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2015 Street schedule 23 pay request 1 100515 Lease 204 5 Sch # (Street Dept.) Payment Request # EXHIBIT A PAYMENT REQUEST FORM I 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(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: ‘Kt.)..6 CA\ ttANCi\-11)._. Amount: Description of Equipment Item Cost: (,Y) 9,0ft1.) CkA0\\C\ k Iff Dated: q 110 I LESSEE: City of Carmel One Civic Square Carmel, 037,, By: Name: Diana Cord ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: cee.,_ Y to6(nitc-floms PAGE I • a t ' z dba Stoops Freightliner /,` lV; �,,...,.Y.' • 1851.W Thompson Rd J Indianapolis,IN 46217 r 800-899-1533 (317) 782-4037 fax viussumszca,,,....„.i.,,,,. d„' FAMILY OWNED SINCE 1958 Re: Wire Instructions - Equipment Funding BANK NAME: FIFTH THIRD BANK 251 N. ILLINOIS STREET, SUITE 1200 INDIANAPOLIS, IN 46204 Sharon Chandler, 317-383-5317 ROUTING NO: 042000314 Wires 074908594 ACH ACCOUNT NO: 7653181417 ACCOUNT NAME: TRUCK COUNTRY OF INDIANA, INC. OBI: PLEASE INCLUDE LAST 6 OF THE VEHICLE ID NUMBER AND CUSTOMER NAME IN THE OTHER BENEFICIARY INFORMATION If you have questions please contact your sales representative • TRUCK COUNTRY - INDIANAPOLIS -est 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 fREIGIITIINER-QUAIITI TRAILER Phone:(800)899-1533 DIVISION Of Tiff 3 /U' ' Fax:(317)781-4387 Vehicle Invoice/Bill Of Sale Deal Number: VM1301001037 Sold To: QPw CITY OF CARMEL IN Invoice Date: 9121/15 ONE CIVIC SQ..3RD FLOOR Cus Id: 116233 CARMEL,IN 46032 Salesperson:HASKETT,LORFN 3 Cash Price Vehicle: 157190.00 Added Equipment: 0.00 Registration Fee: 0.00 Sales Tax: 0.00 Excise Tax: 0.00 Service Contracts: 0.00 Title Fee: 0.00 Loan Filing Fee: 0.00 License Fee: 0.00 Counter Service Fee 0.00 Doc Fee: 0.00 Doc Fee Discount: 0.00 Total Price: 157190.1)0 Trade Allowance: 0.00 Payoff on Trade: 0.00 Equity in Trade: 0.00 Payment with Order: Cash 0.00 Rebates 0.00 Total Down: 0.00 Amount Due: 157190.00 Lien Holder: THE HUNTINGTON NATIONAL BANK *Please see attached addendum for the list of vehicles* Sales Person Signature: Customer Signature: Page 1 of 2 • TRUCK COUNTRY - INDIANAPOLIS ta013.S 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 fREINITIINER-SillifiT TRAILER Phone: (800)899-1533 DIVISION Of Fax (317)781-4376 Fue&•0*.06(16.54 Mai ADDENDUM Sold To: RPNY CITY OF CARMEL IN Deal# VM301001037 ONE CIVIC SQ.,3RD FLOOR CARMEL,IN 46032 Invoice Date: 9/21/15 Cus Id: 116233 Salesperson:I1ASKETT,LOREN J Description of Purchased Vehicle(s): UntId ModelVear VIN Make Model Selling Price 403693 16 IFVHG5CY9GHHC8234 ETL 108SD 157,190.00 TOTAL 157,190.00 Sales Person Signature: Customer Signature: Page 2 of 2 1 ..,•,7,7):•,„-A _t l.',� a .4 a4 f y a nom{ y" cq, rtes 4t n4 rr ,. � *..-:::J.;,.:::::1,,.,:••: . 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''-';',..;',:',i,',;:-,'- r.41`,. t ,,,..';''''''''':•:',;,.6.".',..-!.. „h.:: 1 1k4 • s. � �T �?� i �k'4 +A F r t .� �•� Y ,* rrnca�rr � �.''-'"4..,...,,,,. t �” ., acs r s Y r, ,. '';, x rya a> j t, ? • taa� �?1 �.at r YY. d 7 } .-s fYJ Ek' `... �� � � :•1'.0...r.!.',-.s. .'; '�v .4 a 1 'if Qf�"�e Ki..�'a'•:..,,i.o.' f 4.4.'- SSS.. r y,P 5 . . x ''-..4...:- .' tt a a r-,3).;.:..,.,: •4 �'' .£_fw r« S . ,5 �� 9 F al ';,,;. a,v Y 6 i 4`t4� ,., ,./.'7.::::,,‘..'',':!,,,,.,:s. '.''',..: "' :k, .. t •t ,,,....,..„,:,:,,,,J:,.,4 e � 3 7 � � s f � \ • i Curb rs*feneaned seer cwdttae to the Dost of bta anaetrg s.b loimsSat and beard undo'penahy d tam that Ise veN*k noun old has not baen reptatame In i tfda or any atate;at the Mate of urethral,Ind the*Wets to net aut4eot to any eMaegy Interests oder than those da Nosed here'n and venom Oki to pia vatuto. - FOR VALUE RECEWEO I TRANSFER INE VEHICLE DESCRIBED ON THE FACE OF THIS CERTIFICATE TO: _.. . m N:a OhmsBPW CITY OF CARMEL" IN . DR 8 1nIQF SITVT f SQ, •. a• of ► • hole; rlarla�sy ivtiEthe gine i dotty to 4+0 bqi W Z LSV�.I�"Z.,V V 1'7 3:t'C i c'�. " Nv �°.' a!fs� 'anwr!!!; DEALER NAME OF DEALERSHIP DEAL9A S.UOENRu NUMBER Being duty sworn uppo, oath leis that the statement:est 3lraso' forth krs W�-6L.lYJJfay a Soho DS County of– Notary PULaa •ot tUSE NOTARIZATION ONLY F REQUIRED IN TITLING JURISteet ION to NAME OF _ • PURCHASER($)) _ ADDRESS _No Tenths t candy to the best et my knowledge Vat she odometer read+ip le- DEALER NAs E of DEALERSHIP oF1d ER s LiCErJRe ni duly BWng duty swam upon oath says Mal the memento eat i 1 , Stet of tem are true and retract.Subscribed sod sworn to Ms before this day at " Notary ptdtila ‘It Catstyot a s • USE NOTARIZATION ONLY IF REQUIRED Cd TITLING JURISDICTION. re NAME OF PURCHASER(S)' ADDRE$O NO TMW I wady to the;Set of my Wa»tedge mat the 00anater raadng b DEALER ET` tr NAME OP DEALERSHIP DEALERS LICENSE NUMBER - . Cuing duty avis upon oath Bays that Its Matemente lei i Statue( g •forth are tnhe end coned.Subscribed end sworn to ma I Desist/ot--...1--- before thte -, deY of Notary Potreo USE NOfARD'ATION ONLY IF REOUIPED IN TITLING JURISDICTION I.,. e -NAME OF , . ADORERS ;, .- – Na'tBMD I coney to are brat of my kaoetad*e that the odometer reading le ____ h, DF7; BY:NAME OP DEALERBHtP DEALER'S LICENSE NUMBER '. } Soho et Sen upon oath says test the atetemame eat Stats of forth arb-tore and catrect.8ubsadbed end sworn to me • COON before iftte day of I — y i Notary Publlo -_......-�_.__ USE NOTARIZATION ONLY IF REQUIRED IN TITUNS JURISDICTION. _ Fadernt Low toq(aros you to stats the odometer adtasge be ernmac Lan slat lee teamster at oerefdp »a .Falun)to oomptote or paroling a Iain etffiement may res t �y in tense and/or Imprtoonme nt >3 ia+ed�ad.Odometer I SWIM to ON bofitot my>7rn tsdEe ear the odometer;vodkas the Word mileage of Pro whist,unless one of the Wowing s!alemtrds \aseem Roadraio ., Ida Tenths.D11a ram*.ram*.elated Ia m excess at Re meths ttati I�bs.OTTe odometer reading N not the a mates. WARNED ODOMETER DISCREPANCY 8 q atm Ma)Ot8l NrtN tea el Sl swam oats of Sste� a Bding duly upon oath says that the el tar.+mU as t Fantod Nes(e)at Sallem(e) Castor's No.__ forth are true and eonost.8ubabttbaa amt scram to me 6wrkWontthds dey of -1 SfyoaUs(a)of Purchasers) - so .Nolan/Pubti Printed fearrete) W o1 rdtant(s) State of t . Address of P Id) r'' County at • USE NOTARIZATION ONLY IF REQUIRED IN T 1.1140 JURISDICTION tawntsuarat THE HUNTINGTON NATIONAL BANK hoseeddtasaW 105 ser 4TH STr--CNQ-1r CINCt.DTDTATIr'—(Ili 45202 end eon in mmdr a • wham nearestl6 - . DATE ACO CERTIFICATE E OF LIABILITY INSURANCE10/5120Mroorrm) 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 poilcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may reituire an endorsement. A statement on this certificate does not confer rights to the certificateholderIn lieu of such endorsement(s). PRODUCER. CONTACTNAME: MarianneUban -- Hylant Group PHONE alXX,Nei:317-517 5151 PHO No.E>ttI:317-817-5136 301 Pennsylvania Parkway,#201 E-MAIL " Indianapolis IN 46280 ADDRESS:Marianne.uban@bylant.com NAlcs INSURER(S)AFFORDING COVERAGE INSURER A:Charter Oak Fitejnlsurance Co 25615 INSURED CARME8O INSURER B: ...._.._._ City of Carmel INSURER C: __.._ —.... " One Civic Square INSURER D: Carmel,IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1766587775 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. IAODL SUER POLICY EFF POLICY EXP LIMITS INSR l POLICY NUMBER IMMfDDIYYYYI IMM!DOIYYYYI, LTR= TYPE OF INSURANCE I INSR.WVD _. � A GENERAL LIABILITY ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE i$2,000,000 DAMAUETOT ELATED .550 OOG X COMMERCIAL GENERAL LIABILITY I PREMISES_ (Ea occurrence) _---- - ■■CLAIMS-MADE X i OCCUR MED EXP(Any one person) 1 SO PERSONAL E.ADV INJURY i$2,000,000 i - GENERAL AGGREGATE i,$2,000,000 r I GEN-L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGG I$2,000,000 PRG- j POt ICY 'Pi LOC A AUTOMOBILE LIABILITY H8103036P84ACOF15 1/112015 1/1/2016 UOMHtN ent! ,$2.SINULt LIMI I S (Ea accide000.000 BODILY INJURY(Per parson) I.S X ANY AUTO i ......_____....___ ALL OWNED I SCHEDULED BODILY INJURY(Per accident)`S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE i$ --.-. I HIRED AUTOS __AUTOS (Per accident) X !COMP IX Call Comp/Coll Ded ($2:500 I UMBRELLA LIAR I OCCUR EACH OCCURRENCE I S I EXCESS UAB CLAIMS-MADE] : AGGREGATE 15 3 DEC RETENTIONS ( I WC STATU- IQER-I WORKERS COMPENSATION TORY LIMITS AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE I E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED/ 1 N I A E.L.DISEASE•EA EMPLOYEE~S i (Mandatory In,NH) AS if yes,aesanhn under E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS below j I E 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 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 mal'l I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • AGENCY CUSTOMER ID: CARME80 LOC#: AC D ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Hylant Group City of Carmel One Civic Square POLICY NUMBER Carmel, IN 46032 CARRIER NATO 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#1FTBF2B6OFEC46708 2016 FORD ESCAPE 1 FMCU9GX6GUA55303 2016 FORD ESCAPE 1FMCU9GX8GUA55304 2016 FORD ESCAPE 1FMCU9GXXGUA55305 2016 Freightliner 2 Ton VIN#1 FVHG5CY9GHHC8234 ACORD 101 (2008/01) ®2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD