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2013 Fire lease 16 pay request 1 060415 Lease 2013 -- Sch # 16 (Fire Dept.) Payment Request # 2 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 October 2. 2013 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:roradition.and hereby accepts the Equipment described on the attached invoices. Payee: Municipal Emergency Services Amount: 7.• 90.74 Description of Equipment Item Cost: 3 Remaining Sets ref Turn-Out Gear Dated: June 1,201 5 LESSEE: City of Carrrte! One Civic Square Carmel, IN 46032 Fay: r`. . , Name: Diana Com ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PIRASE PAY VIA WIRE TRANSFER: pAGE `S6‘. Invoice IVIES Indiana Number 0083 6916_,SNV til) mEs 6975 Hillsdale Court Date.. ..._ ..,_. 6/112015 Indianapolis, IN 46250 Sage • 1 of 2 Sales order • SO 540479 ifuiCICIMFMF7xeO CERAM,INC, Requisition • Your ref.........,: Telephone..:(888)322-8402 Our ref •kschulthei Fax. :317-596-1701 Payment...,.., ;Net 30 Sales Rep_....:kschulthei Inv Acct • 30195 Bill To: Ship To: CARMEL FD CARMEL FD 2 CARMEL CIVIC SQUARE 2 CARMEL CIVIC SQUARE CARMEL,IN 46032 CARMEL. IN 46032 Denise Snyder Item number Size Color Description Quantity Unit Unit price Amount INCARM00107 LTO-4173 Tail Black-Carmel 3.00 EA 1,498,80 4,496 40 Fire Dept-IN Zipper Closure INCARM00108 LTO-4123 Pants Black-Carmel 3.00 EA 964.78 2,894,34 Fire Dept IN Merchandise Restocking Fee S&H Sales tax Discount Total due 7,390.74 0.00 0.00 0.00 0.00 7,390.74 USD Thank You For Your Order ! All returns must be processed within 30 days of receipt and require a return authorization number and are subject to a restocking fee. Custom orders are not returnable.Effective tax rate will be applicable at the time of invo till1114441111116' Invoice# 00636915 SNV MEG ourdiam.acme*SWIM,Wit. Payment Remittance Slip To insure proper processing,please return this slip with your payment. Please Send Payments To: ••• -•-•••••••-••• Routiag#: 121000246 Municipal Emergency Services Acco#:2000030294606 Depository Account Bank Name:Wells Fargo Bank, N.A. 75 Remittance Drive Co Name Municipal Emergency Services,Inc. Suite 3135 PO Box 656 hicago, IL 60675 Southbury,CT 06488 Remittance Advice:ar@mesfire com Include customer#and Inv# Amount Due 7,390,74 Amount Enclosed*..: Customer name - CARMEL FD Customer number : 30195 Additional Payment Notes: A OW El® EVIDENCE OF COMMERCIAL PROPERTY INSURANCE 4/1/20 D5""ryl 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 317-517-5136 COMPANY NAME AND ADDRESS NAIC NO: 25674 CONTACT PERSON AND ADDRESS (A/C,No.Emb Hylant Group Inc Travelers Prop Cas Co of Amer 301 Pennsylvania Parkway, 1)201 Indianapolis IN 46280 ( L,No} 317-817-5151 A D o RIESS:ma ri.anne.ubanmhylanL.corn IF MULTIPLE COMPANIES,COMPLETE SEPARATE FORM FOR EACH CODE: SUB CODE: POLICY TYPE AGENCY PACKAGE POLICY CU$TOM FR ID F: NAMED INSURED AND ADDRESS LOAN NUMBER POLICY NUMBER City of Carmel H630581M4076TIL15 One Civic Square Carmel, IN 46032 EFFECTIVE DATE EXPIRATION DATE CONTINUED UNTIL 01/01/2015 01/01/2016 TERMINATED 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) BUILDING OR ❑ BUSINESS PERSONAL PROPERTY LOCATION/DESCRIPTION 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 I BASIC j BROAD `X I SPECIAL I 1 COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: $ OFD:25,000 YES NO MA ® BUSINESS INCOME ❑ RENTAL VALUE X If YES,LIMIT: 29,000,000 ! Actual Loss Sustained,#of months: BLANKET COVERAGE X If YES,indicate value(s)reported an 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(I!"YES",specify organization's foes used) X REPLACEMENT COST X AGREED VALUE X COINSURANCE X If YES. EQUIPMENT BREAKDOWN(If Applicable) X If YES,LIMIT: POLICY LIMIT OED: 25,000 ORDINANCE OR LAW -Coverage for loss to undamaged portion of bldg X If YES.LIMIT: 2 5 0,0 0 U OED: 25,000 -Demolition Costs x EYES.LIMIT: 250,000 DED: 25,009 -Incr.CostofConstruction X If YES,LIMIT: 250,000 CEO: 25,000 EARTH MOVEMENT(It Applicable) X If YES,LIMIT: 10,000,000 CEO: 50,000 FLOOD(If Applicable) IX EYES.LIMIT: 3.0_.coo 000 DED: 50,000 WEND I HAIL(If Subject to Different Provisions) X If YES,LIMIT: DED: 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 '}L LOSS Payee NAME AND ADDRESS The Huntington National Bank & it's Assignor & Assignees c/o American Lease Insurance 654 Amherst Rd. , Ste. 335 Sunderland MA 01375 AUTHORIZED REPRESENTATIVE Page 1 of 2 ©2003-2011 ACORD CORPORATION. All rights reserved. ACORD 28(2011111) 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 93% COINSURANCE APPLY TO THE SPECIFIC LINT 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; CARAMEL REDEVELOPMENT COMMISSION; CARMEL REDEVELOPMENT AUTHORITY; CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION ACORD 28(2011/11) Page 2 of 2