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2015 Police Schedule 24 pay request 5 042915 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 5 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: Truck.Vault Amount: $607.28 Description of Equipment Item Cost: Custom Daybox Dated: 04/28/2015 LESSEE: City of Carmel One Civic Square Carmel,1N 46032 Name: iana Cord�ray Title: Clerk Treasurer lif (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Truck Vault P.O. Box 734 Sedro-Woolley, WA 98284-0734 PAGE 1 mylor.r Invoice etce P.O.Box 734 Sedro-Woolley,WA 98284-0734 Invoice Number: 145974 Telephone (360)855.0464 US Toll Free (800)967.8107 Invoice Date: 04/22/15 Facsimile (360)855.0834 Invoice Due Date 05/22/15 Branch 30 Bill To: Ship To: Carmel Police Department- IN Carmel City Garage 3 Civic Square Attn: Chad Attn: Pat Young 3400 W 131st St. Carmel IN 46032- Carmel IN 46074- USA _ rm,Customei IR k .. _ .gig ?w,,,,.Customer,Pp ' �, Special Instructions ,: ,,, , Invoice;Terms; CAR0119 32805 Net 30 Days it ,_ Sales OrderpNo,.. Ship 145974 04/16/15 UPS JS1 `':Qty__. Stock#l Serial# R' ,g Description Unit Price Extension 1 S-DBO1 N-Z1 Custom Daybox 580.00 580.00 1 S-DBBRK-Z1 Custom Daybox Mounting Bracket 68.00 68.00 Open Market Line Item 12 Gauge Steel Heavy Duty Welded Hinges&Hasp 1/2" Plywood Lining Powder Coated, *Lock Not Included 18" Lx 14"Wx8"H Products will be exported from the United States in accordance with the Export Gross Amount 648.00 Administration Regulations. Diversion or use contrary to U.S. law is prohibited. Adjustments -90.72 TruckVault is an equal opportunity employer. Sub-Total 557.28 Shipping and Handling 50.00 Sales Tax 0.00 ACCOUNT IS CONSIDERED DELINQUENT 1 DAY PAST THE DUE DATE. THE FINANCE CHARGE 607.2$ IS 1.5%(18%PER ANNUM). ALL TRANSACTIONS TO BE COMPLETED IN US DOLLARS. Total Order A C� DATE(MMID D/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 PHONE FAX 301 Pennsylvania Parkway,#201 (EAMANo.EXu:317 817 5136 (A/C,No):317-817-5151 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY Y LP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED $50,000 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 AGO $2,000,000 7 POLICY PRO n LOG $ JECT A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/112016 COMBINED SINGLE LIMIT (Ea accident) .32,000,000 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 I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE- E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (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. c/o American Lease Insurance 654 Amherst Rd., Ste.335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 tn ID� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD