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2014 Police Schedule 17 pay request 16 16Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-16 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: Express Graphics Amount: $1,236.00 Invoice: 86719 86803 Description of Equipment Item Cost: Lettering for new Police vehicles • Dated: August 14, 2014 LESSEE: City of Carmel One Civic Square Carmel,' 46032 By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Express Graphics 620 S Range Line Rd, Suite D Carmel, IN 46032 PAGE 1 P?ii invoice Express Graphics 620 S. Range Line Rd. Suite D Carmel, IN 46032 ph. (317) 580-9500 fax. (317) 580-9550 Page: 1 of 1 Invoice No. 86719 Order Date: 7/29/2014 Teresa Anderson Invoice Date: 7/29/2014 1 Carmel Police Dept. Terms: Net30 I 3 CIVIC SQUARE CARMEL, IN 46032 Ordered by: Johnathon Foster PO/Reference: I Salesperson: Vanessa Suiter l Amount Due: $618.00 —_ I Joh Description: Police V ehicle Letter ng - Interceptor Fleet 2014 11 Units #91 &#10 _ ^�_ LQty Description Sides Size Unit Cost Total 2 Vehicle Lettering (2) Interceptor Police Vehicles to be 1 0"x0" $309.00 $618.00 lettered on 2 sides and rear wl High Grade Exterior Graphics. I Produced & Installed. Units#91 & #10 Notes: (Carmel Police Interceptor Vechicle Graphics-New 2014 Shield) Units#91 &#10 Notes: Install Date:7/29114 Line Item Total: $618.00 Remit Payment to' Tax Exempt Amt: $618.00 a Shipping Info: Install at Street Department Y Subtotal: $618.00 Garage Express Graphics Taxes: $0.00 620 S. Range Line Rd. Total: $618.00 Carmel, IN 46032 ph. (317) 580-9500 Total Payments: $0.00 fax. (317) 580-9550 Balance Due: $618.00 Please include invoice #with payment. A late fee of 1.5%per month will be added to all past due amounts. Invoice Express Graphics 620 S. Range Line Rd. Suite D ,. 1 if Carmel, IN 46032 ph. (317) 580-9500 fax. (317) 580-9550 Page: 1 of 1 Invoice No. 86803 Order Date: 8/5/2014 Teresa Anderson I Invoice Date: 8/5/2014 Carmel Police Dept. 3 CIVIC SQUARE Terms: Net30 CARMEL, IN 46032 Ordered by: Johnathon Foster PO/Reference: Salesperson: Vanessa Suiter Amount Due: $618.00 Job Description: Police Vehicle Lettering - Interceptor Fleet 2014/1 Units #1 & #20 Qty Description Sides Size Unit Cost Total! 2 Vehicle Lettering (2) Interceptor Police Vehicles to be 1 0"x0" $309.00 $618.00 lettered on 2 sides and rear w/ High Grade Exterior Graphics. Produced & Installed. Units#1 &#20 Notes: (Carmel Police Interceptor Vechicle Graphics-New 2014 Shield) Units#1 &#20 Notes: Install Date:8/5/14 Line Item Total: $618.00 Remit Payment to: Tax Exempt Amt: $618.00 Shipping Info: Install at Street Department y Subtotal: $618.00 Garage Express Graphics Taxes: $0.00 620 S. Range Line Rd. Total: $618.00 Carmel, IN 46032 ph. (317) 580-9500 Total Payments: $0.00 fax. (317) 580-9550 Balance Due: $618.00 Please include invoice#with payment. A late fee of 1.5%per month will be added to all past due amounts. ACCPRO CERTIFICATE OF LIABILITY INSURANCE 4/21/2014(MMIDD/YYTY) 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/ No.ONE Eet):317-817-5136 FAX No):317-6 7-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER a Charter Oa. - tl. . +l - • 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 POLICY EFF ' POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) 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&ADVINJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO- JECT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF14 1/1/2014 1/1/2015 COMBINED 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 (Per accident) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ,TORY LIMITS ER - ANY PROPRIETOR/PARTNER/EXECUTIVE 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 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. Go American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 O ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD