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2012 Police pay request 8 Lease 2012 Sch #9 (Police Dept.) Payment Request 2012 -8 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 8, 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: Waymire Amount: $10,057.60 Description of Equipment Item Cost: New Vehicle Equipment Dated: May 31, 2012 LESSEE: City of Carmel One Civic Square Cannel, IN 460 2 By: Name: Dia na Cordray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Waymire A.P.S., Inc. 820 Chadwick Street Indianapolis, IN 46225 PAGE 1 AC®RO OP ID: 79 1/4.-- DATE (NMODA yy) 04/20112 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(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 800 678 0361 CONTACT Marianne.Uban Hylant Group Inc Indianapolis 301 Pennsylvania Parkway, #201 317 PH°N PHONE a Ealt.317 8175136 FAX Noy 3,7.817 5151 Indianapolis, IN 46280 E -MAIL W. Michael Wells ADDRESS mari anne.uban @hylant.com PRODUCER CARME80 LUSTOMERID e: INSURERIS)AFFOROING COVERAGE 1 NAM g INSURED City Of Garmel INSURER A: Travelers Insurance Companies Steve Engelking One Civic Square INSURER a: Carmel, IN 46032 INSURER C INSURER 0: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE, POLICIES DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR 1 TYPE OF INSURANCE I R WW1 BR POLICY EFr I POLICYE%P POLICY NUMBER MRJ (MISOIYYYYI (IAMIDD/YYWI LIMITS GENERAL LIABILITY EACH OCCURRENCE I5 2,000,000 A i X COMMERCWL GENERALLIABILIrY GP09315757 01/01/12 01/01/13 DAM AE G70ENTED D t G ET Ea 50,000 j CLAIMS -MADE f X j OCCUR I MEDEXP(Any onepersDn) I5 0 PERSONAL B AOV INJURY 5 2,000,000 GENERAL AGGREGATE s 2,000,000 I GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG i 5 2,000,000 POLICY i I PRO i LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 5 2,000,000 A X ANY AUTO 8103036P64A 01/01/12 01/01/13 (Ea accident) BODILY INJURY (Per person) 5 ALL OWNED AUTOS BODILY INJURY (Per actidenl) 5 SCHEDULED AUTOS 1—i AUTOS PROPERTY DAMAGE (Per 1 NON -OWNED AUTOS 1 UMBRELLA LIAR 1 OCCUR I 1 5 1 EURRENCE MB B CLAIMS-MADE I AGGREGATE I DEDUCTIBLE I i 5 RETENTION 5 1 i S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YU TORY LIMITS I ER_I ANY PROPRIETOR/PARTNERJEXECUTIVE 7 OFFICER/MEMBER EXCLUDES? 1 1 E. L. EACH ACCIDENT NIA /Mandatory In NH) i E.L. DISEASE EA EMPLOYEES II yes, describe under I DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT 15 A PROPERTY 6 3 0 5 81104 0 76 I 01/01/12 I 01/01/13 ;SEE i ATTACHED DESCRIPTON OF OPERATIONS I LOCATIONS VEHICLES {Attach ACORD 101, Additional Remarks Schedule, If more space Is required) SEE ATTACHED. CERTIFICATE HOLDER CANCELLATION HUNTI -2 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. its assignors and assignees CIO American Lease Insurance AUTHORIZED REPRESENTATIVE 654 Amherst Rd. Ste 335 /J /7�L��c�ancsC Sunderland, MA 01375 ©1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NOTEPAD CARMESO PAGE 2 INSURED'S NAME City of Carmel OP ID: 79 DATE 04120112 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: $360,243,099 REPLACE COST, AGREED VALUE SPECIFIC BUILDING LIMIT: $2,623,959 SPECIFIC BUSINESS PERSONAL PROPERTY LIMIT: $150,000 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 NOTEPAD: NOLDERCODE HUNTI -2 CARME80 PAGE INSUftED's NAME City of Carmel OP ID: 79 DATE 04/20/12 The Huntington National Bank and its Assignors and ulp Assignees, ATIMA are named ed as s Lender's Payee Re: Various Police Equlprrenl/Veh c es WAYMIRE A.P.S., INC. d /b /a THE WAYMIRE GROUP 820 Chadwick Street, Indianapolis, IN 46225 TEL: (317) 634 -4824 FAX: (317) 634 -4833 Warehouse Tel: (317) 631 -7551 Fax: (317) 631 -7552 BUSINESS HOURS: 8:00 -5:00 MON -FRI CLOSED SAT /SUN ACCOUNT CPD50 INVOICE 283627 DATE 05/23/12 PO 26110 Stk /Re1 PURCHASED BY: SHIPPED /DELIVERED TO: CARMEL POLICE DEPT CARMEL CITY GARAGE 3 CIVIC SQUARE 3400 W 131st ST CARMEL, IN. 46032 WESTFIELD, IN. 46074 317 733 -4600 317 733 -4600 TERMS: PAYMENT DUE IN FULL WITHIN 30 DAYS OF INVOICE DATE,THANK YOU! DESCRIPTION: LOCAL NORTH /JASON OGLE VEHICLE: YEAR 2012 WC CAPACITY: WDH CAPACITY: SLS PER: FLTMK Tag MAKE CHEVROLET GTW: N/A GTW: N/A MECH.. MODEL: IMPALA /TAHOE /CAPR TW N/A TW N/A WRNTY JS QTY PART 4 ITEM DESCRIPTION MFG SRP COST EA PARTS LABOR TOTAL 4 LG45Y00009 45 "LGND RB LED TD /AL R 2835.25 1000.00 4000.00 4000.00 4 330104T "SMC1 "CONTROL 253.50 85.50 342.00 342.00 2 HKBCAP11* 11" CAPRICE HOOK 0.00 0.00 2 HKBIMP7* 06" IMPALA HOOK KIT 0.00 0.00 2 SSP3000 SMART SIREN PLATINUM 1699.00 999.00 1998.00 1998.00 6 ES100 DYNAMAX 100W SPEAKER 299.00 125.00 750.00 750.00 4 ESB -CAP11 ES100 11 "CAPRICE BRKT 25.00 11.80 47.20 47.20 3 ESB -TAH08 ES100 03 -11 TAHOE BRKT 25.00 11.80 35.40 35.40 20 VTX609C VERTEX LED, WHITE 123.00 59.25 1185.00 1185.00 20 RE7019 MAGLITE SYS NIMH 12V 142.22 85.00 1700.00 1700.00 rDOME7 S z 3 1 z 1 .2:4/9 R Call US for dl�ALITY Produz Service! Ref: W# 105797 MERCHANDISE....$10057.60 SALES TAX 0.00 RECEIVED BY S &H /COD, ETC $ 0.00 Amount Method of Paymei1t INVOICE TOTAL $10057.60 Invoice Total 'h..rged Tcf Cu_tomer Account AMOUNT RCVD $ 0.00 BALANCE DUE $10057.60 Use of provided equipment in any vehicle is the driver's responsibility.