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2015 Street Schedule 26 pay request 1 121515 Lease 2015 — Sch # 26 (Street Dept.) Payment Request # I 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 August 15, 2015 by and among the Escrow Agent,the Lessee and Lessor, to the person or corporation designated below as Payee,the sumset 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: Iv-u, LOA"Fy ,11(ltGvIcl ,V1L,. Amount: g1r £ i Description of Equipment Item Cost: � ) ao\it VC ;,q .-Int 108 31) Dated: 11161rN LESSEE: City of Carmel One Civic Square!! Carmel,IN 4603 fig, ✓ By: Name: Diana Cordray _ Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VILA WIRE TRANSFER: .Q1a Z*(- c:Alt,k,LL \-n PAGE I dba Stoops Freightliner" ' � 1851 W Thompson Rd Indianapolis,IN 46217 800-899-1533 (317) 782-4037 fax FAMILY OWNED SINCE 1958 Re: Wire Instructions - .Equipment Funding BANK NAME: FIFTH Tb-tIRD 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 IANAPOLIS m ® ® 1851 W THOMPSON ROAD �... INDIANAPOLIS,IN 46217 FBfI6161LiINER QtIAL11 T$AIIER Phone:(800)899-1533 DIVISION OF t f � Fax:(317)781-4387 Vehicle Invoice/Bill Of Sale Deal Number. VM301001271 Sold To: CITY OF CARMEL Invoice Date: 12/11/15 ONE CIVIC SQ.,3RD FLOOR Cus Id:116233 CARMEL,IN 46032 Salesperson:HASKETT,LOREN J Cash Price Vehicle: 341354.00 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 Freight Fee: 0.00 • Doc Fee: 0.00 Doc Fee Discount: 0.00 Total Price: 341354.00 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: 341354.00 Lien Holder: HUNTINGTON NATIONAL BANK *Please see attached addendum for the list of vehicles* Sales Person Signature: Customer Signatta r a f t Page 1 of 2 , TRUCK COUNTRY- INDIANAPOLIS M , ® re 4,fiv,a 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 fREIGHTllNfA OIIALIID!TMA/LNI Phone:(800)899-1533 ©!MUSIN Of P!fi,_r J/ Fax:(317)781-4376 ADDENDUM Sold To: CITY OF CARMEL ONE CIVIC SQ.,3RD FLOOR Oeal# VM301001271 CARMEL,IN 46032 Invoice Date: 12/11115 Cus Id:116233 Salesperson:HASKETT,L OREN J Description of Purchased Vehicle(s): Untld ModelYear N Make Model Selling Price 430311 16 IFVHG5CY8GHHG0544 FTL 108SD I70,677.00 430312 16 IFVHG5CYOG11H00540 FTL 108SD 170,677.00 TOTAL, 341,354.00 • Sales Person Signature: / Customer Signature iOA_,I. /, Page 2of2 I I TRUCK COUNTR"Jo. —INDIANAPOLIS $ ,ist of ® 1851 W TROMPSON ROAD 4-1," FMNINUMMLOWITTMMUR INDIANAPOLIS,IN 46217 Phone (800)899-1533 DIVISION OF Fax�r' `' Fax.(317)781-4387 Vehicle Invoice/Bill Of Sale Sold To: CITY OF CARMEL Deal Number: VM301001270 ONE CIVIC SQ.,3RD FLOOR Invoice Date: 12/11/15 CARMEL,IN 46032 Cus Id:116233 Salesperson:HASKETT,WREN J Cash Price Vehicle: 631436.00 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 Freight Fee: 0.00 Doc Fee: 0.00 Doc Fee Discount: 0.00 Total Price; 631436.00 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: 631436.00 Lien Bolder: HUNTINGTON NATIONAL BANK *Please see attached addendum forthe list of vehicles* ::: ' Signature:0 ,.106,.„,) Page 1 of 2 TRUCK COUNTRY - INDIANAPOLIS ` ® . 1851 W THOMPSON ROAD INDIANAPOLIS,IN 46217 fRflGIJT1fNE11-0I1hLII Y'TRAILEII Phone:(800)899-1533 DIVISION OF i•',y Fax:(317)781-4376 Ili; i ADDENDUM Sold To: CITY OF CARMEL Qeal# VM301001270 ONE CIVIC SQ.,3RD FLOOR CARMEL,IN 46032 Invoice Date: 12/11/15 Cus Id:116233 Salesperson:HASKETT,LOREN.1 Description of Purchased Vehicle(s): Untl4 jllodelYear VIN Make Model 5eliingPric4 429711 16 IFVHG5CY2GH1100541 FTL 108SD 157,859.00 429712 16 IFVHG5CY4GHHGOS42 FTL 108SD 157,859.00 430268 16 1FVHO5CYX011HG0545 FTL 108SD 157,859.00 430285 16 IFVHGSCY6GHH00543 FTL 108SD 157,859.00 TOTAL 631,436.00 Sales Person Signature: Customer Signature:.., ���✓✓✓ Page 2 of 2 t 1 �. 2 ��.'j 3' x a P5t#£°' < s v.rye, � Y R Yv'f i .4 ti �.4 r ,!u ..f ! a P Ps P7 - + -. 11 , t 1r t 1' iE (, 'k '^' '''i' '''x='49' CERTIFICATE"OFrQRIGINvFOR QiIEHIC-: r yr ��tt ,�C„}{��f7,� ,i Tykj.+l 7'a t M •..s54 c.. .t-''., h i rt tt,}"7":4V, ` sti r ti ti Itrok a _,,,��� r�pp-.p���� e x �,,j a J. . 7 n!�a 4`1k"r tnt 1,4 k 1� to s� ,.-r+ta>.�.--y ' nK r4,,...,,;•,-,,,,,h y"sy '4.!.-1;;;K$'-1,i; L s " T.,'arL' x b''J`' ,,,, .. }+-•,r t •ns bv.' iv',J 54,� 1 ' i4 S t a. n. 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It3S rri3aild � do Ev11N 401311/71itta33 S01140 30Vd 31.11110 0341134)830 3907$3111341 U345-r014L 100413031.19114141 200.. :.• ' -017[4000 a4101010 Its 0304 1 p1404 430040.+0,Tsa10'0'O ue?a$Man*409404 Asgma13413.!41*3o(4m 104 3$0AI404 0141 P30 R+30n,N aWr mil re la.,w S;41 99 P? ?100110 10u ra4 Pum ie.,/4*4010*3+13 IN%stip N*4.1(0134)30104104 put,u010410N1'a4Paix+car.i g4 JO:044400310211511131111.4410031840401111.42141_ 1 1 x . 1 �1 A E)® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDmrY) 12/18/2015. 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: the certificate holder Is an ADDITIONAL INSURED,the policy(les)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 PHONE FAX (ac.No.Ext)317 817 6136 IA/C,No):317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL Indianapolis IN 46280 ADDRESS:marianne ubanr)a')ylant.com INSURERS)AFFORDING COVERAGE NAIC tY ! INSURER A:Charter Oak Fire Insurance Co 25615 INSURED CARME80 INsuRERe: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E INSURER F: . COVERAGES; CERTIFICATE NUMBER:149406080 . . 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 - 1 LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS A GENERAL LIABILITY ZLP14T62033 1/1/2015 1/1/2016 EACH OCCURRENCE $2,000,000 81. •• X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence 550,000 CLAIMS-MADE X OCCUR MED EXP(An one•• .• $0 PERSONAL 8 ADV INJURY 52,000,000 GENERAL AGGREGATE 52,000,000 _ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG 52,000,000 _ 1 —1 POLICY jie LOC A AUTOMOBILE LIABItm H8103036P64ACOF15 1/1/2015 1/1/2016 t:oMHINLU SINGLE UMI 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 Col Comp/Coll Ded $2,500 UMBRELLA LIAR OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED.)-. ' RETENTION S 5 I WORKERS COMPENSATION WGSTATU- OTH- t AND EMPLOYERS'.LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/Pr ARTNER/EXECUTIVENIA E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (Mandatory In NH): E.L.DISEASE-EA EMPLOYEE $ If yes,describe under ! DESCRIPTION OF OPERATIONS below E :DISEASE-POLICY LIMIT S { DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,I1 more apace 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:6-2016 Freightliner, Model 108SD with the following VIN#'s: 1 FVHG5CYOGHHG0540 1FVHG5CY2GHHG0541 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 ti(OLL r��J ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CARME80. LOC#: A D ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED Hylant Group City of Carmel POUCY NUMBER One CivicSquare Carmel, IN 46032 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE 1 FVHG5CY4GHHG0542 1F UHG5CY6GHHG0543 1 FVHG5CY8GHHG0544 1 FVHG5CYXGHHG0545 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. 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