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2015 Police schedule 24 pay request 13 062415 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 13 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: Imaging Solutions and Services, Inc. Amount: $1,182.83 Description of Equipment Item Cost: Fujitsu Color Scanner Dated: 06/02/15 LESSEE: City of Carmel One Civic Square Carmel, IN 46032 By. .$6,....4 .)/e16/11.0 Name: Diana Cor ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Electronic transfer information included on separate sheet. PAGE I ACCARD CERTIFICATE OF LIABILITY INSURANCE 1/13/2015 TE(MM/ DIYYYY) 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 NAME: Marianne Uban Hylant Group RIC No.Exu:317-817-5136 FAX No1:31 7-817-51 51 301 Pennsylvania Parkway,#201 E-MAIL SS:marianne.u�a Indianapolis IN 46280 n@hylant.com INSURERO AFFORDING COVERAGE NAIC# INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square Carmel, IN 46032 INSURER D 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 ADIIITSUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIODlYYYY) IMMIDDlYYYY) A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 TO X COMMERCIAL GENERAL LIABILITY DAMAGE RENTED PREEMISEMISES(Ea occurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(My 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 PRO- -1 POLICY JECT LOC $ 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 i 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 $ DEC, 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/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 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 t � y-t' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Imaging Solutions and Services, Inc. Invoice EIN: 62-1615066 • DATE 'INVOICE#: Remittance Address: Billing Inquiries: P.O. Box 1000, Department 6 (901) 767-4636, x1455 6/2/2015 M15-1203 Memphis, TN 38148-0006 BILLTO . SHIPTO,, i ' �, ' Carmel Police Department Carmel Police Department Attn: Pat Young Attn: Laura Mulligan 317-571-2730 3 Civic Square Records Division Supervisor Carmel, IN 46032 3 Civic Square Carmel, IN 46032 P:O NUMBER TERMS •.,• DUE DATE;,:. REP., SHIP DATE • SHIP VIA 32895 Net 15 6/17/2015 MC15 6/2/2015 QUANTITY.:. REFERENCE ' : ' DESCRIPTION PRICE EACH AMOUNT 1 Fujitsu Color Scanner fi-7160, 60ppm/120ipm 876.00 876.00 SN:A36D183892 1 Advance Exchange Service for fi-7160, 3 Year Advance 189.00 189.00 Exchange: 8x5x24, Parts, Labor, Shipping 1 ScanAid Kit, fi-7xxx 85.00 85.00 1 Parcel Delivery Charges 32.83 32.83 UPS Tracking 1Z5F01W20357710838 Imaging Solutions and Services, Inc.'s "Terms and Conditions of Sales" apply and are a part of this invoice. Total $1,182.83 Young, Patricia A From: Kay Barrow[kbarrow©ISSI-Online.com] Sent: Tuesday, June 23, 2015 3:17 PM To: Young, Patricia A Subject: ACH Payment Information Hi Patricia—here is our information for ACH bank payments: Bank: First Tennessee Name on Account: Imaging Solutions and Services, Inc. Routing No.: 084000026 Account No.: 185326695 Remittance detail can either be e-mailed to CustSery @issi-online.com or faxed to (901) 767-2852. Thank you. Kay M. Barrow Imaging Solutions and Services, Inc. 1845 Moriah Woods Blvd., Suite 7 Memphis, TN 38117 (901) 767-4636, x-1100 (901) 767-2852 fax 1