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2014 Street Dept schedule 22 pay request 4 071415 Lease 2014 — Sch # 22 (Street Dept) Payment Request # 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 1;2014 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 (ofall/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, f1 \--(5t Payee: 4C \ Amount: 43 (t ( Description of Equipment Item Cost: Dated: . ( -° LESSEE: City of Carmel One Civic Square Carmel,I. '46032 By: Name: ]liana Cordrav Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE 1 .r ,07 .1' H9eti t CJ iA{ tE +ENT k 1 1 x ri Date: 6/23/2015 Pearson Ford,Inc. Name: City of Carmel Street Department Attention: 0 10650 North Michigan Road Address: 1 Civic Square INVOICE Zionsville,Indiana 46077 City: Carmel, IN 46032 317.873.3333 www.pearson1ord.net Phone: - Fax: - ... � m w VEHICLE ORDERi1!FORMATIONIty,w ,m �Ww E 4 � 0,l MSRP/Selling Price $ $3 7,530.00 ® New Used riDemo Optional Accessories: , Year: 2015 Make: Ford 1, Boss RT3 8'SD plow $ 4,850.00 Model: F-250 Reg Cab 4x4 Color: Red 2. SN 239608 $ 0.00 Stock 4: 24600 Salesperson: C. Barkduli 3. Strobes $ 530.00 VIN#: 1 FTBF2B60FFC4670$ 4 Roush Propane System $ 11,350.00 MILEAGE: 97 Actual/Not Actual 5 Gass Prep $ 270.00 *NOTES: 6 $ 0.00 Sub-total $ 54,530.00 TRADE ALLOWANCE: (•) t $ 0.00 €z x i : i5 M---tpV ( ` e 1" -,, k , Y o Fleet Discount (-I $ 10,869.00 ;?y.4 ATIPPA0u sa4gi4 rcw. .Id . s 8v� Flt I t :THIS ON7 ACT it nraTaNits r wrowArpi ovg m m ; , eencenive (-) $ 0,00 cbi.it lit 46VS:tos iN 611` 0 e 91 N ,4 Sher ') $ 0.00 ,i �...+ t itnri r ; t � ... .. ... . ... �. TRADE-IN VEHICLE INFORMATION TOTAL SELLING PRICE $ 43,661.00 (1)Year: Make: 7% Sales Tax: (+) $ 0.00 Model: Color: TRADE PAYOFF CO $ VIN#: Service Contract (+) $ Mileage: Tire Tax (+) $ Amount of Lien. Luxury Tax (4) $ Lienholder: Capped Acq Fee: (+) $ 0.00 Address: Other Amounts Owed (+) $ Total amount due (=) $ 43,661.00 Phone: Down payment/Deposit (•) $ 0.00 Stock#: Rebate (-) $ 0,00 (2)Year: Make: $ Model: Color: AMOUNT DUE AT DELIVERY $ 43,661.00 VIN#: MILEAGE: Actual/Not Actual I Amount of Lien: By signing this "Vehicle Order Agreement" I /We Lienholder: agree to the terms and conditions herein: Address: Company Name:_ Phone &, ,. ,� ;' , 4 3,. 011 '.�. rP P;0 * °- % t Authorized Signature: ' TRADE'IN CERTIFICATI dN,Zgt"14`.�«� *F� +"r . e sc�{sry) t Via co on ro`#he uoj 10,0,9raca d trig dm oI doI,cr -C.stonier t arraiits;that he�frace�in vahi0011 are o,nets univ b 'ci.s4o'mar and are free inaia c[dnr of a:i lensfand eneumbtanas axcep>ra$�tnervied nwv r drig`'ho , Cuaiemar„ et4[I a #hat they-i4 '''A sule�{'y�r,a?di e sronsequuipmetiti r th tads-tn vehioielaphaslllaa ❑s's'bae and Gate nr requrrett<t�tlse Nded in nWstat .its:,d i e,rebulfd:- e,`fisodE je en arb.i beL,r vn i,. and have nuwerbeer(sarde,od07 rl,�,.w , �" r ''' Dave, Below is our wiring information. I will be sure the C of 0 has that will have that info on it. Beneficiary Bank: Lake City Bank 202 East Market Street Warsaw, in.46580 Routing Number:074903719 Account Number: 1011170639 Account Name: Pearson Ford, Inc. Account Address: 10650 N. Michigan Road,Zionsville,Indiana 46077 Thanks, Chad Chad Barkdull Pearson Ford Commercial Account Manager 10650 North Michigan Road Zionsville, Indiana 46077 PH: 317.873.3333 FAX: 317.873.3152 cbarkdyll@myindyford.com www.myindyford.com `.------.1 ® DATE(MMIDDIYYYY) AWR® CERTIFICATE OF LIABILITY INSURANCE 7/13/2015 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). CONTACT PRODUCER NAME: Marialine-Uban ' Hylant Group PHONE (A/C.N G.EXte317-817-5136 FAX c ,N ot317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC B INSURER A:Charter Oak Fire Insurance Co 5615 INSURED CARME80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE jtgTh1BER: 45696 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 (MMIDD(YYYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED X COMMERCAL GENERAL LIABILITY PREMISES(Ea occurrence) $50,000 __CLAIMS-MADE X OCCUR MED EXP(Any one person) $0 PERSONAL&ADV 4NJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GE 'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000 PRO- $ POLICY .IFCT LOC CCWMkitNEU SINGLE LIMI I A AUTOMOBILE LIABILITY HSIO3036P64ACOF15 1/1/2015 1/1/2016 Ea accident) $2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS _ NON-OWNED PROPERTY DAMAGE $AUTOS (Per accidert) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS_- ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it 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 named as Loss Payee Re:2015 Ford F250#40970 and 2015 Ford F250#40967, 2015 Ford F250#0969, 2015 Ford F250#0968 (City of Carmel Street Dept.) Re:2015 Subaru Forester#4258, 2015 Subaru Forester#6408, 2015 Subaru Forester#6484, 2015 Subaru Forester#7856 (Community See Attached... 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 ACCORDANCE WITH THE POLICY PROVISIONS. 105 East 4th Street(CNO1) Cincinnati OH 45202 AUTHORIZED REPRESENTATIVE mc24_y_ I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CARME80 LOC#: ACGRD ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Hylant Group City of Carmel One Civic Square POLICY NUMBER Carmel, IN 46032 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Services-Bldg Inspectors) Re: 2014 Ford F150#5094,2014 Ford F150#5093(DOC) Re: 2015 Freightliner Trk#1 FVHG5CY1 FHGS0905, 2015 Freightliner Trk#1 FVHG5CY3FHGS0906, 2015 Freightliner Trk #1 FVHG5CY5FHGS0907,2015 Freightliner Trk #1 FVHG5CY7FHGS0908, 2015 Freightliner Trk#1 FVHG5CY9FHGS0909(Street Dept.) 2015 Ford F-250 VIN#1 FTBF2B6OFEC46708 ACORD 101 (2048101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 'U r CERTIFICATE OF ORIGIN FOR A VEHICLE 1 : h ';.-1 ''' . '''''''''"'' ' '.'"2"'''. ' t y ''..-------2--- ---'7;' ' c.''''''. ''`... -------•--- '''''#,•" ' % . . .: .='' "....... '," : 1'......4. ��r!4 t �) tI� [3lCE NGl DEAR 15,2G14 E 46108 2 ,.'••."' V£RrCLE�DE66nFican(Nv NO (-AR M'K _„ ',:if'• '1FTBF2B6OFEC46708 2.015 FORD: .4 • BODY TYPE:: i 137 F2 O 4 t4 RE CAl3` $8..SRW 6136 WEIGHT ! . H,P tSA E.).; 6'1f W 3i. s• :NO CYLS SERIES OR MQD€t q F, .51'. 60 10000 LB$ $ F2BH ... y4 ! r . NOMINAL TONNAGE S/4 f Iof .1,the undersgned'atuthanzeifrepresentative cdf lie company firm orcorporahannOrtted beigw,�hereby cer- trfy that the naw vghlcle descnkied".ob4v61s(he property of the said company firm or c nahn,anr:cle %;11::: + transferred qn the above date and under the invoice tNagt or indreaed fq the tpllowrng ..., ., r;or.degfer ,: F WAM OF<Dt$TRl9UTQR DEALER`ETC is r Pearson Ford, Inc,. F 10650 North btiahigan Road z Ziorlsv111es° IN 4:6077 r `. F 47:033 ft.is further certified that this was the,first transfer of such new motor vehFcle in ordinary trade and commerce, pp.eeg� np �j �r+ s ,''. La�7 428. 9D.'.. Ir F, 1!�':MO DA FORD .MOTOR COMPANY FIAANCE SOU/CE ,¢0900 •:,04 r Fprd Motor Credit CQ " ADLEYNt.GA CQETARY (AQENT} P:O. Lox 1 132 Ra aR s Dearborn M'I DEARBORN. MICHIGAN �t , 48141 q e r 4 u• .1 1! 1 IL i:l ill I i I I I ii I f 4 111 ,ii rt 1 lI ; i\ -..?,-.,..3....„....„...,.-..,,,,,,,.... „.....,, ,.....,-_;,.,.....,...,:-..„. .---..! I 1 r13 I it J�I it a, ! Li tlwl 1 Y rtl Jl L $ 1!E !� .,...._.., .„..„:.:-...„-.., . ._. _ he undersigned seller cer-tikes to the best al his knowledge.informaliOn and Irk el tt.tder penalty ot law II>al the vehicle is new and has not been registered in this or any slate at We time 01 delivery and the vehicle Is not subject 10 any soarnty interests other than those disclose°herein and wart ant title to the vehicle FQR VALVE RECEIVED!TRANSFER THE VEHICLE DESCRIBED ON THE FACE OF THIS CERTIFICATE TO: . NAME OF t• 0 1` l tirrr� D - ` �°'-^/'�^'"�('�"" E_. • ti¢. PURCHASERIS). ,.- .- r"'IWy , J_. _.� . tLs+ 1�.t� 4 ADDRESS _ . ..-. No Tenths 't • Z Z f reIl ly In the best of my knowiadgR fi the oUOmnter reading is-..-- "-- fti..�l� Q_�� :i"• 511'1 DEALER NpM �.rso 0 Pry-_(I4/��9lriny duly sworn up o k-tyr Ikr antlaswlom w me • m2 "'-'^ •s a, tnrin are true and correct .�'' r[ Slate o1_.. - —_. betura this ' .,._[lay of�_ _20_. Notary P-ubliic • Its'. - O Q County it - —_ - i' USE NOTARIZATION ONLY IF RCn E..!En lv'Ir NG Juftisolc l to,r • m NAME OF — �¢ PURCHaSER1Sl-------- - '.' -..,.- ui2 ADDRESS---- .__..T------._.. _... _- F O7 —, ,�_.--- NE Tents z z 1 ceelity to me best of my Knowledge that the odometer reading is --------- L) O 5 to _ BY: ._—.�.y _ 2 m Z DEALER NAME Or UE A�ERSH�n n�ALETIS LICLn15E riUKIPEr� Sell[dar A�true a and correct lhSubsci bed andaswom to neio Slate Of -, ---- t r.I trh ILL __-day of__,. ?0.--. _ •- _..._ Notary Public 2 Ga County of_. - USE NCII 50ZAT ION ONL 11!YouliL11 +TtIUNODUftl$OICTLS— ` NAME OF 4, -- CW 4i WCA PURCHASER(S)- .._ _—._ -- -'-- --- _ w T _ .T.--.—�_ g �f ADDRESS_ '— �... .,—.......__..,_T.___ O " _ �_No Tenths h- IG Z= t r.et l t m the best OI my I.-IoaACUge trial the odometer reading is.--- --- - -- -'-""- -� 1- O_ _ _ W Z _.. 9Y:'— X•7 i NAME OF DEALERS!". 'DEALERS LK.EN5E N' . earth g8 elyhuOand pon and sworn tO e -- Y•P. Sk-Il6Pf .._ - .be10(5this-.. •------day01--.-.-20_.. 4 Notary Public Z Da County ul • — -- -- - m N uSE N61 ARWa IUN ONLY iii r.Elara.ir'N Trt LING JUIasOICT!ON Z v NAME OF - --' -_— _..� IX Minfo PURCHASER(S)-' ---._ - --- -- - ._ - - 2 Z a m 0 O iu7 ADDRESS— _.—.., O o �_ �. Na Tenths 2 I- OZ I cec!Ay to the best ul my knowledge,trial me.udometer reading is. -- - " `_ - - - W µ ta 8Y t'. w DEALER NAME Ill JLh ER$VI 1• t1EAL°aS LICENSL vUhle_H-..�umg duly swan upon bath says Ihal the statements set - U mm Ir eh are true arid correct SubsCnbed and sworn to me • 0 z Stale or - - urlore this _day of ;...-20__.' ,p Notary#UOIIC J 0 5o) Cr0lrnty ul _.._,.—. —" JSE Nr')TARIZAf10N ONLY If Ir�[YJII tf•I IM1 irl_INC JUeiSthcTA)N _ J I Federal Law+oquiles-you to state the odOlneier RYleage Ill ConneCllon vri171 lot 11:3rtaler d nvme/ShiV.Farlllre to['-Onlplele 0[prOVidtn(J a tOtse Slaloment fik"iy resa l S in fines and.or imprisonment. ' m I certify to the best 01 my knowledge that the odometer reading is the actual mileage of Pre Vehicle unless one of the following Statements is checked Odor peter reading-s not the WW1 mileage. • ' :, Reading__ .T No Tenths.' J The mileage slarrd is It excess Sits mechanical limits JTllg WARNING ODOMETER DISCREPANCY Oa T .__ Dale ciStatement_-�.- " Datea1'Sale ' O n Signature(s)urBls)rn SAIto fs1•- - _.-- v1 1 r- - Berry Uu'y SNnrn upon oath says!hat the stater7tenls net wPrine,c1 Na refs)of SeUars(s)_ -- DearerS"NO"------ beth are true and correct. Sebscribed and Sworn to me ru F _ _ before tni,—_..T---- day ol..:..._ 20— O Signature!sl of PurchaserN-- - - _ . Notary Public ; M LL Printed Name's)of r'+Jrz teaser lsl....--,:-. -'- - ,.."_ ._ t O .. Stale t1!-- ._-�_. _ - 0 Company Name tlf Applicable)—.. - - Address of Purchaser(s).—.. .— County ul.-.._ - 7,�r. •t1 nU Et-ndTARIZATII ONLY Ir a Op! IAN�ni LING JURISOICIKA tat IICII in luoct of` ���Y�ii,�l1..a�l'AP•t�l''f,,Ifl A.� `f�:`1= �_' .,�mu, ahgsn.address Ls-W. v - .--: _'-'" ,'� _ Z 2nri lien in favor 01 - --.. ... �_ _ I _'. w• w•lnsn.ild dre SS is •____._. .__— .. _,,.-._ _... ..C • ■ J —