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2015 IS Lease pay request 1 040815 Lease 2015 — Sch # 25 (Information and Communications Systems) Payment Request # / 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 5, 2015 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: 64-5Y-ie,,y( S— f`0-'✓ Amount: 3 33 948-. O 7 Description of Equipment Item Cost: N D4( ix ,< V r Dated: 'Y"2- -- LESSEE: City of Carmel One Civic Square Carmel,IN ' 032 ie By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE l Hewlett E •Microsoft p�'�10 •Juniper \N eGly Mitel• REMIT TO:.Matrix Integration LLC • 417 Main Street, Jasper IN 47546 • Phone 812-634-1550 • Fax 812-634-2573 Bill toy j�` Ship to a City of Carmel City of Carmel Terry Crockett Terry Crockett Carmel. City Hall 31 1st Ave NW One Civic Square One Civic Square Carmel IN 46032 Carmel IN 46032 (317) 571-2567 Ext. 0000 PurchaseHOrder# Account ID 4 Salesperson ShipawVia F,, Terms Invoice# Invoice Date Page 32667 1CARMEL BALLINGER DROP SHIP Net 30 INV1057363 3/16/2015 1 Quan ; Item# , Description , 'i'74 ' ' , Serial # Unit Price r Extended Price .a. 1, NX-3160 NUTANIX - Virtual Computing Platform -- $27,646.36 $27,646.36 1 C-MEM-126C13-30$0 NUTANIX - Config: Includes 1280B (8x16 $0.00 $0.00 1 S-GULL-3160-1YR NUTANIX - 1YR COLD System support for $3,317.56 $3,317.56 2 C-CBL-3M-SFP+-SFPNUTANIX - Cable 3m SFP+ to SFP+ $77.19 $154.38 1 NOS-3.5.1 NUTANIX - OPERATING SYSTEM VERSION 3.5 $0.00 $0.00 1 CNS-TNST-1-NC NUTANIX - OFFERING: Nutanix cluster de $1,739.77 $1,739.77 1 CNS-T&E-NC NUTANIX - Time and Expense (T&E) . Pric $750.00 $750.00 FREIGHT $320.00 $320.00 1 1 Card/Check#,I. ORDH AQ108202 Subtotal $33,928.07 V V -3 THANK YOU!! ENR / BWL Misc $0.00 ICOMMENTS..;'' Tax $0.00 „ .h Freight $0.00 Due: 9/15/20.5 Total $33,928.07 Batch ID: 3 16 15BWL Payment Received $0.00 0' :'� Invoice Balance Due $33,928.07 ,,� , � ix° y�'1^`..� 7,P it,'a' :�r .r, R'""' Lyra. ,r . Please pay from this.invoice All past due charges are hsubtect to a `13I4°Ao per month penalty SAVE'THIS RECEIPTLIT IS hYOUR PROOF OF PURCHASE FOR WARRANTY REPAIRS `Spa.xF k� VV S`a R x y ryTerms sand.conditions on.-the rever�se8 sidL;` . ,,L •;'`;. 411' White Copy Customer Yellow Copy File PLEASE PAY FROM THIS INVOICE WWW.MATRIXINTEGRATION.COM A COW ICI® EVIDENCE OF COMMERCIAL PROPERTY INSURANCE 4/1/2015` ) THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW.THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE ADDITIONAL INTEREST. PRODUCER NAME, PHONE 3 17-817-5136 COMPANY NAME AND ADDRESS NAIC NO: 25674 CONTACT PERSON AND ADDRESS (A/C,No,Ext): Hylant Group Inc Travelers Prop Cas Co of Amer 301 Pennsylvania Parkway, 4201 Indianapolis IN 46280 _(A/C,Nol:3 17-817-5151 pDDRIESS:marianne.uban@hylant.corn IF MULTIPLE COMPANIES,COMPLETE SEPARATE FORM FOR EACH CODE: SUB CODE: POLICY TYPE AGENCY PACKAGE POLICY CUSTOMER ID II: NAMED INSURED AND ADDRESS LOAN NUMBER POLICY NUMBER City of Carmel H630581M4076TIL15 One Civic Square Carmel, IN 46032 EFFECTIVE DATE EXPIRATION DATE 01 2015 01/01/2016 CONTINUED 01 01 01 / / / / TERRMMINATTED ED C IF CHECKED ADDITIONAL NAMED INSURED(S) THIS REPLACES PRIOR EVIDENCE DATED: SEE REMARKS PROPERTY INFORMATION(Use REMARKS on page 2,if more space is required) IX BUILDING OR ❑ BUSINESS PERSONAL PROPERTY LOCATIO WOESC RIPTION SEE SCHEDULE ATTACHED IF APPLICABLE 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 EVIDENCE OF PROPERTY INSURANCE 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. COVERAGE INFORMATION PERILS INSURED I BASIC I BROAD X SPECIAL COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: $ BED: 25,000 YES NO N/A BUSINESS INCOME ❑ RENTAL VALUE X If YES,LIMIT: 29,000,000 1 Actual Loss Sustained;#of months: BLANKET COVERAGE X If YES,indicate value(s)reported on property identified above:$ TERRORISM COVERAGE X Attach Disclosure Notice/DEC IS THERE A TERRORISM-SPECIFIC EXCLUSION? X IS DOMESTIC TERRORISM EXCLUDED? X LIMITED FUNGUS COVERAGE X If YES,LIMIT: 25,000 DED: 25,000 FUNGUS EXCLUSION(If"YES",specify organization's form used) X REPLACEMENT COST X AGREED VALUE X COINSURANCE X If YES, EQUIPMENT BREAKDOWN(If Applicable) X If YES,LIMIT: POLICY LIMIT BED: 25,000 ORDINANCE OR LAW -Coverage for loss to undamaged portion of bldg x If YES,LIMIT: 2 50,0 0 0 DED: 25,000 -Demolition Costs X If YES,LIMIT: 250,000 DED: 25,000 -Incr.Cost of Construction X If YES,LIMIT: 250,000 DED: 25,000 EARTH MOVEMENT(If Applicable) X If YES,LIMIT: 10,000,000 BED: 50,000 FLOOD(If Applicable) X If YES,LIMIT: 10,000,000 DED: 50,000 WIND/HAIL(If Subject to Different Provisions) x If YES,LIMIT: BED: PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE HOLDER PRIOR TO LOSS X CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ADDITIONAL INTEREST MORTGAGEE _ CONTRACT OF SALE LENDER SERVICING AGENT NAME AND ADDRESS LENDERS LOSS PAYABLE X Loss Payee NAME AND ADDRESS The Huntington National Bank & it's Assignora & Assignees c/o American Lease Insurance 654 Amherst Rd. , Ste. 335 Sunderland MA 01375 AUTHORIZED REPRESENTATIVE r /Phyt Page 1 of 2 ©2003-2011 ACORD CORPORATION. All rights reserved. ACORD 28(2011/11) The ACORD name and logo are registered marks of ACORD EVIDENCE OF COMMERCIAL PROPERTY INSURANCE REMARKS-Including Special Conditions(Use only if more space is required) BLANKET REAL & PERSONAL PROPERTY LIMIT: $400,152,920. SPECIFIC LIMIT REAL & PERSONAL PROPERTY TOTAL: $1,475,444. BLANKET LIMIT STREET LIGHTS: $3,599,500; BLANKET LIMIT TRAFFIC SIGNALS $3,278,642. ACTUAL CASH VALUE AND 90% COINSURANCE APPLY TO THE SPECIFIC LIMT REAL & PERSONAL PROPERTY. FLOOD SUB-LIMIT APPLIES TO CERTAIN LOCATIONS. ANY LOCATION IN FEMA ZONE A OR V IS EXCLUDED FROM FLOOD COVERAGE. CONTRACTORS EQUIPMENT LIMIT: $3,071,364; MISC. SCHEDULE EQUIPMENT LIMIT: $4,906.092; COMPUTERIZED BUSINESS EQUIPMENT LIMIT: $685,600; COMMERCIAL ARTICLES LIMIT: $1,148,203; FINE ARTS LIMIT; $1,509,975 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 ACORD 28(2011!11) Page 2 of 2