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2015 Police schedule 24 pay request 16 080315 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 16 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: 3S1 Security Systems Inc Amount: $1,233.00 Description of Equipment Item Cost: satellite tracking system Dated: 08/03/15 LESSEE: City of Carmel One Civic Square Carmel,IN 46032 By: ._�1 - � _. `' Name: 7 iana Car i ray Title: Clerk Treasurer lif (Attached duplicate original of Payee's statement) Make check payable to: 3SI Security Systems Inc PO Box 5146 New York,NY 10087-5146 PAGEI Igo Page No: Page 1 Security Systems Invoice No: 0000400459 3SI Security Systems 101 Lindenwood Drive Malvern, PA 19355 800.523.1430 Invoice Date: 07/22/2015 INVOICE Bill To: Ship To: Customer No: G09728 Customer No: G09728 LT LARRY COLLINS CARMEL POLICE DEPARTMENT CARMEL POLICE DEPARTMENT TR-CARMEL PD 3 CIVIC SQUARE 3 CIVIC SQUARE CARMEL IN 46032 CARMEL IN 46032 Our Order No: NEWESP000217808-0000 Bill to Rep: 100 Ship to Rep: 100 Terms: NET 30 NRD: 07T Net Due Date: 082115 Shipment No: 000393530 Ref: P.O.NO: 32980 Pro No: CSR: 008 Qty Qty Item Unit Price Extd Price Ordered Shipped Number US DOLLARS US DOLLARS NEW SECURITY INSTALLATION TR-CARMEL PD CUSTOMER INSTALL SHIPPED 7/20/15 1 1 32010300 • 400.00 400.00 3XG-G ESO HARD CASE RT W/O LEDS SERIAL NO: 354676051036852GA QTY: 1 1 1 32010561 400.00 400.00 3XG-C ESO SOFT POUCH SERIAL NO: A10000458BBF24GA QTY: 1 1 1 32010000 0.00 0.00 3XG SIM ATT SERIAL NO: 5442620599 QTY: 1 2 2 51075471 204.00 408.00 ANNUAL USAGE-TRACKING 1 1 51074397 0.00 0.00 SELF INSTALL ADMIN FEE FREIGHT 25.00 Remittance Address SALES TOTAL: 1,208.00 SALES TAX: 0.00 3SI Security Systems Inc FREIGHT: 25.00 PO BOX 5146 LESS: 0.00 New York, NY 10087-5146 OTHER CHARGES: 0.00 INVOICE TOTAL: 1,233.00 US DOLLARS A 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 INSURERS), 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 U_12an Hylant Group 301 Pennsylvania Parkway,#201 PHONE •E:m317 817 513fi _fare,No):317-817-5151 Indianapolis IN 46280 ADDREss:marianne.uban @hylant.com INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Charter Oak Fire InsU(aace Co 2561.5 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 ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) A GENERAL LIABILITY Y ZLP14T62033 1/112015 1/1/2016 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED $50,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) 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 JECT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/112015 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 LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORJPARTNERIEXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I 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. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 /01 1--lp ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD