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2014 Police Schedule 17 pay request 7 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-07 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: Safety Systems Amount: $883.20 Description of Equipment Item Cost: Motorcycle Lighting Dated: May 28, 2014 LESSEE: City of Carmel One Civic Square Carmel,IN7 132 _ -n M By: Name: Diana Cordray ; Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Safety Systems 4113 Turner Road Richmond, IN 47374 PAGE I Safety Systems 1,ik 4 41 rei% %.„.„„ I 4113 Turner Road Richmond, IN 47374 Invoice Number: 1452015 Invoice Date: May 20, 2014 Page: 1 Voice: 765-935-3566 Duplicate Fax: 76 5-9 35-971 3 Carmel Police Department 3 Civic Square ATTN: Pat Young Carmel, IN 46032 Customer ID Customer P0 , Payment Terms Carmel P.D. 31957 Net 30 Days Sales Rep ID Shipping Method Ship Date Due Date Hand Deliver 6/19/14 Quantity Item Description UnitPrice Amount 2.00 Whelen Motorcycle Lighting MO6MJ2 441.60 883.20 Subtotal 883.20 Sales Tax Total Invoice Amount 883.20 Check/Credit Memo No: Payment/Credit Applied TOTAL 88320 ACCoRD CERTIFICATE OF LIABILITY INSURANCE 4/21/2014 DPI 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 IA/cC.No.Fxt(:317-817-5136 FAX X 17 817 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:C arter Oak Fire Ins Iurance Co 125615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: 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 -ADDL SUBR I POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY Y IZLP14T62033 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) SExcluded 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 PRO- JECT LOC A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 C O aBIINdEDOSIAGLE LIMIT 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 I(MILS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/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 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 rtkitt I O ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD