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2015 Police schedule 24 pay request 17 091515 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 17 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: MCCI Amount: $1,535.05 Description of Equipment Item Cost: Laserfiche software support Dated: 09/11/15 LESSEE: City of Carmel One Civic Square Carmel, IN 46032 By j/. - 1rrh- Name: �I Tana Cor ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Make check payable to: MCCI PO Box 2235 Tallahassee,FL 32316 PAGE 1 1 --Ner ICCi P.O.Bos 2235 Tnllahossee,FL 32316 I�VOI CE FE1�:33-1069550 ExperienceExcellence Questions:finance@mccionovations.eont Bill To: CARMEL, INDIANA Invoice Number 00007181 ***tcrockett @carmel.in.gov - TERYY CROCKETT, IT DIRECTOR Invoice Date 8/25/2015 THREE CIVIC SQUARE PO Number 32996 CARMEL, IN 46032 Customer Id 60-61101 Payment Terms Net 30 - ----- Description--_ -_- ---- 1Shipped Unit Price Extended Price --- — — — --- -- 1 LF SOFTWARE ADDITIONAL $660.000 $660.001 1 LF SUPPORT ADD ON $113.850 $113.85 ,SOFTWARE AND SUPPORT FOR 1 USER I(TOTAL OF 2 COMING ONLINE THIS MONTH) PRORATED 9 MONTHS • Subtotal $773.85 .Discount $0.001 i Freight $0.001 Please remit one copy with payment 1 Tax $0.00! Page 1 'Total $773.85! 1 C C i INVOICE P.O.Box 2235 Tallahassee,FL 32316 FEIN: ExperienceExcellence Questions:finence@mccinnovations.com Bill To: CARMEL, INDIANA Invoice Number 00007062 ***tcrockett@carmeLin.gov TERYY CROCKETT, IT DIRECTOR Invoice Date 7/31/2015 THREE CIVIC SQUARE PQ Number 32996 CARMEL, IN 46032 Customer Id 60-61101 ------ — — Payment Terms Net 30 Shipped Description Unit Price Extended Price 1 LF SOFTWARE ADDITIONAL $660.000 $660.00 1 LF SUPPORT ADD ON $101.200 $101.20 ADDITIONAL SOFTWARE AND SUPPORT PRORATED FOR 8 MONTHS Subtotal $761.20 Discount $0.00 Freight $0.00 Please remit one copy with payment Tax $0.00 Page 1 Total t $761.20 A CERTIFICATE OF LIABILITY INSURANCE 1I1DATE 3I2015(MMIDDNYYY) 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:CT A Marianne Uban Hylant Group IPA"c°.P .Ext):317-817-5136 is c,Ner:317 817 5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne.uban@hylant.com INSURER(S)AFFORDING COVERAGE NAIC 11 INSURER A:Charter Oak Fire Insurance Co 25615 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 SUBR POLICY EFF POLICY EXP W D/ LTR INSR VD POLICY NUMBER I(MM/DYYYY) (MMIDDIYYYY) LIMITS A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 X COMMERCIAL GENERAL LIABILITY PR PREEMIMI ESES S a RENTED Ea occurrence $50,000 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 POLICY PRO- JECT LOG $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/1/2016 EOa aBINEDtSINGLE LIMIT ,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 I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY ,,,/N •i. -u $ ANY PROPRIETORJPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE o $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 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&Assignee- ACCORDANCE WITH THE POLICY PROVISIONS. do American Lease Insurance 654 Amherst Rd., Ste. 335 AUTHORIZED REPRESENTATIVE Sunderland MA 01375 1O�Y� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD