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2015 Police schedule 24 pay request 21 100615 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 21 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: Dell Marketing Amount: $2,614.24 Description of Equipment Item Cost: Computer Software Dated: 10/05/15 LESSEE: City of Carmel One Civic Square Carmel,IN 44 032/ ,e1 Y: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Make check payable to: Dell Marketing C/O Dell USA L.P. PO Box 802816 Chicago,IL 60680-2816 PAGE 1 This is your INVOICE Page 1 Of 1 FID Number: 74-2616805 Customer Number: 98574231 Invoice Number: XJT17XKT1 Sales Rep: MICHAEL SHARKEY Purchase Order: 33170 - For Sales: (800)981-3355 Order Number: 896061567 Invoice Date: 09/29/15 Sales Fax: (800)433-9527 Order Date: 09/29/15 Payment Terms: NET DUE 30 DAYS Customer Service: (800)981-3355 Due Date: 10/29/15 Technical Support: (800)822-8965 83 01 O 01 00 N Shipped Via: STANDARD GROUND Dell Online: www.dell.com Waybill Number: MS-VIRTUAL SOLD TO: SHIP TO: ACCOUNTS PAYABLE Terry Crockett IN CITY OF CARMEL CITY OF CARMEL ONE CIVIC SQUARE INFORMATION SYSTEMS CARMEL,IN 46032 3 CIVIC SQ CARMEL,IN 460322584 PLEASE REVIEW DELL'S TERMS 8 CONDITIONS OF SALE AND POLICIES AT www.dell.com/us/policy OR UPON REQUEST,WHICH GOVERN THIS TRANSACTION Ordered Shipped Item Number Description Unit Unit Price Amount 8 8 A6591288 VLA OFFICE PRO PLUS 2013 EA 326.78 2,614.24 MfgPartNum:79P-04712 MfgName:MICROSOFT CORPORATION Ship.&tor Handling $ 0.00 Subtotal $ 2,614.24 FOR SHIPMENTS TO CALIFORNIA,A STATE ENVIRONMENTAL FEE OF UP TO$5 PER ITEM WILL BE ADDED TO INVOICE Taxable Tax S FOR ALL ORDERS CONTAINING A DISPLAY GREATER THAN 4 INCHES.PLEASE KEEP ORIGINAL BOX FOR ALL RETURN $ 0.00 $ 0.00 S.COMPREHENSIVE,ONLINE CUSTOMER CARE INFORMATION AND ASSISTANCE ISA CLICK AWAY AT WWW.DELL.COM/PU ENVIRO FEE $ 0.00 BLIC-ECARE TO ANSWER A VARIETY OF QUESTIONS REGARDING YOUR DELL ORDER. Invoice Total $ 2,614.24 DETACH AT LINE AND RETURN WITH PAYMENT Ship.&/or Handling $ 0.00 Invoice Number XJT17XKT1 Subtotal $ 2,614.24 Ett•ILL Customer Name: IN CITY OF CARMEL Taxable Tax Customer Number: 98574231 $ 0.00 $ 0.00 • Purchase Order: 33170 ENVIRO FEE $ 0.00 Order Number: 896061567 Invoice Total $ 2,614.24 MAKE CHECK PAYABLE/REMIT TO: $ DELL MARKETING L.P. $ C/O DELL USA L.P. $ PO BOX 802816 Balance Due $ 2,614.24 CHICAGO,IL.606802816 Amount Enclosed 000XJT17XKT100000002614248300985742312 CERTIFICATE/� /� �+ p®/� @ DATE(MM/DDNYYY) A``R®® CERTIFICATE OF LIABILITY INSURANCE 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 CONTACT NAME: Marianne Uban Hylant Group (A//CC.NNo.Ext):317-817-5136 FAX No):317 817 5151 301 Pennsylvania Parkway,#201 AoREss:marianne.uban@tylant.com IN 46280 ss:marianne.uban ylant.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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NW SR SVD POLICY NUMBER /YPOLICY EFF POLICY EXP (MM/DDYYY) (MMIDD/YYYY) LIMITS 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 PRO- POLICY JECT LOC $ A AUTOMOBILE LIABILITY H8103036P64ACOF15 1/1/2015 1/112016 COMBINED-SINGLE LIMIT (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 accident) X Comp X Coll Comp/Coll Ded $2,500 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED F RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITYY/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N IA (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 IOC-.fes ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD