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2014 Police Schedule 17 pay request 6 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-06 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 18,2014 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. Payee: Mill Supplies, Inc Amount: $689.00 Description of Equipment Item Cost: Aluminum Saddle Box Dated: May 28,2014 LESSEE: City of Carmel One Civic Square Carmel,1N) (032 , ,rAtiOje , By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Mill Supplies, Inc P.O. Box 11286 Fort Wayne, IN 46857 PAGE I IS P.O. Box 11286 INVOICE Fort Wayne, IN 46857 Mill Supplies,Inc M'd,�,al SuppI;, 260-4848566 CAR347 2280533-01 2280533-01 BILL SHIP TO: TO: CARMEL POLICE DEPARTMENT CARMEL POLICE DEPARTMENT 3 CIVIC SQUARE 3 CIVIC SQUARE CARMEL IN 46032 CARMEL IN 46032 CUSTOMER P.O.NO. 31956 CUSTOMER P.O.NO. 31956 »;:INV..._E N .....'A$:»#>#>::;s:......: 1 SNIN::>»>':>:<:»::: His R::1Jti7E?: :: .... .. ......>::<:<:>?:<::>%:':``::<:»`::>:«<:>)A......:> 2280533-01 208 05/20/14 420 31956 05/20/14 MggEggagingEgUROggnIMEIEgganaggiliglffanallalMingOARIMPAIMMEgIggglIMMITPRIPRiieaff WILL CALL REFER TO 2279181 B 1 «2% z< .ITi ::.p,:::;:.:-:":::`: ::';,•,:iii`:??,, ::i:::;:£:,; ?; UNIT:i8 .::.::::...:::::::•;:;:�:::.;:.,.:,..:::.;:;;;:::,:<;:::...:::::.:;::.pl&R�:>::>:::>:>;:<fi?>sEE:a:?:<::5:. f.EMLZ;typE�liNp'p1;5GR1'T1pPf......:...::...... ..... .0 ..:....:..UNIT PRIt;E:;>:;::?<:::�<: :;:? ?AMOUNT MISCELLANEOUS FUEL SURCHARGE MAY APPLY 1 1 *WEA 127-5-02 EA 689.0000 689.00 Saddle Box - Aluminum coDEE%nANAnoN 4 *** THIS IS YOUR INVOICE *** SUB TOTAL 689.00 STATE TA%APPLICABLE C •CONSIDER COMPLETE 1 �[FD.gTNER TA%APPLICABLE 0 -DIRECT SNIPMEITT �/.{� """"-' ":�'•� MISC CHARGE I STATE IS FEDERAL TAX f •FACTORY MINIMUM ti!N77 IIY Gi:[�l�f.1 • B BALANCE RACE ORDERED II RETURNED cn. - TELE.CHARGE FREIGHT.TOTAL NET TERMS: INV 30 DUE: 06/19/14 FED./OTHER TAX *** ORDER COMPLETED *** STATEjTAX PAYMENT RECD. 0.00 TOTPL AMT:;'DUE 689 XLOPTB 8/88 689.00 A°R I$ CERTIFICATE OF LIABILITY INSURANCE 4/21/2014 Del 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 301 Pennsylvania Parkway,#201 E-MAIL PHONE O Extr317 817 5136 (A/C,No):311 81 7-515 1 Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIL II 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 NUMBER:970829312 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 IN R I vo POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDDIYYYY) (MMIDD/YYYY) A GENERAL LIABILITY Y ZLP14T62033 1/1/2014 1/1/2015 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) $Excluded PERSONAL&ADV INJURY $2,000,900 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $2,000,000 POLICY j T. LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 COMBINkD SINGLE LIMIT (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 (Peracciden0 - X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED _ RETENTION$ $ WORKERS COMPENSATION II WC STATU-AND EMPLOYERS'EMPLOYERS'LIABILITY YIN l TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N!A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If es,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 EquipmentNehicles 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. C/o American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 tAiu ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD