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2015 Police Schedule 24 pay request 9 052115 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 9 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: $1,440.10 Description of Equipment Item Cost: Scanner brackets Dated: 05/20/2015 LESSEE: City of Carmel One Civic Square Carmel,IN 46032 By: Name: Diana Cor•ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Wire transfer information included on separate sheet. PAGE I Safety Systems 4113 Turner Road Richmond, IN 47374 Invoice Number: 15051312 Invoice Date: May 13, 2015 Page: 1 Voice: 765-935-3566 Original Fax: 765-935-9713 - V""kr..,41,,c'jr;• 4., r .41,2j4,..f*se 4t41.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 tits tdrile t.1D'. 'A'• fk,,7-:"411•90ii-firie61;:teinii<1.Atgl'''#;;;•;;;:,AA -;t - Carmel P.D. 32865 Net 30 Days .Shiphg UPS Ground 6/12/15 Quantity • De6ciiption'. Price • 1.00 shipping shipping 49.70 49.70 80.00 Havis C-EB30-U15-1P Brackets 17.38 1,390.40 Subtotal 1,440.10 Sales Tax Total Invoice Amount 1,440.10 Check/Credit Memo No: Payment/Credit Applied TOTAI 4 •— . 4-101,54A 4,-, 4 N: 1 '440 10 Secure Message: Blunk Safety Systems Inc keyl23 Page 1 of 2 Help I Forget me on this computer (Log Out) (i^^ p R 4 ^»S :t" Secured Message Reply l ReplyAll I t Forward s From: vicki.hoober @usbank.com To: pyoung @carmeLin.gov Date: 05/20/2015 07:51:28 PM GMT Subject: Blunk Safety Systems Inc key123 Good Afternoon Here is the information for wiring funds: US Bank N.A. 800 East Main St Richmond, IN 47374 Routing number: 074900783 BLUNK SAFETY SYSTEMS INC Account#930078951 Any questions, please contact me. Thank you. Vicki Hoober Commercial Banking Relationship Assistant Richmond Main 800 East Main St Richmond, IN 47374 Mail Loc CN-IN-0223 phone (765) 965-2251 fax (765) 965-2324 email vicki.hoober@usbank.com " ..Life is not waiting for the storms to pass....its about learning how to dance in the rain..." Electronic mail sent through the Internet is not secure. U.S.Bank National Association cannot guarantee that time-sensitive, action-oriented messages, transaction orders, fund transfers or stop payment request sent through electronic mail will be processed as requested or received by the proper representative of US Bank National Association. If you are not the intended recipient of this message, notify the Sender. This information is intended only for the person named and for the purposes indicated. Do not distribute this message without the written consent of the author. Non-business opinions may not reflect the opinions of US Bank and its file:///ClUsers/pyoung/Desktop/securedoc_20150520T125131.html 5/20/2015 Acc,RD•® DATE(MMIDDIYYYY) 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 Ujtan Hylant Group (alc°.No.Ext):317-817-5136 FAX No):317 X317 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne uban©hvlant CQm INSURERS)AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insuran.ge o 25615 INSURED CARM E80 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 �DLISUER POLICY EFF POLICY EXP LIMITS LTR INSR I WVD POLICY NUMBER (MMIDD/YYYY) (MMIDD/YYYY) A GENERAL LIABILITY Y 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 IX 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 -1 POLICY n PRO- JECT $ JECT 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) 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- I OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS I 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/LOCATIONS 1 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 t 01 . ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD