2015 Police Schedule 24 pay request 20 100615 Lease 2015 — Sch # 24
(Police Dept.)
Payment Request # 20
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: L3 Mobile-Vision, Inc
Amount: $1,414.00
Description of Equipment Item Cost: In car camera equipment
Dated: 10/05/15
LESSEE:
City of Carmel
One Civic Square
Carmel,IN -6032 J
By: dj
Name: Diana Cordray
Title: Clerk Treasurer
(Attached duplicate original of Payee's statement)
Make check payable to: L3 Mobile-Vision,Inc
PO Box 5580
New York,NY 10087-5580
PAGE 1
�, . Invoice
communications
Mobile-Vision, Inc. Invoice Number: 0230763-IN
90 Fanny Road Invoice Date: 9/25/2015
Boonton, NJ 07005
Phone: (800) 336-8475 Order Number: 0143855
Fax: (973) 257-3024 Salesppee orsrson: ZLMBDate 9/18/2015
LMB
Customer Number: INCARME
Tracking Number: 1zx5x9890367232582;
Sold To: Ship To:
Carmel Police Department Carmel Police Department
3 Civic Square 3 Civic Square
Attn:Brian Smith Attn:Brian Smith
Carmel,IN 46032 Carmel, IN 46032
Confirm To:
Brian Smith Page: 1
Customer P.O. Ship VIA F.O.B. Terms
33164 UPS GROUND BOONTON,NJ Net 30 Days
Item Number Unit Ordered Shipped Back Order Price Amount
VLXFA EACH 2.00 2.00 0.00 455.00 910.00
VLX Kit-includes wireless mic, In-Car base. Include panavise mount and lapel mics.Does r Whse: 000
SNI FB217342-FB217343
MVD-MC-ASSY EACH 1.00 1.00 0.00 395.00 395.00
Console Assy,monitor,FB Whse: 000
SN:FB134668
MV-ICV-EMIC EACH 2.00 2.00 0.00 45.00 90.00
Microphone,backseat,HD,Sys7,15'cable Whse: 000
PLEASE REMIT PAYMENT TO L-3 COM MOBILE-VISION, INC Subtotal: 1,395.00
PO BOX 5580 NEW YORK,NY 10087-5580
Ship/Handling: 19.00
Sales Tax: 0.00
Invoice Total: 1,414.00
These commodities are controlled under the Export Administration Regulations(EAR)and may not be
exported without proper authorization by the US Dept of Commerce.
A CERTIFICATE OF LIABILITY INSURANCE DATE DnrvY)
1/13/2015
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).
PRODUCER CONTACTNAME: Marianne Uban
Hylant Group CNIA/ o,Exu;317-817-5136 (A/C,No):317-817-5151
301 Pennsylvania Parkway,#201 DRl
Indianapolis IN 46280 ness:marianne.uban ADDRESS:marianne.uban@hylant.com
INSURER(S)AFFORDING COVERAGE NAIC#
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 LTR TYPE OF INSURANCE INSR DDL SUBR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
(MM/DDIYYYY) (MM/DD/YYYY)
A GENERAL LIABILITY Y ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000
X DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES(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 dECDT 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 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 $
DED RETENTION$ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY Y/N 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/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 ML �,/)�
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®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD