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2012 Fire bond pay request 1 Lease 2012 Sch 10 (Fire Dept.) Payment Request 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 March 12, 2012 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:�ti��tiQ Amount: Description of Equipment Item Cost: X S \S ��d� sN— S—s &o s ss, Dated: S- LESSEE: City of Carmel One Civic Square B armel, IN f60�/��,J By: Name: Diana Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE PAY VIA WIRE TRANSFER: PAGE 1 Product Billing Page: 1 PHYSIC CONTROL INVOICE CONTROL Mail payments via US Mait to this address only 1 12100 Collections Center Drive 1 I 112109461 I Physio Control, Inc. Chicago, IL 60693 11811 Willows Road NE Post Office Box 97006 Plea reference Invoice Number on your cheek. ',9 04/03/1 2 Redmond, WA 98073 -9706 USA For Inquiries, Call tolt •free:1- 800 -426 -8047 Telephone: 425 867 4000 4' Fax: 425 881 -2405 F.E.I.N. 91- 0697691 BILL TO ACCOUNT: 1 10774201 I SHIP TO ACCOUNT: 10774201 Sold To: 10774201 CARMEL FD CARMEL FD 2 CIVIC SQUARE 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032 UNITED STATES UNITED STATES Please return top portion wall payment. DATE SHIPPED I PURCHASE ORDER NUMBER SALES /SERVILE REPRESENTATIVE -i T`A%QBU` E $10EBAPt 04/03/12 24326 CELLP1 EALL71 liyabj11 003120155002/mj CARRIER CARRIER TRACKING NUMBER SALES ORDER PAYMENT TERMS GRD 2647405515 1 53172364 -00 Net 30 Days $.1.110:.: ;GAPALDG •iafM6e13 ritta1htJON a 0310 x/M '4Ty SNp dtg tO Ct !i !C� Ex't.1t33`avt P1 1 99577 001256 ILP15 MONITOR /DEFIB, CPR, 15 EA y 15 0 33295.001 352039.95 T.j Pace, to 360j, SP02 /CO Discount 9825.67- 1 112L GL, NIBP, CO2, Trend, FT I S /N: 40335281 4033652 I 1 40342627 4034293' II 1 '40344395 4034439' '40344398 40344399 '3 11 40344400 40344401 140344402 40344401 40346170 40346171 1 40346172 Unit pricing reflects trade -in discount. Traci: -in units must be returned within 60 de of receipt of neW equipment. I not rieceivled in 60 days you will be rebelled to reflect the price .without the trade -in discount-I Please refer to the trade -in information packet ini used in your new equipment shipment to locate shipping labels and the Return Materials Authorization number. This will ensure the prompt and acc acceptance of our !units to complete the trade -in portion of your order. 1 *R Clerk Please retain packing mat rial to return trade -in units. I 214'11577 000126 L915 ACCRY SHIPKIT,AHA,S 15 EA 15 0 0.00 k 0.00 IT1 L /C: 40353173 15 CONTINUED M u r II tea ACCEPTED NOTE: TERMS CONTAINED ON THE REVERSE SIDE OF THIS DOCUMENT ARE EXPRESSLY MADE A PART OF THIS SALES AGREEMENT AND ARE INCORPORATED HEREIN. Product Billing Page 2 P CONTROL INVOICE Mail payments via US Mail to this address only 1 12100 Collections Center Drive I 112109461 Physio Control, Inc. Chicago, IL 60693 11811 wi Box Road NE Pl reference I Number on our check. 04/03/12 Post Office Box 97006 Y Redmond, WA 98073 -9706 USA Far Inquiries, Call toll free; 1. 800 -426 -8047 Telephone: 425 867 4000 ......;L ..........:i Fax 425 881 -2405 FE 91- 0697691 BILL TO ACCOUNT: 1 10774201 I SHIP TO ACCOUNT: 10774201 Sold To: 10774201 CARMEL FD CARMEL FD 2 CIVIC SQUARE 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032 UNITED STATES UNITED STATES Please return top portion with payment. DATE SHIPPED PURCHASE ORDER NUMBER SALES/SERVICE REPRESENTATIVE i T TAi(AHLE e E?EEPAPt 04/03/12 24326 CELLP1 EALL71 liyabjl 00312oissod2/mj CARRIER CARRIER TRACKING NUMBER SALES ORDER PAYMENT TERMS GRD 2647405515 I S3172364 -00 Net 30 Days oms t CA oat *mum atciiiim©N :..l art OUA ttiM tITY Slit ltyBiG *P4Vt Pmes to tam, Pt l 3 11996-000091 ELECTRODE ASSY ADULT, QC 30 PK 30 0 37.00 0 -00 IT STD, WORLDWIDE Discount 37.00 i L /C: 204731 Expires: 08/2 /14 30 sz3fY 41.21330- 001365 ASSY TEST LOAD, ENGLISH 15 EA 15 0 90.00 0.00 T] Discount' 90.00- 5,_21340 000438 CD -ROM, SERVICE_MANUAL';. 1 EA 1 0 #61 -00 0 .00 T3 IL915, ENG Discount) 61.00 1 6 21330-001357 iDVD ROM, ASSEMBLY, 1 EA 1 0 29.00 0.00 TI INSERVICE,LP15 Discount' 29.00- 1 7 21330-001176 LI IONBATTERY 5.7 AMP' 48 EA 48 0 400.00 14976.00 T;j HOUR CAPACITY Discount 88.00- L /C: 1211 Expires: 03/1 '/1.7 48 I 3 8 11140-000052 LP 15 ADAPTER- 8 EA 8 0 175.00 1120.00 T REDI- CHARGE BATTERY Discount 35.00 CHARGER L /C: 110609 8 rr: i 9,11171-000049 'd RAINBOW DCI ADT REUSABLE 21 EA 21 0 ::773.00 12600.00 T CONTINUED VISA ACCEPTED NOTE: TERMS CONTAINED ON THE REVERSE SIDE OF THIS DOCUMENT ARE EXPRESSLY MADE A PART OF THIS SALES AGREEMENT AND ARE INCORPORATED HEREIN. Product Billing Page: 3 PHYSIO CONTROL INVOICE Mail payments via US Mail fo this address only 12100 Collections Center Drive I 112109461 Physio Control, Inc. Chicago, IL 60693 s Post 11811 Willows Road NE 4 pl reference invoice Numb er on cur check II 04/03/12 Post Office Box 97006 k y Redmond, WA 98073 -9706 USA F or Inquiries, Call toll freed 800 426 8047 1 Telephone: 425 867 4000 ......J: Fax: 425 881 -2405 F.E.I.N. 91- 0697691 BILL TO ACCOUNT: 1 10774201 I SHIP TO ACCOUNT: 10774201 Sold To: 10774201 CARMEL FD CARMEL FD 2 CIVIC SQUARE 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032 UNITED STATES UNITED STATES %ease velum top Portion with payment. DATE SHIPPED PURCHASE ORDER NUMBER SALES/SERVICE REPRESENTATIVE ENEEDRAWCORVIRSMS 1 04/03/12 24326 CELLP1 EALL71 liyabjl 003120155002/mj CARRIER CARRIER TRACKING NUMBER I SALES ORDER PAYMENT TERMS GRD 2647405515 I S3172364-00 Net 30 Days IIis GAPAI.4G t i Nip pE&l`.RIP oti Otq erip Ih4 pyy SHP 4ty Nib t sr Pico k%T1'4TAt, tt SENSOR, REF 2696 Discount' 173.00 1 1 L /C: 12AT1 21 11M 10 11171 0.00050 (RAINBOW DCIP PED REUSABLE !.21 EA 21 1 0 '.912.00 13440.00 T3 SENSOR, REF 2697 Discount 272.00- L/C: 12 CQ4 21 11 .1AA11160L-000001H IBP CUFF- REUSEABLE,INFANT j15 EA 3 15 0 119.00 228.00 T1 Discount 3.80 11160 000003 !N IBPCUFF REUSEABLE,CHILD €15 EA 15 i 0 '.22.00 I 264.00 Tj I Discount 4.40- 13 11160 000007 NIBP CUFF- REUSEABLE,LARGE 15 EA 15 0 30.00 360'.00 T- ADULT Discount 6.00 14411577 00:0002 KIT CARRY BAG, MAIN EAG 16 EA 15 0 2 68 00 3328`.00 T' Discount 60.001 1511577- 000001 KIT -CARRY BAG,- SHOULDER +:16 EA 16 0 ::30.00 4 0' j l 16 11220 000028 Top Pouch 15 EA 15 0 1 u :48.00 564'.00 T? Discount 10.40 1 CONTINUED sm v� magelaull ACCEPTED NOTE: TERMS CONTAINED ON THE REVERSE SIDE OF THIS DOCUMENT ARE EXPRESSLY MADE A PART OF THIS SALES AGREEMENT AND ARE INCORPORATED HEREIN. Page: 4 PHYSIO Product Billing CONTROL INVOICE Mail payments via US Mail to this address only 12100 Collottions Center Drive 1 I 112109461 I Physio Control, Inc. Chicago, IL 60693 n s11 Willows Road NE Post Office Box 97006 Pleas r eference invoice Number on your. check. 04/03/12 Redmond, WA 98073 USA E Por Inquiries, Call toll free !1 -BOO -426 -8047 Telephone: 425 867 4000 ...i. Fax: 425 -881 -2405 F.E.I.N. 91- 0697691 BILL TO ACCOUNT: 1 10774201 I SHIP TO ACCOUNT: 10774201 Sold To: 10774201 CARMEL FD CARMEL FD 2 CIVIC SQUARE 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032 UNITED STATES UNITED STATES P /ease return top portion with payment. DATE SHIPPED PURCHASE ORDER NUMBER SALES /SERVICE REPRESENTATIVE ?'i t' 3�ANF1BIE E':C�1Rt 04/03/12 24326 CELLP1 EALL71 liyabjl 003120155002/mj CARRIER CARRIER TRACKING NUMBER SALES ORDER PAYMENT TERMS GRD 2647405515 I 83172364 -00 Net 30 Days 04tig TA1,17 HESM6 R S ih'bR N MY:.OHA, Jll /t�kI bwt StiP .Ff.YY 1}7Q UNFT Pfk1C1 i ct 1'X T4S T tE 17 11260 000039 KIST CARRY BAG, REAR !16 EA 16 0 X69.00 857 60 T;i POUCH Discount 15.40- 18 11141- 000115 BASE -REDI CHARGE MOBILE 6 EA 6 0 1.295.00 6216.00 T" 1 'BATTERY CHARGER Discount 259.00 L/C: 101102 6 19 11140-000015 ILIFEPAK 20 AC POWER CORD f 6 EA 6 0 `69.00 321.60 T Discount 15.40 20 11171-000037 RC 4, PATIENT CABLE,' 4FT, 6 EA 6 0 242.00 1128.00 I .T 'REF 2406 Discount 54.00 L /C: 11N53 6 21 CABLE, 4 WIRE LIMB LEAD 4 EA 4 0 '320.00 1024.00 T' SFT AHA, 12 LEAD ECG Discount 64.00- 1 L /C: 0212 4 22 11111-000022 CABLE, 6 WIRE PRECORDIAL Y 6 EA 6 0 128.00 614.40 T AHA, 12 LEAD ECG Discount 25.60 L /C: 0112 6 23111113- 000004'.QUIK -COMBO THERAPY CABLE 2 EA 2 0 324.00 504.00 1T I 1 CONTINUED v a -..d. ACCEPTED NOTE: TERMS CONTAINED ON THE REVERSE SIDE GE THIS DOCUMENT ARE EXPRESSLY MADE A PART OF THIS SALES AGREEMENT AND ARE INCORPORATED HEREIN. Product Billing Page: 5 P CONTROL INVOICE l Mail payments via US Mali to this address only i 12700 Collections Center Drive I 112109461 Physio Control, Inc. Chicago IL 60693 11811 Willows Road NE Post Office Box 97006 Pleasereference Invoice Number ott your cheek j 04/03/12 Redmond, WA 98073 9706 USA For Inquiries Call toll fres 1 800 42fi 8047 ]3 Telephone: 425 867 4000 ....I..i1 Fax: 425 881 -2405 F.E.I.N. 91- 0697691 BILL TO ACCOUNT: 1 10774201 I SHIP TO ACCOUNT: 10774201 Sold To: 10774201 CARMEL FD CARMEL FD 2 CIVIC SQUARE 2 CIVIC SQUARE CARMEL, IN 46032 CARMEL, IN 46032 UNITED STATES UNITED STATES Please return top portion with payment DATE SHIPPED I PURCHASE ORDER NUMBER SALES /SERVICE REPRESENTATIVE Y Y i*Og E' NOTR 104/03/12 24326 CELLP1 EALL71 liyabjll 003120155002/mj CARRIER CARRIER TRACKING NUMBER SALES ORDER PAYMENT TERMS GRD 2647405515 I S3172364-00 Net 30 Days i •_CAtAi,tY#;: f iMB t7£Sh R3P't16N O0.1 O iA tt1M OV SHP ,G.tY iO :�:#inxrf AkICk i' £XY T iMf, t Si Dis 72.00 L/C: 1206 2 39;26500- 002930 Other labeling,MIN label 1 '15 EA 15 0 0.00 0' ?00 for UPS Ground From Used with Trade -in Mailings 140;26500 0,02743 OTHER LABELING,_TRADE IN is 1 EA 1 0 0.00 0.00 T INSTRUCTIONS Contact: MARK HULETT Phone: 317.571.2663 Sub Total 409585.55 gg Freig t and Handlin•, 185.00 QUOTE #1 210663146.6 I TRADE IN SN:' 80678995,14210497,31516391 ,13044134,11870820,3151639 ,12954817, {30689228,12984818 13044135 ,14210498,1298481.,3151638x,, 70423,11984880 DSBI04 /01/12 PARTIAL NO 1 1 I 409770.55 Site: 15 O R I G I N A L V_ =stead E.— ACCEPTED NOTE: TERMS CONTAINED ON THE REVERSE SIDE OF THIS DOCUMENT ARE EXPRESSLY MADE A PART OF THIS SALES AGREEMENT AND ARE INCORPORATED HEREIN. /—Th OP ID: 79 AI 05 /21/112 2 ORLY CERTIFICATE OF LIABILITY INSURANCE DATE 1 Y, 05/2 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 800 678 0361 CONTACT Marianne Uban Hy /ant Group Inc Indianapolis PHONE FAX 301 Pennsylvania Parkway, #201 317 817 5151 1A/C NEE 317 817 5136 A( IC, No). 317 817 5151 Indianapolis, IN 46280 EMAIL W. Michael Wells ADDRESS: marianne.uban @hylant.com PRODUCER CARME80 CUSTOMER ID p. INSURERIS) AFFORDING COVERAGE NAICV INSURED City of Carmel INSURER A: Travelers Insurance Companies Steve Engelking One Civic Square INSURER B: Carmel, IN 46032 INSURER C: INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 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, EXP INSR LTR I TYPE OF INSURANCE IINDRWV[I POLICY NUMBER IIMM/DD/YYYY) IIMM/DD/YYYYI I LIMITS GENERAL LIABILITY EACH OCCURRENCE 1$ 2,000,000 A X COMMERCIAL GENERAL LIABILITY GP09315757 01/01/12 01/01/13 DAMAGETORENTED 50,000 PREMISES (Ea ocmrtence) CLAIMS-MADE X OCCUR MED EXP Any one permn) I 0 PERSONAL BADV INJURY 2,000,000 GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG 2,000,000 POLICY ri PRO n LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000 A X ANY AUTO 8103036P64A 01/01/12 01/01/13 BODFL Ydenl) BODILY INJURY (Per person) ALL OWNED AUTOS BODILY INJURY (Per accident) 5 SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) NONOVNED AUTOS 5 I UMBRELLA LIAR OCCUR EACH OCCURRENCE I EXCESS LIAB CLAIMS -MADE AGGREGATE DEDUCTIBLE S RETENTION 5 WORKERS COMPENSATION 'AC STATU- OTH- AND EMPLOYERS' LIABILITY TORY LIMITS ER V/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/ A E.L. EACH OCCIDENT 5 OFFICER /MEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE EA EMPLOYE 5 II yes. RIPT O E O DESCRIPTION OF OPERATIONS below E.L. DISEASE POLCY LIMIT I 5 A PROPERTY i 630581M4076 01/01/12 01/01/13 SEE ATTACHED DESCRIPTION OF OPERATIONS/ LOCATIONS VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more apace is required) Certificate Holder is named as Loss Payee re: 15 LP 15 Monitor /DEFIH, CPR, Pace. Account 410774201 CERTIFICATE HOLDER CANCELLATION PHYSIO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Physio-Control, Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 1811 Willows Road NE PO Box 97006 AUTHORIZED REPRESENTATIVE Redmond WA, 98 �u4#(_✓ 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD CARME80 PAGE 2 NOTEPAD INSURED'S NAME City of Carmel OP ID: 79 DATE 05/21/12 NAMED INSURED: CITY OF CARMEL CARMEL CLAY PARKS BUILDING CORPORATION CARMEL CLAY BOARD OF PARKS RECREATION CARMEL REDEVELOPMENT COMMISSION CARMEL REDEVELOPMENT AUTHORITY CARMEL CITY CENTER COMMUNITY DEVELOPMENT CORPORATION PROPERTY LIMITS: BLANKET BUILDING AND BUSINESS PERSONAL PROPERTY: $359,353,676 REPLACEMENT COST, AGREED VALUE SPECIFIC BUILDING LIMIT: $2,118,959 SPECIFIC BUSINESS PERSONAL PROPERTY LIMIT: $205,000 BLANKET BUSINESS INCOME/EXTRA EXPENSE /RENTAL VALUE: $5,000,000 ACTUAL CASH VALUE, AGREED VALUE SPECIAL CAUSE OF LOSS FORM EQUIPMENT BREAKDOWN- INCLUDED DEDUCTIBLE: $25,000 FLOOD LIMIT: $10,000,000 W /$50,000 DEDUCTIBLE EQ LIMIT: $10,000,000 W /$50,000 DEDUCTIBLE CONTRACTORS EQUIPMENT LIMIT: $2,9,47,385 W /$1,000 DEDUCTIBLE CONTRACTORS LEASED EQUIPMENT: $100,000 W /$1,000 DEDUCTIBLE MISC. SCHEDULED EQUIPMENT: $2,732,599 W /$1,000 DEDUCTIBLE EDP LIMIT: $880,591 W /$1,000 DEDUCTIBLE COMM'L ARTICLES: $875,830 W /$1,000 DEDUCTIBLE FINE ARTS: $1,759,975 W /$1,000 DEDUCTIBLE