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2014 Community Service Schedule 21 pay request 2 022415 Lease 2O14 — Sch # 21 (Community Services Dept.) Payment Request # o 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 October 1, 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: � r10,f j 1) 6:0,004 s 46J y'J 3: 1 Amount: rse/ (5) Description of Equipment Item Cost: 1'S1...) Dated: / '� LESSEE: City of Carmel One Civic Square Carmel,IN-46032 • • By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE 1 Stewart, Lisa M From: amy cook <arcook34 @yahoo.com> Sent: Friday, February 20, 2015 10:49 AM To: Stewart, Lisa M Subject: Bank info for Advantage Ford Fifth Third Bank Routing# 074908594 Acct#74811201 Thanks Amy Cook 1 2350 Park Road 4 ° y . S 765-825-0594 Connersville, IN 47331 - `t v, y,, www.advantagefordsales.com . 4y - 416'97 DO I herby agree to purchase from you,under the terms and 571-2418 conditions specified,one motor vehicle as herein described. nv _s= CONTROL NO. 1.41.114k1gOTAN HOUSE SALESPERSON PURCHASER'S CITY OF CARMEL 01/23/15 NAME _ DATE ADDRESS 1 CIVIC SQUARE CITY CARMEL CO. • STATE IN ZIP 46032 E-MAIL PHONE NO. SERIAL NO. MILEAGE STOCK NO. • 1FTFX1EFOEK035093 10 J855R MAKE YEAR r`MODEL BODY STYLE COLOR NEED FORD 2Q14 USED F150 PICKUP OXFORD -WHITE TRADE IN 2008YE R ESCAPEE MODEL CASH DELIVERED PRICE $ 0.2700 OC ACCESSORIES: SERIAL NO. MILEAGE 1FMC'U59H88KD45502 53625 P.O.B. USED CAR ALLOWANCE NAME $ 5500.00 STREET $ DEALER INSTALLED OPTIONS CITY 1 BY TIL ( N/A ) 2 NET EQUITY USED CAR $ ccn('_nn 3 ,DEPOSIT-REC.NO. $ FORD REBATES $ N/A TOTAL CREDIT • $ Sof _nn SUB-TOTAL(Price of Unit,Accessories&Freight) •i -7 l3 P AA BALANCE DUE ON DELIVERY $ NON-REFUNDABLE REC.NO. N/A A DOCUMENTARY FEES $ — • Y TOTAL $ sOt� on TAX(Sales) $ e /r rt ( ) Contract to be paid to h I A TIRE TAX $ In Payment(s)of Due GAP INSURANCE $ r EXTENDED SERVICE PROTECTION E.S.P. $ i'r'n It is understood and agreed that this contract cash delivered price includes money it /A that is owed by Purchaser upon Purchaser's trade-in in excess of the Fair Market TITLE FEES $ Value of that trade-in. This purchase and the financing of this purchase are TOTAL OF ABOVE ITEMS(Delivered Cash Price) $ 727S2Q nt? conditioned upon adding that additional debt to this purchase by either increasing TOTAL CREDIT(Transferred from left column) $ C[;n(•t riff the sale price and/or adjusting the value of the trade-in. BALANCE DUE $ 1 R2AP In "The amount owed upon the trade-in in excess of its Fair Market Value is FINANCE SOURCE: $ NM,' which has been added to this contract." ADDRESS: . WARRANTY INFORMATION t- IF THIS ORDER IS FORA NEW VEHICLE AND THE MANUFACTURER OF THE VEHICLE DOES NOT NEW OR DEMONSTRATOR:If the Vehicle is a new or demonstrator vehicle,the only written- DELIVER SAME TO DEALER,THIS ORDER IS VOID AND BUYER'S DOWN PAYMENT SHALL BE REFUNDED. warranty provided with respect to the Vehicle and factory installed accessories is the most recent applicable printed warranty which is made solely by the Manufacturer of the.Vehicle. 2- IF BUYER FOR ANY REASON,REFUSES DELIVERY,THE DOWN PAYMENT OR DEPOSIT SHALL Dealer installed Accessories are not included in the Manufacturer's warranty on the Vehicle NOT BE REFUNDED,BUT RETAINED BY DEALER,AS LIQUIDATED DAMAGES. and may or may not be included in separate written warranties which are made solely by the Manufacturer of the Accessories. 3- CALCULATION OF FIGURES ON THIS ORDER ARE SUBJECT TO CORRECTION IN THE EVENT OF USED:lithe Vehicle is a used vehicle,the Vehicle is sold by Dealer AS IS-WITH ALL MATHEMATICAL ERROR OR OBVIOUS MISTAKE,AND BOTH BUYER AND SELLER AGREE TO FAULTS.The information you see on the window form for this vehicle.is part of this contract. COOPERATE IN EXECUTION OF ANY DOCUMENTS NECESSARY TO CORRECT SUCH ERROR y p OR MISTAKE,AS WELL AS THE BUYER.AGREES TO PAY TO THE SELLER ANY AMOUNT Information on the window form overrides any contrary provisions in the contract of sale. . NECESSARY TO CORRECT SUCH MISTAKE,AND SELLER AGREES TO REFUND TO BUYER ANY ALL VEHICLES:WHETHER THE VEHICLE IS NEW,A DEMONSTRATOR,OR USED, FUNDS NECESSARY TO CORRECT SUCH MISTAKE, DEALER DISCLAIMS ALL WARRANTIES,WRITTEN,EXPRESS OR IMPLIED,INCLUDING ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE AND 4- IN THE EVENT THE EQUITY OF ANY TRADE-IN IS INCORRECTLY STATED,DEALER,MAY VOID DEALER EXPRESSLY DISCLAIMS ANY LIABILITY TO PURCHASER FOR ANY CONSEQUEN- THIS ORDER. TIAL DAMAGES,LOSS OF TIME OR INCONVENIENCE ARISING OUT OF THE PURCHASE OR OPERATION OF THE VEHICLE. CONTRACTUAL DISCLOSURE STATEMENT FOR USED VEHICLE ONLY. I HAVE READ FRONT AND BACK AND RECEIVED A The information you see on the window form for this vehicle is part of this centred.lniornition on the window COPY OF BUYER'S ORDER AND ACKNOWLEDGE form overrides any contrary provisions in the contract of this sale.' ACCEPTANCE OF VEHICLE DESCRIBED. . I i / t 111. �X n,Pi X /] SALES MANAGER TITLE 0 V 1 THIS ORDER IS NOT VALID UNLESS SIGNED AND ACCEPTED BY DEALER OR HIS AUTHORIZED REPRESENTATIVE .J • 1 � _"_` !,;.101b;: . I A IFICATFOF ORIGIMEOR A UEHICEE m �.1 •• "I • � � CERT a � � � : . , r T r r =:r r r .r r .r ‘,/ tir- i- ,/� /� .\ / i 1 I ,1!! `'Y,�• :1 ,W 111 1 1 •j. _. :: J.I.. Ly.-.4:z.!.: : ee -: . . . . ,--. .r .:' A i n , r � ry I . . . y 1 j . 4 t ,. $'LiWd44y.:,I` q'(". . Tt - - INVOICE NO - NOVEMBER 12,2014 KG35093 0 :J / VEHICLE IDENTIFICATION NO YEAR MAKE , 1FTFX1EFOEKG35093 X2014 :: FORD ; . I ' BODY TYPE - - 'SHIPPING WEIGHT : I 145 F150.:SUPERCAB 4X4 SS 5241 LBS. .• H P(S A.E.) 'G V W.R NO.,CYLS SERIES OR MODEL ; 42 16 7350 •LBS :8 :-X1EN. NOMINAL TONNAGE `' : 1/2 I,the undersigned authorized representative of the company, firm or corporation named below, hereby cer- =� • . :. tify that the new vehicle described above is;the property of te said company,firm s nd ti i or•cor oraon.a pp _ transferred.on°,the above date and under the Invoice Number indicated to;)he:following distributor or dealer. NAME OF DISTRIBUTOR,.DEALER,ETC ' E�. . .. aJ rAPII Advantage FL-Gov' t Sales' :\ 'P. O. BOX 639 Connersville IN 47331 1 47W779 _{ It is further certified that this was the first transfer of such new motor vehicle in ordinary trade and commerce.•' MEMO DATA B34188783 7::L.:1 . .: -- - .. •• - : - :..E.: . FORD MOTOR COMPANY ; 1, FINANCE SOURCE 000001 BY . ' Ford Motor Credit Co BRADLEY NI,. d SECRETARY .. (AGENT) P:O. Box 1732 , Room: . Dearborn MI DEARBORN, MICHIGAN 1 48121 CITY:-STATE ' i(''! ;:::1', 1111111111111111 1111111111 11 11 11]1 1 I1111111111111111111111111111111111111111111111111111 11 1 11111111111 :.;i1:11;:i ° r-.. ? rimer 5-�,,,:..'. ;�. k.^-S:`'"� �a..r 'i 3. .,:``��`;h,t. r �,"��.a,,,,,t--•:',.1'.:=.. .X.'� ::d..., '� - �.}S, ;s;^fi.��ol,.'f �•',..._ p R, ~ p 4]rf'ryr. F - Te Y. t 7f+ '#.;:s. L --SSSI "C a : tit.4..s �, ^i:. XF ''"$t''''' '.-+d,TS r - S ' Each undersigned.se ter ce fies to the i° '91 his knowledge information and belief under;penalty of law chat the vehicle is new and has not been rag stared In' r this or any 5-14''''t at the time of'tle w�ry and_the vehicle rs not subject to X4-1 secunty Interests,oiher than those disclosed herein and Warrarn title`to the vehicle L; fOR VALUE RECEIVED irTRANSFEA i7IE CLE t7ESGHIBED flN TFtE FACE OF THIS CCRTIFICATE TO , " ' a r '`'`,. NAME OF. : 'F ;; ' . ' ( :T �f Ww; PURCHASER(S) t CITYz OF CARP1EL 3; r' ,, � € 1 h© a ADDRESS 1 .CIVIC SQUARE CARMEL, INS 4SO32 x� G ; 4!' fo t C�r t1y to?the beStof'n1 knowledge that the odometerreadingas., 1 ' 1.- No•Tenths i p ADVANTAGE FORD LINCOLN I N1_•:_,'•-e,,;:- 4� i�� ,e®® y' p �„�m ;t a DEALER NAMEOF DEALERSHIP DEALERS LIceNSE NUMBER Bein 3.r jam, '' ft •�' � ' err a 5 z t,# tv folft61, tru c Ibe■- am,.me A� � State of y 8 207 1.4 h y : 1 N; _ B6tor this�.�• da of 11 rn- Co R1 oI as ty r Nota-:- . :c * qa ro 4 S USE MOTAWZATIOti ONLY IF RC-OUIREDIN TITLING JURi$OICFION w° NAME OF .-t Z w¢ PURCHASERS) r 'fY eog ADDRESS y Z Z='. l certify to the best of.my knowledge that the gdemeter reading is ' 1Vo Tenths�� z Oh- M r .z r ri 4 f■`�w DEALER BY y st a w m NAME OF❑EALERSHIP DEALERS LICENSE NUMBER Being duly sworn upon Oath says that the statements set ,C;4¢ Lu ' m z " '' forth are trueand correct Subscribed and sworn to me ¢ State of ,w 'T. tS rn- before ibis day of ',.,:',0-.-','/,''' (),L' '. , o rn" County of "� - _-Notary Public j,; Wa USE NOTAPo ZATION ONLY IF REOtJffED IN TITLNG JURISDICTION ?y ¢rn. NAMPOF ti S w urx" PURCHASERS} ¢y wg ADDRESS 7 's. z Z I certify 1.0,,t,!..7..;e best of my knowledge that the odometer'reading Is No Tenths `' pZ . 1� nom. m ID DFIILER NAME OF OEALER$HIP.• DEAL€RS LICENSE-NUMBER eetng duty sworn upon Oath Says that the statements set x j'. i W a Z ., State of faith are true and correct Subserided ar,d sworn to the a3 x Z,.;,E,,.5,1?--..;~ ` t t s before this .,, day of - ' 20 J p' x Z.i., t-1 County of ..'- i Notary Put llc S .� 4°•. , - :.:k' ., - . ' . .USE NOYARIZATION ONLY tF REOUIREOIN TtTh1NG Jae. . .... ON =c r ., Zi,;4-4`..,'.4-i`.. NAMEOF a ,4 » ,? m5 RQ m¢ PUF1CHASER(S) m SOr wg ....',:j;,8'014 § ,-.''.1;',) { � f Y Z H Z; I certify to the best'ot my know}edge that the odometer;reading is' No Tenths Z ;7 W Off: i i1 "^-t Wf -k` uw. } i ce , i ©FACER NAME OF OEAI.ERSHIP_, DEALER5 LICENBENUMB£R Being dgy sworn Upon Oath say$that'the statements.set r'c 8 z forth are true and correct Subscnbed and Sworn tome ;, yy V<. il 5y7*; State ai .: before this dayjof t 20_ ;7,tyA § O O m'; Counyof Notarypublic { a,� it �x4,` ; ii US£NOTAAISNTIONONLYTF REQUIRED IN"(ITt,ING.JURISDICTIOM ;?A.J r`' . F Federal Lgw requires'.you to state,the odometer mileage Ira cgnnecaori wittt the transfer of owner5f ip Failure to complete at providing a false statement may result O 3 q�1 : to fines and/or imprisonment `' ' f ; } I ce uy,ta the best of.my knowledge that the odometer reading is the,actual mileage of the vehicle unless one of the'following statements is checked Odometer Reading No Ten s 0he m gestated is to excess of its mechanicattimits bTheodometer reedingfs lair theagflial mileage +g WARNING ODOMETER DISCREPANCY i t U�'" Signatures)of Seffer(s t•oj.Statemaht I`z�z g�Ya�F:cif 1�/�9 I - f ,� . ` ? '-: Italy sworn upon,oath gays thatthestatements set`' r y -.: e z0 W., nnteNam (s)of Sei] 74p L?ealet'S Na are t ue bscribed and swain to me 1 a, � �w� ► .Y/��y.TAGE FORD LICOL°N, ethic .� �9fat DEC .zo 20a1A < a< lgntare()of PurE r s aY Pnnted Nsme(s)of P chasers) tY >`x , ` '�r �l'r'l,:::.;;-',.--::::- '' ;CIT{Y :OFD CARIIEL4 NotayPabJc) 5 y r �.�r t �� rssNN e(),ofeSUARE :. CA. .I:N . 4S03Z�r f r<C t -+ :',.. A t USE NOFARIZAT1Q l ONLY IF REQUl5Ef)IN TITLING JLI9lSOlCTI3N 4 t � d t E a ! t"!'"1.1:-.-;,.'-':1 n1 `r J fJ'F r I'it7r.,. ` �J n1i., :f , � t 1st Ilan IrS favor o1 . Whose address Is ra r, a" ;u 4 € z 2nd tlen_E'n favor of c I �1 i� � �, whose address is _ .., i :,.. ,'n}iw •, 5 r _...¢Y I A ° DATE(MMlDD/YYYY)® CERTIFICATE OF LIABILITY INSURANCE 2/24/2015 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). CONTACT PRODUCER NAME: Marianne Uban Hylant Group IA/CC.No.Ext):317-817-5136 (FAX ANe):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:2050719743 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 (MMIDDIYYYYI (MMIDD/YYYY) A GENERAL LIABILITY ZLP14T62033 1/1/2015 1/1/2016 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) $0 PERSONAL&ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/0P AGG $2,000,000 7 POLICY PRO $ JECT LOC A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 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) AUTOS ED X Comp X Coil 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 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/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 named as Loss Payee Re: 2015 Ford F250#40970 and 2015 Ford F250#40967, 2015 Ford F250#0969, 2015 Ford F250#0968 (City of Carmel Street Dept.) See Attached... 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 ACCORDANCE WITH THE POLICY PROVISIONS. 105 East 4th Street(CNO1) Cincinnati OH 45202 AUTHORIZED REPRESENTATIVE /JUJU tilt ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CARME80 LOC#: A O D ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Hylant Group City of Carmel One Civic Square POLICY NUMBER Carmel, IN 46032 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Re: 2015 Subaru Forester#4258, 2015 Subaru Forester#6408,2015 Subaru Forester#6484,2015 Subaru Forester#7856 (Community Services-Bldg Inspectors) Re: 2014 Ford F150#5094, 2014 Ford F150#5093(DOC) • ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD