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2014 Police Schedule 17 pay request 15 Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-15 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: AMK Services Amount: $1,525.00 Description of Equipment Item Cost: Universal headrest mounts for E-ticket units Dated: August 4, 2014 LESSEE: City of Carmel One Civic Square Carmel,IN / r 32 By: Name: Diana Cordray 40" Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: AMK Services 4885 N. State Road 9 Anderson, IN 46012 PAGE I L11Ydd1� �gg INVOICE Services,LLC ! VOICE Invoice# 4550 4885 N. State Road 9 Anderson, IN 46012 (765) 642-2995 (765) 642-4875 (0 SOLD Carmel Police Dept. SHIP Carmel Police Dept. TO c/o IS-Communications TO c/o IS-Communications 31 1st Avenue Northwest 31 1st Avenue Northwest Carmel, IN 46032 Carmel, IN 46032 'AO COUNT NO `PO NUMBER RATE SHIPPED `TERIIS,M`' INUOIGEDATE.' .PAGE CARMPD 32071 Net 30 7/23/2014 1 , ITEM;NO ', 7 !ANTITY . DECRIPTION!27 "_ 7 ; x �_.� '�� _1��?�. � .UNIT PRICE :7 7 wE)cTENDED; 21299 5 Universal Headrest Mount 305.00 1,525.00 PO #32071 Sales Tax 0.00 TOTAL AMOUNT 1,525.00 • X a eYx ' .. 3 . Ib.. f- ; ' Please Remit To: AMK Services LLC 9291 Crouse Willison Road Johnstown, OH 43031 This account may be subject to delinquency fee charges of I '/% per month(18%annum)of the unpaid balance,when the invoice becomes 30 days past due. /...', ® DATE(MM/DD/YYYY)• AR o CERTIFICATE OF LIABILITY INSURANCE 4/21/2014 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_IUban H lant Group P PHONE(A/C.No.Exu:317-817-5136 FAX Na)_317-8 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE I NAIC# INSURER A:Charter Oak Fire ns-u_rance_Co 25515 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. ADDL SUBR W POLICY EFF POLICY EXP INSR LTR I TYPE OF INSURANCE I INSR I VD I POLICY NUMBER I(MM/DD/YYYY) (MMIDD/YYYY)I LIMITS A GENERAL LIABILITY Y IZLP14T62033 1/1/2014 11/1/2015 EACH OCCURRENCE $2,000,000 DAMAGE X PREMISES O(Ea occurrence) $50,000 COMMERCIAL GENERAL LIABILITY CLAIMS-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 PRO- $ I POLICY I TA I I LOC COMBINtb31NGLE LIMI I A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 (Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ 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 $ I DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- TORY LIMITS ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/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 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. c/o American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 nikit-t I IQy�t ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD