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2013 Police schedule 15 pay request 22 Lease 2013 — Sch # 15 (Police Dept.) Payment Request # 2013-22 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: Dell Marketing L.P. Amount: $4,901.70 Description of Equipment Item Cost: 15 - 2013 VLA Office Pro Plus Licenses Dated: November 12, 2013 LESSEE: City of Carmel One Civic Squar• Carmel,IN 4 I, By: Name: Diana Cord ray Title: Clerk Treasurer (Attached duplicate original of Payee's statement) PLEASE MAIL CHECK TO: Dell Marketing L.P. c/o Dell USA L.P. P.O. Box 802816 Chicago, IL 60680-2816 PAGE 1 ® DATE(MMIDD/YYYY) ACCoR D CERTIFICATE OF LIABILITY INSURANCE 3/25/2013 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 NAME: Mara a Uban Hylant Group Inc Indianapolis (ac°.No.EXt):317-817-5136 (Arc,No):317-817-5151 301 Pennsylvania Parkway,#201 E-MAIL ss:marianne.uban h lant.com Indianapolis IN 46280 @-Y — INSURER(S)AFFORDING COVERAGE NAIC INSURERA:Charter Oak Fire Insurance Co 5615 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 TYPE OF INSURANCE IADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR wVD POLICY NUMBER (MM/DDIYYYY) (MMIDD!YYYY) A GENERAL LIABILITY ZLP14T62033 1/1/2013 1/1/2014 EACH OCCURRENCE $2,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea 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 PRO- JECT A AUTOMOBILE LIABILITY H8103036P64ACOF13 1/1/2013 1/1/2014 COMBINED SINGLE LIMIT (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 Coll Comp/Coll Ded $2,500 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E .DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD rnls Is your lrtvuit.t rage l t . FID Number: 74-2616805 Customer Number: 98574231 Invoice Number: XJ897N395 Sales Rep: Brenda Wade Purchase Order: 31350 For Sales: (Boo)981-3355 Order Number: 499852420 Invoice Date: 11/07/13 Sales Fax: (800)433-9527 Order Date: 11/07/13 Payment Terms: NET DUE 30 DAYS Customer Service: (800)981-3355 Due Date: 12/07/13 Technical Support: (800)822-8965 83 01 0 01 00 N Shipped Via: STANDARD GROUND Dell Online: www.dell.com Waybill Number: MS-VIRTUAL SOLD TO: SHIP TO: ACCOUNTS PAYABLE Terry Crockett IN CITY OF CARMEL IN CITY OF CARMEL ONE CIVIC SQUARE 3 CIVIC SQUARE CARMEL,IN 46032 CARMEL, IN 460322584 PLEASE REVIEW DELL'S TERMS&CONDITIONS OF SALE AND POLICIES AT www.dell.com/uslpolicy OR UPON REQUEST,WHICH GOVERN THIS TRANSACTION Ordered Shipped Item Number Description Unit Unit Price Amount 15 15 A6591288 VLA OFFICE PRO PLUS 2013 EA 326.78 4,901.70 MfgPartNum:79P-04712 MfgName:MICROSOFT CORPORATION Ship.8./or Handling $ 0.00 Subtotal $ 4,901.70 FOR SHIPMENTS TO CALIFORNIA,A STATE ENVIRONMENTAL FEE OF UP TO$5 PER ITEM WILL BE ADDED TO INVOICE Taxable Tax S FOR ALL ORDERS CONTAINING A DISPLAY GREATER THAN 4 INCHES.PLEASE KEEP ORIGINAL BOX FOR ALL RETURN $ 0.00 $ 0.00 S.COMPREHENSIVE,ONLINE CUSTOMER CARE INFORMATION AND ASSISTANCE IS A CLICK AWAY AT WWW.DELL.COM/PU ENVIRO FEE $ 0,00 BLIC-ECARE TO ANSWER A VARIETY OF QUESTIONS REGARDING YOUR DELL ORDER. Invoice Total $ 4,901.70 DETACH AT LINE AND RETURN WITH PAYMENT Ship.&/or Handling $ 0.00 Invoice Number: XJ897N395 Subtotal $ 4,901.70 CD Customer Name: IN CITY OF CARMEL Taxable Tax Customer Number: 98574231 $ 0.00 $ 0.00 Purchase Order: 31350 ENVIRO FEE $ 0.00 Order Number: 499852420 Invoice Total $ 4,901.70 MAKE CHECK PAYABLE/REMIT TO: $ $ DELL MARKETING L.P. CIO DELL USA L.P. $ PO BOX 802816 Balance Due $ 4,901.70 CHICAGO,IL.606802816 Amount Enclosed 000XJ897N39500000004901708300985742318