2012 Police pay request 2012 11 Lease 2012 Sch #9 (Police Dept.)
Payment Request 2012 -11
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 acknowlalges delivery, installation and receipt in good condition, and hereby
accepts the Equipment described on the attached invoices.
Payee: Kelley Chevrolet LLC
Amount: $39,124.15
Description of Equipment Item Cost:
New Vehicles
Dated: June 18, 2012
LESSEE:
City of Carmel
One Civic Square
Carmel, IN 4 032 f�/ ;J
By: ...ti 1:
Name: Diana Cordray
Title: Clerk Treasurer
(Attached duplicate original of Payee's statement)
PLEASE MAIL CHECK TO: Kelley Chevrolet, LLC
500 E. State Boulevard
Fort Wayne, IN 46805
PAGE 1
OP ID: 79
,acoizo CERTIFICATE OF LIABILITY INSURANCE DATE, 04/20/12
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
600 678 -0361 NAME. Marianne Uban
301 Hy lant
Pennsylvania nsylvania Indianapolis 3 817 5151 PHONE 317 817 5136 FA 317 817 5151
301 Pennsylvania Parkway, #201 (A/C, No,E.p: (Ai no):
Indianapolis, IN 46280 E R marianne.uban@hylant.com
A DUCE �.Y
W. Michael Wells PRODUCER CARME80
CUSTOMER ID*
INSURER(S) AFFORDING COVERAGE NAIC
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. 7 LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN I TYPE OF INSURANCE I I 1 POLICY NUMBER (MM/DD/YYYY) IIMMDDIYYYYI I LIMITS
I LIABILITY EACH OCCURRENCE 2,000,000
A A COMMERCIAL GENERAL LIABILITY GP09315757 01/01/12 01/01/13 DAMAGE TO RENTED
PREMISES (Ea occurrence) 50,000
1 CLAIMS MADE X OCCUR MED EXP(Any one person) 0
PERSONAL B ADV INJURY 2,000,000
GENERAL AGGREGATE 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP /OP AGG 2,000,000
POLICY n TPA I LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 2,000,000
A X ANY AUTO 8103036P64A 01/01/12 01/01/13 (Ea acodenp
BODILY INJURY (Per person)
ALL AUTOS BODILY INJURY (Per accident)
SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Per acadent)
I NONOVVNED AUTOS
UMBRELLA LIAB I OCCUR EACH OCCURRENCE
EXCESS LIAB I CLAIMS -MADE AGGREGATE
DEDUCTIBLE
RETENTION
WORKERS COMPENSATION I WC STATU- OTH -I
AND EMPLOYERS' LIABILITY IN TORY-LIMITS ER
ANY PROPRIETOR /PARTNER /EXECUTIVE I NIA E.L. EACH ACCIDENT
OFFICER /MEMBER EXCLUDED?
(Mandatory In NH) E.L. DISEASE EA EMPLOYEE
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE POLICY LIMIT I
A PROPERTY 630581M4076 01/01/12 01/01/13 SEE
ATTACHED
DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Attach AGGRO 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
C/O American Lease Insurance AUTHORIZED REPRESENTATIVE
654 Amherst Rd. Ste 335 --E4 oc &74/_
,Sunderland, MA 01375
1988 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
LAME NOTEPAD OP I D: 790 PAGE 2 20M2
NSORED'SNAME City of Carmel OP ID: 79 DATE 04/
D INSURED:
CITY OF CARMEL
CARMEL CLAY PARKS BUILDING CORPORATION
CARMEL CLAY BOARD OF PARKS 6 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
CTUAL 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
ISC. 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: HOLDER CODE HUNTI -2 CARME80 RACES
INSURED'S NAME City of Carmel OP ID: 79 DATE 04/20/12
The Huntington National Bank and its Assignors and Assignees, ATIMA are
named as Lender's Loss Payee Re: Various Police EquipmentNehicles
o' -fs: ---7
BUYERS ORDER FOR A MOTOR VEHICLE 4-_,,,,./ f
U N JUN 1s 201
®NEWX USED cb DEMO (USED) MILEAGE 105. /i Date
V CH ISVRO
MAKE CHEViti.4..L1 1RUCII( MODELTA14QE KELLEY CHEVY, LLC
YR. Z0I2 ENG. 8 STK. 14816 500 E. State Blvd.
CYL. No. Fort Wayne, IN 46805
SERIAL 1UfS 2EQ /CR310564 260-0 EUSt 4:40)38
84-5566.800. 553 -5539 DEAL :3I 1
No.
COLORiRi_Al1K TOP TRIM E BON 1 PREII Pease NAME LIMY OF CARMEL
PURCHASE PRICE 28341.50
PLIJQK MA1.) 10U.00 ADDRESS
Please Print I CIVIC SO
EXTRA KEYS 125.00 CITY STATE ZIP
N/A CARMEL IN 46032 -2594
Phone Bus.
N/A (317)571-2414 (317)571 -2414
N/A SS No, E mail
deer drav @carme1.in.gov
N/A
TOTAL CHSbb. Sit SETTLEMENT AMOUNT AMOUNT
PURCHASE PRICE BROUGHT FORWARD 285fi1;- 50
LEASE/PURCHASE ORDER TERMS AND CONDITIONS USED CAR ALLOWANCE/DISCOUNT N jp
This Lease/Purchase Order is subject to the following terms and o«kdons: TRADING DIFFERENCE 28586.50
1. TRADEIN CERTIFICATION: If the customer hes traded in a motor vehicle On this purchase Or lease. the customer N/A hereby warrants, represents, and coral fu th
s Dealer that e trade-in Vehicle has never been tided t0 required be INDIANA SALES TAX
trawl under any state «federal Law as a'Rebuilt: or'Sahrage' «'Flood; Or'Detective; Or 'Manufacturer Buyback'
motor vehide. If the customer has 0 badean vehicle. the customer further: (1) warrants. represents, and centres N BALANCE ?Rh. 50
Dealer tlal the trade-in veh0e is treed any and all dens or encumbrances of any kind or nature whatsoever. Other than
the spoors balance owed (d any) as set ter h on this Purchase order, and (2) the dale to the trade-in vehicle shall be BALANCE DUE ON TRADE -IN 11 A
delivered to the Dealer free and clear of alt liens and encumbrances thereon at time too custaner takes p013005inn
of motor vehicle purchasedneased pursuant to this Purchase Oder, provided, however, in the event the dale is in GOOD UNTIL:
the possession of denholder being paid on as set forth on this Purchase Order. then tide shall be delivered to the
Dealer wren. seven (T) days from the date hereof. BAL. OWED TO:
2. WARRANTY INFORMATION:
a. NEW OR DEMONSTRATOR: II the motor vehicle is new or a demonstrator. the only warranty provided wed respect
10 the motor vehicle and factory Maenad accessories is the most recent apprised° pnnted warranty winch i0 made
Sd01y by tba Manulaclurer of the motor vehicle and delivered to customer or found In the motor vehicle at the time
of delivery. A demonstrator is considered a used vehicle and not a new motor vehicle. Dealer Installed Accessories
are not included in the Manufacturers warranty on the motor vehicle and may or may not be inducted In Separate
waren warranties which are made sorely by the manufacturer, installer or supplier of the Accessories.
G "AS IS': If the motor vehicle 5 a new demonstrator. or used motor vehicle. Pie moIO. vend° is sold Or leased by
Ma Dealer 10 the costumer in 'AS IS rmdhion,ex<eq for any Palled "drone provided sdelybY the deulaciate, RUSTPROOFING FAB. COAT SEALANT H R
with respect to new w demonstrator motor vehicles. and except I« any Separate wnnen warranty, 0 any, expressly
ns
made or ludshed by the Dealer on its own behalf with respect m used motor vehicles, in whim rase. the only EXT. WARRANTY L,
On warranty provided Is m k et spec express written warnry, II any. a the customer has purchased a service contract N A
We vehicle, the Customer understands that the customer Nall look solely to the provler4ssuer of that service EVR FILING FEE �d
contract, and shall not look to Dealer Mr honoring or perlomunce of that service contract. (I A
c. DISCLAIMER OF WARRANTIES: ALL VEHICLES: WHETHER THE VEHICLE 15 NEW, A DEMONSTRATOR OR
USED: UNLESS DEALER FURNISHED BUYER WITH A SEPARATE WRf TEN WARRANTY OR SERVICE TITLE LICENSE 01 R (1 /p
CONTRACT MADE BY THE DEALER ON DEALER'S BEHALF. DEALER DISCLAIMS ALL WARRANTIES, DOCUMENT PREPARATION AND
WRITTEN, EX PRESS OR IMPLIED, INCLUDING ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR VEHICLE DELIVERY CHARGE WA
A PARTICULAR PURPOSE, AND DEALER EXPRESSLY DISCLAIMS ANY LIABILITY TO PURCHASER, FOR
ANY CONSEQUENTIAL DAMAGE, LOSS OF TIME, OR INCONVENIENCE ARISING OUT OF THE PURCHASE TIRE TAX j 25
OR OPERATION OF THE VEHICLE. THIS DISCLAIMER OF WARRANTIES AND FOR ANY INCIDENTAL ON
CONSEQUENTIAL DAMAGES APPLIES TO PERSONAL INJURY. BODILY INJURY OR WRONGFUL DEATH TOTAL 95
ONLY TO THE EXTENT PERMITTED UNDER APPLICABLE STATE LAW. ALL OF THE TERMS AND
CONDITIONS OF THIS LEASE/PURCHASE ORDER ARE SEVERABLE, AND THE INVALIDITY OF ANY BALANCE 28 5ypp 5
.7l
PARTICULAR TERM SHALL NOT OPERATE TO VOID THE REMAINING TERMS. ll1 JTf
3. MISCELLANEOUS: In signing this Purchase Order is 0 t0 be understood that the customer will 000 possession of P ARTIAL PAYMENT
the ,roar vehicle within ten days after notice that same is ready for delivery as per terms agreed upon. In the event of I
this Purchase Order being canceled, No Dealer reserves the right t0 retain all deposits as liquidated damages. when
a mom vehicle is to be purchased an adt or leased. then Me purmasanase is contingent open the Dealer Obtaining BALANCE 2A SAa 7;
the consent and approval of the customer's ledemessor. R such consent H not obtained. dened. or refused. customer
shad immediately return me motor vide to the Dealer. and this Lease/Purchase Order shad be null and void.
TNe of ownership to the motor rondo shad not pass or he transferred one final lull payment is made and dear title
is obtained to any motor vehicle you traded In on the purchase/lease. OuSlomer acknowledges and agrees that a
separate forum Selection and Arbitration Agreement has been executed and is incorporated as pan of this
Lease/Purchase Omer. This Lease/Purchase Order and incorporated incorpoted Fo Selection and Arbitration Agreement CASH ON DELIVERY 9850, -75
contain Me entire agreement between the customer and Dealer. and then are a verbal agreements or uxfersendngs
as to the purmas«Iease of the motor vehicle. BALANCE N/A
This Purchase Order's presented on no basis d a l0 the immediate aeptance.e event a used motor wahine Is being
traded in on a new or nsd motor vehicle purchase, this Purchase Order is subject w the used motor vehicle being
delayed in the same condition and with me same equipment and suwenlilly the same mileage as when appraised. LIEN TO:
When a new motor vehicle is ordered from the factory, the used motor vehicle bade -in Is subject 10 reappraisal at the
time of avail delivery.
Any Btrlden01 Federal or State Tax w enecessitated ma delivery charges necessitated id
ted by Dnlve -aways ce press are t0 be pa
by the customer end al purchase Orders are contingent upon stakes. delays of carder or other causes beyond Jr o
control Al prices on change the motor vehicles are subject t0 ange w hoo!. once a the Manufacturer changes e prices.
n Dealer is providing customer with a free carwasb pass, that lass and the right to a tree smash extends to the
original purchaser only and Is not assignable or transferable, voluntarily 00 unvolunarily. Customer understands that
certain vehicles, due to size or otherwise, may not be able to use the carwash at all or from time to time. Dealer resents
Pie ngM( i) to impose restrictions and c«kitions on the use of the rarnash. including the requirement of a camasa lag RECORD OF CAR TRADED IN
or pass: (e) t0 revise its restrictions and acanthus from .me to time. ed rut) 10 mdM die Wore of the tamash
[¢r350n. 1110 type of wwash equipment used. or to terminate the free aressh program in as entirety.
n the Gst«ner H leasing the motor vehicle. the term customer. whenever used hereinaboe, includes asl«ners
states as alessee. Year Make Type
VWE ACKNOWLEDGE READING the ABOVE TERMS AND CONDDIONS AND THAT THEY ARE BINDING UPON i
ME/US AS A PART OF THIS PURCHASE ORDER.THIS ORDER I5 NOT BINDING UNLESS UNDERSIGNED BY AN
OFFICER OF THE COMPANY. 06/0 Color Serial No.
C J --if I- Dated: Mileage
Customer
t s=w;....._ J....
customer
Pfx tiKloti t till/ARIA ,Oated: tR RECORD OF CAR TRADED IN
Accepted bby f Year Make Typal
f1ARK 1 41R1 A E�LER ORHISAUTHORIZEDREPRESENTATIVE
Color Serial No.
SALESMAN 5S No. Mileage
FORM# 437 (2 08) The Reynolds and Reynolds Company FL620664 Q (01/12)
L
BUYERS ORDER FOR A MOTOR VEHICLE i�
JUN 1s
®NEW Cc USED 03° DEMO (USED)
MILEAGE 105 .�LJ Date t 2012
MAKE 4T (MODEL C HE \/R OL ET
rte;Atw .e t KULA t
KELLEY CHEVY, LLC
YR. ENG. O STK. t 4 040 500 E. State Blvd.
CYL._ No.,. 1.I Fort Wayne, IN 46805 SST #:40136
SERIAL L U t Lt4tU4ta.3tJO1 VC 260- 484 5566.800 -553 -5539 DEAL 4:31252
No.
COLOR" 11111 t W r 1 fOP INT. ti1UK I i'Kt 1 OUST. NAME
TRIM Please Print C 1r t OF CARSSEL
POW- ti1st rKtt_t 25305.55
•Lkn)I; limo l
ADDRESS
tXiFiF1 i.k7J 125 Please Print 1 CIVIC SO
CITY CARtW.t STATE ZIP
Ui.:ryC 46032-25$4
`r,i'� IyS.4U
tr ;sty „-r is
f. 4 2r t lY7r N/A Phone (317)571-2414 Bus. (317)571-2414
rrx,>£,. N/A SS No. Email
dcordray@carmel.in.gov
N/A
TOTAL [5 /[b. b SETTLEMENT AMOUNT AMOUNT
PURCHASE PRICE BROUGHT FORWARD 2;72; [t
LEASE/PURCHASE ORDER TERMS AND CONDITIONS USED CAR ALLOWANCE DISCOUNT NIA
This Lease/Purchase Order is subject to the following leans and conditions: TRADING DIFFERENCE 2579 cc
1. TRADE -IN CERTIFICATION: If the customer has traded in a motor vehicle on this purchase or lease. the customer
hereby warrants, represents, and candies to Dealer that The Trade -in vehicle has never been titled Of required to be INDIANA SALES TAX NIA
tilled under any slate or federal law as a 'Rebuilt; or "Salvage,: or Rood or "Defective,/ or "Manufacturer Buybacl
motor vehicle. If the customer has a traded!' vehicle. the customer further: (I) warrants. represents, and remfles to BALANCE 2577 i. cry,
Dealer that the trade-in venue Is tree of any and all liens or encumbrances of any kind or nature whatsoever, other thee
the specific balance owed Of any) as set forth on this Purchase Order, and the title to the trade-in vehicle shall be BALANCE DUE ON TRADE -IN I'1
delivered to the Dealer Free and dear of all liens and encumbrances thereon at the lime the customer lakes possession
of the motor vehicle purchasedneased pursuant t0 this Purchase Order, provided, however. in the event he the 0 in GOOD UNTIL:
the possession of the Penholder being paid on as set forth on Otis Purchase Order, then title shall be delivered to the
Dealer within seven (7) days from the date hereof BAL. OWED TO:
2. WARRANTY INFORMATION:
a NEW OR DEMONSTRATOR: If the motor vehicle is new or a demonstrator, the only warranty provided with respect
to the motor vehicle and factory installed ac ess0ries Is the most recent applicable printed warranty which is made
solely by the Manufacturer of the motor vehicle and delivered to customer or found in the motor vehicle e at the time
of delivery. A demonstrate( is considered a used velbde and not a new motor vehicle. Deaferinstalled Accessories
are ran included in the Manufacturers warranty on the motor vehicle and may Or may not be included in separate
weber warranties which are made solely by the manufacturer, installer or supplier of the Accessories.
a AS 5 II the motor vehicle is a new demonstrator, or used motor vehicle, the motor vehicle is sell or leased by
the Dealer mine customer in"AS IS" condition, except for any primed warranty provided solely by the Manufacturer RUSTPROOFING- FAB. COAT SEALANT N/A
WM respect to new or demonstrator molar vehicles, and except for any separate written warrant$ 11 any, expressly
made or famished by the Dealer on its own behalf with respect to used moor vehicles, in which case. the only EXT. WARRANTY MM N /A
warrant provided is that specific express written warranty. if am II Ole customer has purchased a service contract
on the vehicle, the customer understands that Die customer shall idol solely to the providerLsarer of that service
M0lract, and shall not look to Dealer for honoring or performance of that service contract
EVR FILING FEE WA
c. DISCLAIMER OF WARRANTIES: ALL VEHICLES: WHETHER THE VEHICLE IS NEW, 4 DEMONSTRATOR OR TITLE- LICENSE @L R I j1A
USED: UNLESS DEALER FURNISHED BUYER WITH A SEPARATE WRITTEN WARRANTY OR SERVICE
CONTRACT MADE BY THE DEALER ON DEALER'S BEHALF, DEALER DISCLAIMS ALL WARRANTIES, DOCUMENT PREPARATION AND
WRITTEN, EXPRESS OR IMPLIED, INCLUDING ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR VEHICLE DELIVERY CHARGE I' /A
A PARTICULAR PURPOSE, AND DEALER EXPRESSLY DISCLAIMS ANY LIABILITY TO PURCHASER, FOR 25
ANY CONSEQUENTIAL DAMAGE, LOSS OFTIME, OR INCONVENIENCE ARISING OUT OF THE PURCHASE TIRE TAX
OR OPERATION OF THE VEHICLE. THIS DISCLAIMER OF WARRANTIES AND FOR ANY INCIDENTAL OR
CONSEQUENTIAL DAMAGES APPLIES TO PERSONAL INJURY, BODILY INJURY OR WRONGFUL DEATH TOTAL 9S
ONLY TO THE EXTENT PERMRTED UNDER APPLICABLE STATE LAW. ALL OF THE TERMS AND
[GNOMONS OF THIS LEASE/PURCHASE ORDER ARE SEVERABLE, AND THE INVALIDITY OF ANY BALANCE 7.y 1 r. 011 'T` f�0
pAATICULIR TERM SHALL NOT OPERATE TO VOID THE REMAINING TERMS. C J l
3. MISCELLANEOUS: In signing this Purdrase Order it is to be understood that the customer will take possession of PARTIAL PAYMENT a, /.a
the motor vehicle within ten days after notice that same is reedy for deliery as per terms agreed upon. In the event 01 ry (q
this Purchase Order being canceled, the Dealer reserves the right to retain all deposits as liquidated damages. When
mole vehicle is to be purchased on credit or leased, then the purdaseAease is contingent upon the Dealer obtaining BALANCE 2S72t. -¢{f
the consent and approval of the customer's lender/lessor R such consent is not obtained, denied, or refused. customer
shall Immediately return the motor vehicle to the Dealer. and this Lease/Purchase Order shall be null and void.
Pile W ownership to the motor vehicle shall not pass or be transferred until final full payment is made and dear title
is obtained to any motor vehicle you traded in on the purchase /lease. Customer acknowledges and agrees that a
sepa1ate forum Selection and Arbitration Agreement has been executed and is corporeled as part of this
Lease /Purchase Omer. thisLease/Purchase Order and the incorporated Forum Selectionanand Arbitration Agreement CASH ON DELIVERY
7;;11.510
contain the entire agreement between the customer and Dealer. and there are no verbal agreements or understandings
as to the W rc asrllease of the motor vehicle.
This Purchase Order is presented on the bass of immediate acceptance. In the event a used motor vehicle is being BALANCE 't(t _(iO
traded in on a new or used motor vehicle purchase, this Purchase Order is subject to the used motor vervcle being
adirerea in the same coneieon and with the same equipment and substantially the same mileage as when appraises. LIEN TO:
When a new motor vehicle is ordered from the factory. the used motor vehicle trade -in is subject to Maur: iaar at the e
time of al delivery. J 1. 5 t: i'
Dial u
AM additional Federal or State Tax or extra delivery charges necessitated by Drive- ewaysor Expressare to be paid
by the customer and all purchase orders are contingent upon stakes. delays of carrier or other causes beyond our
emlyd. All prices on new motor vehttdes are subject to change without notice if the Manufacturer changes the prices.
If Dealer Is providing customer w,h a free carwesh pass, that pass and the right to a free carv2sh wends to the
odarnel purchaser only and i4 not assignable or transferable, voluntadty or unvoluntarily. Customer understands that
certain vehicles, due m size or otherwise. may not be ablate use the camasn at all or from time to tide- Dealer reserves RECORD OF CAR TRADED IN
the right (I) to impose restrictions and conditions on the use of carwesn, including the requirement of a earwasn la g
or pass: (ii) to revise its restrictions and conditions from time 0 time, and (iii) to mor the hours of the canwash
operation, the type of carwasn equipment used, or to terminate the tree catwesn program in its entirety
X the customer 'r5 leasing the moles vehicle, the term customer, whenever used hereinabove, includes customers
status as a lessee. 'fear Make Type
VWE ACKNOWLEDGE READING the ABOVE TERMS AND CONDITIONS AND THAT THEY ARE BINDING UPON
MENS AS A PART OFTHIS PURCHASE ORDER. THIS ORDER 15 NOT BINDING UNLESS UNDERSIGNED BY AN
OFFICER OF THE COMPANY. 'Jb /(.i1 /12 Color Serial No.
1 ea Dated: Mileage
Customer
4e p ed
MAP It 7 LLnTy,•, RECORD OF CAR TRADED IN a ary ti.4a 1 t
Customer
AccepteAby°- L:.- Year Make Type
HAD. i 1 tS tt
P v ALER OR HIS AUTHORIZED REPRESENTATIVE
Color Serial No.
SALESMAN SS No. Mileage
FORM# 437 (2 08) The Reynolds and Reynolds Company FL620664 0 (01/12)
0 k k r w e
l
BUYERS ORDER FOR A MOTOR VEHICLE
NE W th C'' USED ®DEMO(USED) MILEAGE 105 t u Date 1st 2 012
CH EV 6T
MAKE LittvitULtt INU! A MODEL IAHUt KELLEY CHEVY, LLC
YR. LV LG ENG. 8 STK. 14UUJ 500 E. State Blvd.
Fort Wayne, IN 46805 CUST N.740138
SERIAL 1t2 Lt- LkUSLN.'.U3L,30 260- 484 5566.800 -553 -5539 DEAL 0:31258
No.
COLORP Ut..3IA S1f.TOP T I M EBUiYY PRE.1 CUST CITY OF CARlitl
PURCHASE PRICE 2 5305.55
fLUUN FLAIS 100.00 ADDRESS
Please Print 1 CIVIC SO
EXTRA KEYS 125.00 CITY STATE ZIP
N/A CARIIEL IN 46032 -2584
Phone Bus.
N/A (317)571 -2414 (3171571 -2414
t /A SS No. E mail
dcordrav@carmel.in.gov
R/A
TOTAL LSSi ±I SETTLEMENT AMOUNT AMOUNT
PURCHASE PRICE BROUGHT FORWARD �C41 C,T,
LEASE/PURCHASE ORDER TERMS AND CONDITIONS USED CAR ALLOWANCE/DISCOUNT to
s
R Lease/Purchase Order is subject m the following terms and conditions: TRADING DIFFERENCE 7iii11 r1-5
1. TRADE -IN CERTIFICATION: If the customer has traded in a motor vehicle on this purchase or lease. Me customer
hereby warrants. represents, and certifies t0 Dealer that the trade-in vehicle has never been tided a required to be INDIANA SALES TAX N/A
under ei aM stale Or federal law as a'Rebuilt: or :Salvage: of 'Flood: or 'Defective: or 'Man lecturer Buyback'
meta wta vehicle. II the customer pus a bade -in vehicle. the wv mM
aner er: D m N
warrants. represents, e ceres to BALANCE )18" 2541I i CY l
Dealer That Me trade -in vehicle is free 01 any and all liens or encumbrances of any kind or nature whatsoever. other Than
the speck balance owed (il any) as set pnlh on this Purchase Order, and (2) the ale to the Irade-en wllide shall be BALANCE DUE ON TRADE -IN N/A
delivered m the Dealer Use and dear of at lens and encumbrances thereon at the lime the cu5lcmer takes possession
w are motor vehicle purchasedleased pursuant to This Purchase Order, provided, however, in the event the toe is in GOOD UNTIL:
the possession of the Iienholer being paid Oft as set forth on this Purchase Order. then title shall be delivered to the
Dealer within seven (7) days from the date hereof. BAL. OWED TO:
2. WARRANTY INFORMATION:
a NEW 011 DEMONSTRATOR: If the motor vehicle N new or a demonstrator, the only warranty provided with respect
10 the motor vehicle and factory installed accessories is the most recent applicable printed warranty which is made
solely by the Manufacturer W the motor vehicle and delivered to customer of found in the motor vehicle at the time
d deFrery. A demttatrator is considered a used value and not a new motor vehicle. Dealer instaled Aaesswies
are rql included in the MarMadurers warranty On the motor vehicle and may or may not be kcluded in separate
written warranties which are made solely by the manufacturer, Installer or supplier of the Accessories.
b. "AS IS": If the motor vehicle is a new demonstrator. Or used motor vehicle, the mote vehicle is sold or leased by
le Dealer to the customer in IS' condition. except for any pdmed wamanty provided solely by the Manufacturer RUSTPROOFING- FAB. GOAT SEALANT N/4
with respect m new or demonstrator meta vehicles, and except far any separate written warranty, if arty, expressly
made Or furnished by the Dealer on its own behalf with respect to used motor vehicles. in which case. be only EXT. WARRANTY NIA
warranty provided is that spy express written warranty. If any- It the clstaner has Purchased a service contract
on the vehicle, the customer understands Nat the customer shall look solely l0 the prwider'os er Of that service EVR FILING FEE A
contract. and shall not look to Dealer for honoring or perbrnance of that service conl2ct. j
c. DISCLAIMER OF WARRANTIES: ALL VEHICLES: WHETHER THE VEHICLE IS NEW, A DEMONSTRATOR OR
USED: UNLESS DEALER FURNISHED BUYER WITH A SEPARATE WRITTEN WARRANTY OR SERVICE TITLE LICENSE f1L R H /A
CONTRACT MADE BY THE DEALER ON DEALER'S BEHALF, DEALER DISCLAIMS ALL WARRANTIES, DOCUMENT PREPARATION AND I
WRITTEN, EXPRESS OR IMPLIED, INCLUDING ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR VEHICLE DELIVERY CHARGE 0/A
A
PARTICULAR PURPOSE, AND DEALER EXPRESSLY DISCLAIMS ANY LIABILITY TO PURCHASER, FOR
ANY CONSEOUENTIAL DAMAGE, LOSS OF TIME, OR INCONVENIENCE ARISING OUT OF THE PURCHASE TIRE TAX 1 94
OR OPERATION OF THE VEHICLE. THIS DISCLAIMER OF WARRANTIES AND FOR ANY INCIDENTAL OR
CONSEQUENTIAL DAMAGES APPLIES TO PERSONAL INJURY, BODILY INJURY OR WRONGFUL DEATH TOTAL
ONLY TO THE EXTENT PERMITTED UNDER APPLICABLE STATE LAW. ALL OF THE TERMS AND 2C
CONDmONS OF THIS LEASEWURCHASE ORDER ARE SEVERABLE, AND THE INVALIDITY OF ANY BALANCE
PARTICULAR TERM SHALL NOT OPERATE TO VOID THE REMAINING TERMS. CCi+t PIS
3. MISCELLANEOUS: In signing this Purchase Crdor ins to be understood that the customer will ake possession of PARTIAL PAYMENT
the motor vehicle within len days after notice that same is ready loon delivery as per terms agreed upon. In the event d t.{ A
this Purchase Order being canceled. the Dealer reserves the right (0 retain al deposits as liquidated damages. when
a motor vehicle is to De purchased co credit or leased. then the punclased ease 5 contingent upon the Dealer obtaining BALANCE Peel. on
the invent and approval of Pm customers lendereessor. II such wrsenl is not obtained, denied. Or refused. customer
shall immediately return the motor vehicle to the Dealer. and this Lease/Purchase Order shall be null and sM.
Tice of oe ership w vehicle the motor e shal not pass or be transferred until rural lull payment '0 made and dear title
O obtained 10 any motor vhicle you traded in On the purdaselease. Customer acknowledges and agrees that a j
separate forum Selection and ANoation Agreement has been executed and is incorporated as part of N5
Lease/Purchase Order. This Lease//Purdase Order and the incorporated Forum Selection and Arbitration Agreement CASH ON DELIVERY
,mad tae entire agreement between the customer and Deafen, and Mere are no verbal agreements or understandings n.t.l on
as tO the PurthaseAease of the man vehicle. BALANCE
This Purchase Order Is presented on the basis 01 immediate acceptance. In the event a used motor vehicle is being 41/:1
traded in m a new or used motor vehicle Wrcha5e, the Purchase Order 5 subject to the used molar vehicle being
deivered in the same condition and with the same equipment and seboanumly the same mileage as when app raised. LIEN TO:
When a new motor vehicle is ordered from the adota the used mold vehicle trade -in is subject to reappraisal at the
time M foal delivery.
Any additional Federal or State Tax or extra delivery charges necessitated by Drve-aways or Express are to be paid
by tae auMo er and an purchase orders are Contingent Upon stakes, delays 01 carver or other causes beyond our
control, Al plugs On new motor vehicles are subject to change without roles it the Manufacturer charges the prices.
If Dealer is providing customer with a free canvash pass, that pass and the right lo a free carwash extends to the
anginal purchaser only and is not assignable d transferable, whuntarly of unvaunaMY Customer r.dervams That
Certain vehicles, due to size or otherwise. may not be ace to use the carwas.h at all or from time to time. Dealer reserves
the right (1) to impose restrictions and conditions on the use of raw. ash. eluding the requirement ole carwash tag RECORD OF CAR TRADED IN
or pass: Oil to revise its restrictions and conditions from time l0 lime. and (5) to modify the hours of the cmwash
garhen. the type 01 carwash equipment used. Onto terminate tae bee canvash program in is e t dry.
X the ca5lone is leasing the motor vehicle. the term customer. whenever used he,einabove, includes customers
status as a lessee. Year Make Type
NNE ACKNOWLEDGE READING the ABOVE TERMS AND CONDITIONS AND THAT THEY ARE BINDING UPON
MENS AS A PART OF THIS PURCHASE ORDER.THIS ORDER 15 NOT BINDING UNLESS UNDERSIGNED BY AN
OFFICER OF THE COMPANY Color Serial No.
1:< 9y hP a 4N't Dated: Mileage
Customer i i 1 s o....� -.e. n.':...,., f.i....
HARK T WRIGHT FIYAAU Q RECORD OF CAR TRADED IN
Customer
Accept by T L I R 1 R I't I Year Make Type
DEALER OR HIS AUTHORIZED REPRESENTATIVE
Color Serial No.
SALESMAN SS No. Mileage
FORMA 437(208) The Reynolds and Reynolds Company FL620664 0 (01/12)
to v
BUYERS ORDER FOR A MOTOR VEHICLE
`K ®USED DEMO (USED) MILEAGE 105 Date JUl1 1st 2012
Ma NEW
6 N
MAKE Lilt ViWLt iKUL{. MODEL tA11Ut E VR0 L T
E
L
KELLEY CHEVY, LLC
YR. cute: ENG. 1 STK. t4840 500 E. State Blvd.
CYL. No. Fort Wayne, IN 46805 f ttS l #:40138
SERIAL 1 UTLLLttJ 1_K31ZSt5 260- 484 5566.800- 553 -5539 DEAL #:31253
No.
COLORJUt1t11 I WiITOP T RIM EBONY PRE. 1 Please Print f C1Y OF CARtiE1.
PURCHASE PRICE 25305.55
V twill PtM( IUU.UU ADDRESS
Please Print 1 C IVIC SO
EXTRA KEYS 125.00 CITY STATE ZIP
Iattut ((MMRUMMLS 155 -00 CARHEL IN 45032 -2584
re il'freit zit"( Phone Bus.
f}n 4/A (317)571 -2414 (317)571-2414
N/A SS No. E mail
dCordf 8Yetar10e1 i n. gov
N/A
TOTAL [b /4 7? SETTLEMENT AMOUNT AMOUNT
PURCHASE PRICE BROUGHT FORWARD 7577 S5
LEASEPURCHASE ORDER TERMS AND CONDITIONS USED CAR ALLOWANCE DISCOUNT N/A
The Lease/Purchase Order is subject to to 1000wig terms and midtd': TRADING DIFFERENCE 7572 iii
1. TRADE-IN CERTIFICATION: II the customer has traded in a mole vehicle on this purglese M lease. the Customer
hereby warrants, represents, and sentries t0 Dealer mat me lade -In vehicle has never been bled or required to be INDIANA SALES TAX N A
Died under any slate or federal Iew as a'Rebuitt or 'Salvage: or 'Fbod. or'Defective. or 'Manufacturer Buyback'
motor vehicle. t the meaner has a trade-in vehicle, the customer larder: (1) warrants. re(Xesets. and canes to BALANCE 2572 55
Dealer that the lade -in vehide is free d any and all liens or encumbrances d any kind or nature whatsoever, other than
the spacer balance owed (if any) as set forth on this Purchase Order, and (2) are doe to the trade-in vehicle shall be BALANCE DUE ON TRADE -IN NIA
delivered 10 the Dourer free and dear 01 all (lens and encumbrances thereon at time the customer takes possession
d the motor vehicle purchaaedeased pursuant to this Purchase Order. provided. however. in the event the Idle'' In GOOD UNTIL:
the pose sign d the Iien14der being paid on as set bnh on this Purchase Oder, men tide shah be delivered to the
Dealer within seven (7) days from the dale herwl.
2. WARRANTY INFORMATION: BAL OWED TO:
a. NEW OR DEMONSTRATOR: If the motor vehicle is new or a demonstrator, me only warranty provided with respect
to the rotor vehicle and factory Install ed aaessones'is the most event applicable printed warranty which is made
solely by the Maadxlurer of IM motor veNde and delivered to Mtaner or Mud in the meta vehicle at the time
of dedwry. A demonstrator 5 ceasMered a used vehicle and not a new motor vehicle. Dealer inhaled Accessories
are not included in the Manufacturers warranty on the motor vehicle and may or may not be included in separate
written warranties which are made solely by the manufacturer. installer or supplier of Accessories.
b.
AS IS If the motor veNde s a nes demonstrator, or used motor vehicle, the motor vehicle is sod an leased by
the Dealer to the customer in 'AS (5'de ion. except tor any printed warranty provided meaty by the Mmedadurer RUSTPROOFING FAB. GOAT SEALANT
Mth rasped t0 new or demonstrator motor vehicles, and except to any separate wnden warany, i1 any, expressly. a
made or furnished by the Dealer on is own behalf with rasped to m case. used motor vehicles, in whise. the only EXT. WARRANTY N A
on rt eerie provided is Mal express written warranty, a any n the customer has purchased a service contract
the vehicle, the widener understands That the customer shall taw solely to the prodder/awer of that service
contract. FILING FEE I /,Q contract. and shad to m
t look t0 Dealer for honoring or peranarc d that at service Contract.
c. DISCLAIMER OF WARRANTIES: ALL VEHICLES:WHETHER THE VEHICLE IS NEW, A DEMONSTRATOR OR
USED: UNLESS DEALER FURNISHED BUYER WITH A SEPARATE WRITTEN WARRANTY OR SERVICE TITLE LICENSE DLR IIJA
CONTRACT MADE BY THE DEALER ON DEALER'S BEHALF, DEALER DISCLAIMS ALL WARRANTIES, DOCUMENT PREPARATION AND p
WRITTEN, EXPRESS OR IMPLIED, INCLUDING ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR VEHICLE DELIVERY CHARGE 11 /A
A PARTICULAR PURPOSE, AND DEALER EXPRESSLY DISCLAIMS ANY LIABILITY TO PURCHASER FOR
AMY CONSEOUENTIAL DAMAGE, LOSS OF TIME, OR INCONVENIEN CE ARISING OUT OF THE PURCHASE TIRE TAX 1 25
OR OPERATION OF THE VEHICLE. THIS DISCLAIMER OF WARRANTIES AND FOR ANY INCIDENTAL OR
CONSEQUENTIAL DAMAGES APPLIES TO PERSONAL INJURY, BODILY INJURY OR WRONGFUL DEATH TOTAL
ONLY TO THE EXTENT PERMITTED UNDER APPLICABLE STATE LAW. ALL OF THE TERMS AND 7;
CONDmONS OF THIS LEASE/PURCHASE ORDER ARE SEVERABLE, AND THE INVALIDITY OF ANY BALANCE Y
PARTICULAR TERM SHALL NOT OPERATE TO VOID THE REMAINING TERMS. 7 ;7r2 t,. ,l eYya
3. MISCELLANEOUS: In signing this Purchase Order it is 10 be understood that the customer will lake poSSeSSion of PARTIAL PAYMENT
the motor vehicle within tern days alter note that same Is ready for delivery as per terms agreed upon. In the event of ti (11
this Purchase Order being Canceled, the Dealer reserves the right to retain all deposits as liquidated damages. When
a mace vehicle is to be purchased on meet or leased, men the purchase/lease is contingent upon the Dealer obtaining BALANCE 24726. 1{('
end the consent e appr0 of of the customers (endem essor. II such consent is not obtained, denied, or refused. .customer
shall irmedel
ety return the motor vehicle m me Dealer, Ohs s Lease/Purchase w
chase Order shall be null and do
rNe of ownership to the motor vehicle shall not pass or be transferred until final lull payment is made and dear title
is obtained t0 any mots vehicle you vaded In on the putchasMease. Customer acknowledges and agrees that a
oe aeale ban Selection and Art-anon Agreement has been executed and 0 incbporaled as pen 01 this
Lease/Purchase Omer. This Leasemurmase Order and the incorporated Forum Selection and Arbitration Agreement CASH ON DELIVERY �5 ;'i
contain the entire agreement between the customer and Dealer, and there we no verbal agreements a understandings .AA
n
as to the purmasenease 01 the motor vehde. BALANCE
This Purchase Order s presented on the basis of immediate motor acceptance. In the event a used m vNW I� L e is being t 9 lily
traded n on 8 new Or used motor veNde purchase. this Purchase Order is sublet to the used motor veNde being
delivered in the same condition and wgl the same equipment and sobsanvaiy the same mileage as when appraised. LIEN TO:
When a new motor vehicle Is ordered tram the factory. the used motor vehicle trade-in is subject to reappraisal ache
vote a veal delivery 4:j IC h de `i
Any additional Federal or Slate Tex or extra deivery c arises necessitated by Drive Of Express are lobe paid
by the oWOmer and all purchase orders ere contingent upon ddkes. delays d career or other Causes beyond our
control. AN prices on new motor vehicles are subject to change without tetra 0 the Manufacturer charges the prices.
(1 Dealer is providing customer with a tree carwash pass, that pan end the right l0 a free canvash extends to the
original purchaser only and is not assignable or transferable, vduntaNy or unvoluntarily Customer understands that
certain vehdas, due to sae or otherwise, may not be able louse the carwaeh at all or from time 10 time. Dealer wanes
the right ((110 impose reslnlcnns and WMya' on the use of the Canash. including me requirement d a ca Jsh tag RECORD OF CAR TRADED IN
or pass; (1) to revise its reslnctigm and conditions from time 10 time, and hill to modify the hours of the Carwash
cpeanl n, the type of curwaah equipment used. or to terminate the tree ®awash program In as entirety
It the customer Is leasing me mots vehicle. the term customer, whenever used hereinabove.includes customers
SUNS. as a lessee. Year Make Type
ME ACKNOWLEDGE READING the ABOVE TERMS AND CONomONS AND THAT THEY ARE BINDING UPON
ME/US AS A PART OFTHIS PURCHASE ORDER. THIS ORDER IS NOT BINDING UNLESS UNDERSIGNED BY AN
OFFICER OF THE COMPANY. UD/ U 1/ t Color Serial No.
i r
i-'•1 T C t Dated: Mileage
Customer S
t.
HARR T NRiG FrMarii- atempuhilr» RECORD OF CAR TRADED IN
Customer
A¢epteR,Ey: T }IF i e711 Year Make Type
'bEALER OR HIS AUTHORIZED REPRESENTATIVE
Color Serial No.
SALESMAN SS No. Mileage
FORMS 437 (2 08) The Reynolds end Reynolds Company FL6206640 (01/12)
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