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2015 Police schedule 24 pay request 23 102715 Lease 2015 — Sch # 24 (Police Dept.) Payment Request # 23 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: Matrix Integration Amount: $3,099.25 Description of Equipment Item Cost: Software&maintenance Dated: 10/26/15 LESSEE: City of Carmel One Civic Square Carmel,IN 46032 By: k ` �'' Name: ` iana Cor .ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) Make check payable to: Matrix Integration 417 Main Street Jasper,IN 47546 IA p pi y .7,70:., 'MI INVOICE Matrix Integration il'iv: �, i 3U�v to f' 'u t;..`.u& ir.` 417 Main Street P, r- r' .• -r"e•-P� i Jasper,IN 4 c546 t _` <I='.r i i s- (812)634-1550 Bill To: Ship To: City of Gunnel City of Carmel Terry Crockett Terry Crockett Carmel City Flail Director of Information System One Civic Square Three Civic Square Canner IN 40032 Carmel IN 46032 (317)571-2567 Ext.0000 Purchase Order II Account ID Sales Person Ship Via Terms Invoice# Invoice Date Page 33183 CARMEL BALLINGER EMAIL Net 30 INV1060843 10/13/2015 1 Quantity Item ti Description Serial Number Unit Price Ext.Price 25 UN-C-S-1-L500 UNIDESK-1-Year of 24/7 Maintence and $24.56 $614.00 25 UN-C-P-L500 UNIDESK-Desktop Image&App Mgmt,St $99.41 $2,485.25 ORD6 AQ1.13617 Subtotal $3,099.25 THANK YOU!! SG/SMB Misc $0.00 Tax $0.00 Freight $0.00 Due: 11/12/2015 Total 53,099.25 Batch ID: 10/13/15SMB Payment Received $0.00 Invoice Balance Due $3,099.25 Please pay from this Invoice.All past due charges are subject to a 13/i%per month penalty. Remit to:Matrix Integration LLC•417 Main Street,Jasper IN 47546•Phone 812-634-1550• Fax 812-634-2573 www.matrixintegration.com AR®® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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). CONTACT PRODUCER NAME: Marianne Uban Hylant Group (A/C.No.Ext):317-817-5136 (ac,No):317 817 5151 301 Pennsylvania Parkway,#201 E-MAIL :marianne.uban lant.com Indianapolis IN 46280 ADDREssmarianne.uban@hylant.com 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (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 $2,00.0,000 POLICY 'r 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 qi. �,/),� IQ�-�C. ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD