD TO: SHIP TO: ACCOUNTS PAYABLE Terry Crockett IN CITY OF CARMEL CARMEL POLICE DEPT ONE CIVIC SQUARE 3 CIVIC SQUARE CARMEL,IN 46032 CARMEL,IN 460322584 PLEASE REVIEW DELLS TERMS&CONDITIONS OF SALE AND POLICIES AT www.dell.comfus/policy OR UPON REQUEST,WHICH GOVERN THIS TRANSACTION Ordered Shipped Item Number Description Unit Unit Price Amount 27 27 A6591288 VLA OFFICE PRO PLUS 2013 EA 326.78 8,823.06 MfgPartNum,79P-04712 MfgName:MICROSOFT CORPORATION 1 1 A3458532 ELECTRONIC LICENSE CONFIRMATIO N elec dwrld only EA - - MfgPartNum:ELC MfgName.DELL SOFTWARE Ship.&/or Handing $ 0.00 Subtotal $ 8,823.06 FOR SHIPMENTS TO CALIFORNIA,A STATE ENVIRONMENTAL FEE OF UP TO$5 PER ITEM WILL BE ADDED TO INVOICE Taxable Tax S FOR ALL ORDERS CONTAINING A DISPLAY GREATER THAN 4 INCHES.PLEASE KEEP ORIGINAL BOX FOR ALL RETURN $ 0.00 $ 0.00 S.COMPREHENSIVE,ONLINE CUSTOMER CARE INFORMATION AND ASSISTANCE IS A CLICK AWAY AT WWW_DELL.COMIPU ENVIRO FEE 5 0.00 BLIC-ECARE TO ANSWER A VARIETY OF QUESTIONS REGARDING YOUR DELL ORDER. Invoice Total $ 8,823.06 DETACH AT LINE AND RETURN WITH PAYMENT Ship.&/or Handling $ 0.00 Invoice Number. XJCXT4RT8 Subtotal $ 8,823.06 DOLL Customer Name. IN CITY OF CARMEL Taxable Tax Customer Number 98574231 S 000 $ 0.00 Purchase Order 31926 ENVIRO FEE S 0.00 Order Number 590169005 Invoice Total $ 8,823.06 MAKE CHECK PAYABLE/REMIT TO: $ DELL MARKETING L.P. 0/0 DELL USA L.P. $ PO BOX 802816 Balance Due $ 8,823.06 CHICAGO,IL.606802816 Amount Enclosed 000XJCXT4RT800000008823068300985742311 l 0.�l CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) CO �R L.----' 4/17/2014 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 CONTACT NAME: Marianne Uban Hylant Group A1CON o Extr317-817-5136 FAX 0):317-817-5151 301 Pennsylvania Parkway, #201 E-MAIL Indianapolis IN 46280 ADDRESSmarianne,uban lant.com INS URER(S)AFFORDING COVERAGE NAIC B INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER 0: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE AMBER: 4507391 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, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDOIYYYY) (MMIDDIYYYYI LIMITS A GENERAL LIABILITY Y ZLP14T62033 1/1/2014 1/1/2015 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED X _ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000 ICLAIMS-MADE X OCCUR MED EXP(Any one person) $Excluded 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 PFRT LOC COMBINED SINGLE LIMi I $ • A AUTOMOBILE LIABILITY HO103036P64ACOF14 1(1)2014 111/2015 JEa 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 accidert) 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 I N .T_ORY LIMIT$ ER ANY PROPRIETOR/PARTNERIEXECUTIVE NIA 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 $ DESCRIPTION OF OPERATIONS I 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 is an Additional Insured re:Various Police Equipment/Vehicles II 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& It's Assignors&Assignees ACCORDANCE WITH THE POLICY PROVISIONS. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 ri fk ft Z 41 )i ± 1 I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD