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2014 Police Schedule 17 pay request 21 021915 16Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-21 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: PVP Communications Amount: $6,740.00 Invoice: 20779 LESSEE: City of Carmel One Civic Square Carmel,MI 46032 By: A • Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: PVP Communications 2310 W 205'h St Torrance, CA 90501 PAGE I Invoice PVP • Invoice# Date COMMUNICATIONS 20779 01/30/2015 2310 W 205th Street Torrance, CA 90501 Customer Ship To Carmel Police Dept Carmel Police Dept 3 Civic Sq 3 Civic Sq Attention: Pat Young Carmel IN 46032-2584 1 Carmel IN 46032-2584 PO# Terms • FOB Vendor# 32233 Net 30 Item I Description Qty I Price Per I Ext. PVHKR-736R10-B/G3 FREEDOM HELMET KIT WITH WIRELESS 2 695.00 1,390.00 SYSTEM CONTROL, PORTABLE ONLY OPERATION, FOR USE WITH SUPER SEER HALF-SHELL HELMETS, DUAL EARPHONE, WITH BLUETOOTH CELL-PHONE INTERFACE PVHKB-736R10-B/G3 FREEDOM HELMET KIT WITH WIRELESS 2 695.00 1,390.00 SYSTEM CONTROL, PORTABLE ONLY OPERATION, FOR USE WITH BELL HALF-SHELL HELMETS, DUAL EARPHONE, WITH BLUETOOTH CELL-PHONE INTERFACE PVSM-APX/G3 FREEDOM SPEAKERMIC WITH WIRELESS 4 295.00 1,180.00 SYSTEM CONTROL, PORTABLE ONLY OPERATION, FOR MOTOROLA APX SERIES RADIOS PV-H-WW/G3 MOTOR KIT, FREEDOM WIRELESS, 4 695.00 2,780.00 PORTABLE ONLY OPERATION ON HARLEY-DAVIDSON MOTOR WITH PA INTERFACE TO WS320 SIREN Invoices are payable in U.S. dollars only.A 1-1/2% per month (18%annum)service Sub-Total: 6,740.00 charge will be added to all accounts not paid within 30 days from the date of invoice. A FREE GROUND 0.00 15% restocking fee will be charged on all returned goods. Items must be returned with original packaging and in"like-new"condition within 60 days.All sales of custom items Taxes 0.00 or special requests are final. Total 6,740.00 Phone# Fax# (310) 212-5432 (310) 212-5492 • • AC • ® CERTIFICATE OF LIABILITY INSURANCE 1/13/2015 D/YYYY) 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 INC.No.Ext):317-817-5136 FAX No):317 817 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:682333440 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 W LIMITS LTR INSR VD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED 850,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) CLAIMS-MADE X OCCUR MED EXP(Any one person) $0 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 —1 POLICY PRO- JECT $ JECT A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 COMBINED SINGLE LIMI (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 LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'UABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A 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/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 ` �4 -,/> Joey ©1988-2010 ACORD CORPORATION. All rights reserved. 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