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PAYMENT REQUEST AND ACCEPTANCE CERTIFICATE FORM <br /> To: UMB Bank,n.a. <br /> 1010 Grand,4th Floor <br /> Kansas City,Missouri 64106 <br /> and DE LA�E LANDEN PUBLIC FINANCE LLC <br /> DE <br /> Re: CITY OF DECATUR,ILLINOIS Equipment Acquisition Fund No. estab- <br /> lished by the Escrow Agreement, dated as of MAY tBTH 2p �s , (the "Escrow AgreemenY'), among <br /> DE LAGE LANDEN PUBLIC FINANCE LLC ("Lessor"), <br /> CITY OF DECATUR,ILLINOIS ("Lessee") <br /> and UMB Bank,n.a.,as Escrow Agent(the"Escrow Agent") <br /> Ladies and Gentlemen: <br /> Escrow Agent is hereby requested ta pay from the Acquisition Fund to the person or corporation designated below as Payee,the sum set fo�th below in payment <br /> of a portion or all of the cost of the acquisition of the equipment described belaw.The amount shown below is due and payable under the invoice ot the Payee attached <br /> hereto with respect to the cost of the acquis(tion of the equipment and has not formed the basis of any prior request for payment. The equipment described below is part <br /> or all of the"Equipment"that is listed in the Equipment Lease Purchase Agreement(the"AgreemenY')described in the Escrow Agreement. <br /> uantii eria Number Item Amoun[ <br /> rZ <br /> 0 <br /> �4 <br /> �.� <br /> � <br /> OW <br /> W2 <br /> full legal Name <br /> W <br /> W <br /> � Billing Address Phone Number <br /> C�ry Sta1� Zip Code <br /> Lessee hereby certifies and represents to and agrees with Lessor and Escrow Agent as follows: <br /> 1. The Eq�ipment described above has been delivered,instailed and accepted on the date hereof. <br /> 2. Lessee has conducted such inspection and/or testing of said equipment as it deems necessary and appropriate and hereby acknowledges that it accepts said <br /> equipment for all parposes. <br /> 3. Lessee is currently maintaining ihe insurance coverage required by Section 7.02 of the Agreement. <br /> 4. No event or condition that constitutes,or with notice or lapse of time o�both would constitute,an Event of Default(as such term is defined in the Agreement) <br /> exists at the date hereof. <br /> dated: ,20 . <br /> Lessez CITY OF DECATUR fLLINOIS lessor DE IAGE LANDEN PUBLIC FINANCE LLC <br /> � � a <br /> y� Signature o� Signature °r° <br /> yq [pQ N <br /> N C.� <br /> �c_=s PrintName �� PriniName o <br /> rn a, o <br /> ti <br /> Title Tiile n' <br /> N <br /> r <br /> 002012 All Riphls Reserved.Printed in ihe U.S.A.I2PFDQC218A SO/t2 <br />