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2015 Police Schedule 24 pay request 6 050515 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 6 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: Safety Systems Amount: $13,775.44 Description of Equipment Item Cost: Safety equipment for new vehicles Dated: 05/04/2015 LESSEE: City of Carmel One Civic Square Carmel,IN 46032 By: Name: i7.74.7 14 s, Title: Clerk Treasurer I (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Safety Systems 4113 Turner Road Richmond,IN 47374 PAGE 1 III Safety Systems 4113 Turner Road `"` Richmond, IN 47374 Invoice Number: 15042417 Invoice Date: Apr 24, 2015 Page: 1 Voice: 765-935-3566 Original Fax: 765-935-9713 %tit Tiiwx 6 Sh)., t° j m d e rs urg e s 3i� n f.nd r{ ar a .4 Carmel Police Department Carmel Police Department 3 Civic Square 3 Civic Square ATTN: Pat Young ATTN: Pat Young Carmel, IN 46032 Carmel, IN 46032 FV R f a�Customer ID `� �y 'g 5 s' .Customer POD' " iszl n Pa meat Tern7S Mr +sY� .. -. .. ... F..,. .r mi ... .. �. . x. ,.. .�s",.� .<. w= - .. -M. ;'d�.< t. �a'S d....R...: ,. .it'c� .� _m.'^ '�, .n� ., ..-.'P°@>Yt. a✓Se . "���-a n.L'�1 Carmel P.D. 32806 Net 30 Days ° ' 'Sales Re 3ID s Stiff in ,.Metho t„ ', Shy .Date �' � ° � ,.� . P �. .. .�_.:::�� �..Due Daten� Hand Deliver 5/24/15 Quantity "Item a Descriptioin Unit Price k J Amount 4.00 Fed Signal 31 CN Signalmaster Interceptor 599.00 2,396.00 W/Brackets 18.00 License Plate Brackets Horizontal Mount 12.42 223.56 6.00 Whelen Vertex Blue 55.50 333.00 1.00 Whelen SSFPOS 16 Plug in Head Light 62.40 . 62.40 Flasher 1.00 Fed Signal ES100 with 2015 Tahoe Mount 119.20 119.20 19.00 Fed MPS600U-BB(in place of LINZ6) 84.56 1,606.64 19.00 Fed MPS600U-RR(in place of LINZ6) 84.56 1,606.64 6.00 Whelen Vertex RED 55.50 333.00 7.00 Whelen TIR3-Blue 46.00 322.00 1.00 Fed Signal 51 Integrity Lightbar 1,392.80 1,392.80 W/Interceptor Hooks 7.00 Whelen TIR3-Red 46.00 322.00 18.00 Whelen Mirror Beams 208.00 3,744.00 1.00 Fed Signal CN Signal Master with Tahoe 599.00 599.00 Mounts 6.00 Federal Signal ES100 Siren Speaker with 119.20 715.20 Brackets Subtotal 13,775.44 Sales Tax Total Invoice Amount 13,775.44 Check/Credit Memo No: Payment/Credit Applied TOTAL :",V` . . •, � . . .Y"r. _.v. . �* ,4. `a'¢ } y ,� ° 13 7Y75 44, AC°RD 0 DATE CERTIFICATE OF LIABILITY INSURANCE 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 (AIC.No.Ext1:317-817-5136 (A/C,No):317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 n ess:marianne.uban h lant.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 AINSR ISWVD I POLICY NUMBER POLICY YT POLICY EXP LIMITS {M M ID D 1Y YY Y 1 I M M ID D I`f Y Y Y) A GENERAL LIABILITY Y ZLP14T62033 111/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 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/OP AGG $2,000,000 7 POLICY PRO n LOC $ JECT A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 COMBINED SINGLE LIMIT Ea accident ,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/Col)Ded $2,500 UMBRELLA LIAB - OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TeR_ _ u ANY PROPRIETORJPARTNERJEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE= $ If yes,describe under DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 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&Assignee$ ACCORDANCE WITH THE POLICY PROVISIONS. c/o American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 tit ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD