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2013 Police Schedule 15 pay request 19 Lease 2013 — Sch # 15 (Police Dept.) Payment Request 14 2013-19 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 14,2013 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: FastSigns Amount: $3540.00 Description of Equipment Item Cost: Decals for 12 new vehicles Dated: October I, 2013 LESSEE: City of Carmel One Civic Square Carmel, IN 46 2 B : Name: Diana Cordray etliadd Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: FastSigns 3915 East 96'1' Street Indianapolis, IN 46240 PAGE I CERTIFICATE OF LIABILITY INSURANCE 3/DATE(M3DD ) 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 Inc-Indianapolis a 301 Pennsylvania Parkway,#201 .i ro,Exu:31L-8-11-5.136 FAX N0)31.7-817-515_1 Indianapolis IN 46280 ADDRESS:marianne.uban @hylaotcom INSURER(S)AFFORDING COVERAGE NAIC b INSURER A:Charter Oak Fire Insurance_C.o 25615 INSURED CARM E80 INSURER B: City of Carmel INSURER C: One Civic Square INSURER D: Carmel, IN 46032 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1271512319 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 I TYPE OF INSURANCE I NSRI WVDI POLICY NUMBER I(MMILDDV'YVWI I(MM/DDYIYYYY)I LIMITS A GENERAL LIABILITY IZLP14T62033 1/1/2013 1/1/2014 EACH OCCURRENCE $2,000,000 DAMAGE X COMMERCIAL GENERAL LIABILITY PREMISES occurrence) $50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $Excluded PERSONAL ADV INJURY $2,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY I I PRO- E III LOC I $ COMBINED SINGLE LIMIT H8103036P64ACOF13 1/1/2013 1/1/2014 A (AUTOMOBILE LIABILITY (Ea accident) I$2,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED 7 SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) XComP X Coll IComp/Coll Ded $2,500 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE __ $ EXCESS LIAB I CLAIMS-MADE AGGREGATE S DED I I RETENTIONS S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N I TORY LIt41TS_._ER_ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED/ n N I A I (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 II yes.describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ r I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it 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 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& its assignors and ACCORDANCE WITH THE POLICY PROVISIONS. assignees do American Lease Insurance AUTHORIZED REPRESENTATIVE 654 Amherst Rd., Ste. 335 Sunderland MA 01375 I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD "I INVOICE: 98- 91234 Page 1 of 1 Date Ordered: 5/15/2013 8:31:01AM FastSigns Phone 317-845-5051 Due Date: 5/16/2013 Time: 5:00:00PM 3915 East 96th St. Fax. 317-845-4428 Salesperson: Jamie Chowning Indianapolis, IN 46240 Email: 98 @fastsigns.com Entered By: Jamie Chowning Salesperson:jamie.chowning @fastsign Date Printed: 5/15/2013 PO#: 27531 Project Description: Impala and Tahoe Graphics - Installed - PO# 25731 Customer: Carmel Police Dept. 3 Civic Square Ordered by: Lee Goodman Carmel, IN 46032 Phone: (317) 571-2500 Email: Igoodman @carmel.in.gov PRODUCT DESCRIPTION QTY SIDES H x W UNIT COST TOTALS VINYL VEHICLE Installed Vehicle Lettering 12 1 1 x 1 $190 00 $2,280.00 Color: WHITE Text: 9 - Impalas 3 -Tahoe INSTALL SUB LOCAL INSTALLATION 12 1 0 x 0 $105.00 $1,260.00 Color: ITEM Text: Install All Graphics on new Vehicle - No Removal FastSigns will install at Police Garage. Other Payments: / Form of Payment Amount Initials Line Item Total: $3,540.00 TERMS: All payments are Net 30, A Finance charge of 2% per month/24% per annum will be Tax Exempt Amt: $3,540.00 added to all past due invoices. CUSTOM SIGNS ARE NON-REFUNDABLE. All Signs Subtotal: $3,540.00 remain the property of FastSigns until paid in full. I agree that FastSigns can remove Taxes: $0.00 said signs if not paid according to the terms on this order. / Total: $3,540.00 RECEIVED/ACCEPTED BY DATE Total Payments: $0.00 Balance Due: $3,540.00 Bill To: Carmel Police Dept. Attention: Lee Goodman 3 Civic Square Carmel, IN 46032 Copyright©2005 FASTSIGNS International, Inc Open Monday- Friday 8:30-6:00 / Closed Weekends SYST EMIFASTS IGNS__CNYS TAL-Inve ioe.F 1101