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2014 Police Schedule 17 pay request 22 041315 16Lease 2014 — Sch # 17 (Police Dept.) Payment Request # 2014-22 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: Safety Systems Amount: $32,085.16 Description: Safety equipment for new vehicles LESSEE: City of Carmel One Civic Square Carmel,IN 46 2 By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Safety Systems 4113 Turner Rd Richmond, IN 47374 i'AGE 1 Safety Systems 'NtilTIPOCit, 4113 Turner Road Richmond, IN 47374 Invoice Number: 15032512 Invoice Date: Mar 25, 2015 Page: 1 Voice: 765-935-3566 Original Fax: 765-935-9713 '."'4}7' - III TO z t- M, 5hrp tb '`w�� � �u .r?.r+'9RF.z. .. .N.1+:' ,. '4`.f�.i.S-.:. ... ''i, a }� .+ [ rr r -. x3-:?ra!'s, _ .:� .ar� �kkx`-s :u ��"s'6��a,K�x._.A ..�;.k a..._ _ �n Carmel Police Department Carmel Police Department 3 Civic Square 3 Civic Square ATTN: Pat Young ATTN: Pat Young Carmel, IN 46032 Carmel, IN 46032 +y , Carmel P.D. 32264 Net 30 Days ' fi :.F tir�y"^=*ly 8 4�,: e�.M >r >r;s '*'is.; 5 ^ ;s.,. ,..:n� "4>cz ..{ tr', .p, k4 r ^^ �i�,k^; ai as ;4;4:Sales Rep,ID,G °> 3 ShippW g Method y ! " ¢ K xShDate ��:.., ..,...,.k. _.,t 9 -: , .s. [}. _..r. - .. Hand Deliver 4/24/15 Description . G x 01;Unit Price �nAmount a.. _ .3 .e w w S*:_ r M.xtt. .. •Y 2.. ,>2. _�_. k 4.00 Slicktop I unmarked package 2,140.38 8,561.52 10.00 Integrity package 2,170.00 21,700.00 13.00 Whelen TIR3 -Red 46.00 598.00 13.00 Whelen TIR3- Blue 46.00 598.00 80.00 Whelen Vertex LED White 55.50 4,440.00 (rjtll'116f(\;-f--- Subtotal 35,897.52 Sales Tax Total Invoice Amount 35,897.52 Check/Credit Memo No: Payment/Credit Applied TOTAL by r ' _ 4,s 4 <y '- °3< '11 067'S1` Acc•RD e CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYYY) 1/13/2015 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). PRODUCER CONTACT NAME: Marianne Uban Hylant Group (NC.No.Est1:317-817-5136 Fn c,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 5615 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_ I SUBR R TYPE OF INSURANCE N l M M!DDIYYT POLICY EXP SR WVD POLICY NUMBER POLICY LTR Y I I M MI DDlYYYY) LIMITS A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY PR S l RENTED PREMISES(Ea occurrence) $50,000 CLAIMS-MADE Ix OCCUR MED EXP(Any one person) $0 PERSONAL&ADVINJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO n LOC $ 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 AUTOS AUTOS BODILY INJURY(Per accident) $ 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'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE N!A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) F.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 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. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD