8-BID ITEM KEY AND ACCEPTANCE BCUA CONTRACT NO. 25-10 FINAL .pdf

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 1 of 15

BID ITEM KEY AND ACCEPTANCE

FORM

Turbine Generator Maintenance, Inspection, and As-Need

Repair & Replacement Parts

Contract No. 25-10

Solicitation Ref. # BCUA-BID-25-10

TO THE BERGEN COUNTY UTILITIES AUTHORITY:

1. The undersigned Bidder proposes and agrees, if this Bid is accepted, to enter into an agreement with Owner in the form included in the Procurement Documents to furnish and deliver goods and special services as specified or indicated in the Procurement Documents for the Contract Price and within the Contract Time indicated in this Bid and in accordance with the Procurement Documents.

2. Bidder accepts all of the terms and conditions of the Advertisement for Bids and Instructions to Bidders, including without limitation, those dealing with the disposition of Bid Security. This Bid will remain open for sixty (60) days after the day of Bid opening.

Bidder will sign the Agreement and submit the documents required by the Procurement Documents within fifteen (15) days after the date of the Owner's Notice of Award.

3. In submitting this Bid, Bidder represents, as more fully set forth in the Agreement, that the Bidder has examined copies of all Procurement Documents and all addenda. All addenda are issued through the Euna Solutions E-Procurement Portal via

BergenBids.com and the system records each respondent as receiving such addenda.

4. It is understood that the Total Price for the entire contract, including options, stated by the undersigned in the Schedule is based on the lump sum in the awarding of the contract.

5. The estimated quantities of goods to be furnished and delivered under the proposed contract are set forth in the Bid Form. Those quantities are to be considered as maximums and are given solely for the comparison of Bids. The Owner does not expressly or by implication agree that the actual will correspond therewith, but reserves the right to increase or decrease the amount of any item or portion of this work that may be deemed necessary by the Engineer. Total value of goods under the contract shall not exceed 120 percent of contract price in accordance with local public contract law. The Contractor shall at no time make a claim for anticipated profit or loss of profits because of any difference between the quantities of goods actually furnished, and the estimated quantities.

6. Bidder must submit their bid via the Euna Solutions E-Procurement Portal accessible through www.BergenBids.com. No other bid format will be accepted.

7. Bidder agrees that goods and special services will be furnished and delivered in accordance with the technical specifications.

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 2 of 15

8. The terms used in this Bid have the meanings assigned to them in the General Conditions.

9. It is further understood that the following procedure will be used: a. Total Price for the entire contract shall be entered through the Euna Solutions E-Procurement Portal utilizing the template provided. b. The E-Procurement system will tabulate totals automatically based upon the estimated quantities listed in the bid table. NO other format of price submission is allowed. c. All bid tables must be uploaded per the instructions in the E-

Procurement Platform to be accepted.

10. When alternate bid items are listed in the Proposal, the determination of which bidder's response to a request for bids offers the lowest price shall be made on the basis of the price of the BASE BID PROPOSAL item plus the price of OPTION YEARS.

Submitted by:

Title:

Signature: ___________________________________ Date: _________________________

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 3 of 15

BCUA CONTRACT 25-10: BID PROPSAL FORM

TO BE COMPLETED ON THE EUNA SOLUTIONS E-PROCUREMENT PLATFORM VIA BERGENBIDS.COM

The undersigned proposes to furnish all labor, materials and equipment required to perform in accordance with specifications and other contract documents prepared by the Authority, at and for the following:

Item# Description Estimated Quantity

M / Unit Price

Total Cost

YEARS ONE AND TWO - INITIAL TERM

1-1 Parts Contingency Allowance: Material Markup (not to exceed 15%)

$200,000 ___% $________

1-2 Regular Hourly Rate for On-Site Maintenance and Repair (Monday-Friday, 7:00 AM - 5:00 PM)

1,000 Hrs $____ $________

1-3 Emergency Response Rate (24-hour response for repairs/maintenance outside normal business hours)

200 Hrs $____ $________

1-4 Annual Service - 3 Units (ASP-652, ASP-654, ASP-583) per Section 7.1

2 Years $____/Year $________

1-5 Freight Allowance $5,000 N/A $5,000

YEAR THREE (OPTIONAL)

2-1 Parts Contingency Allowance: Material Markup (not to exceed 15%)

$100,000 ___% $________

2-2 Regular Hourly Rate for On-Site Maintenance and Repair (Monday-Friday, 7:00 AM - 5:00 PM)

500 Hrs $____ $________

2-3 Emergency Response Rate (24-hour response for repairs/maintenance outside normal business hours)

100 Hrs $____ $________

2-4 Annual Service - 3 Units (ASP-652, ASP-654, ASP-583) per Section 7.1

1 Year $____/Year $________

2-5 Freight Allowance $2,500 N/A $2,500

YEAR FOUR (OPTIONAL)

3-1 Parts Contingency Allowance: Material Markup (not to exceed 15%)

$100,000 ___% $________

3-2 Regular Hourly Rate for On-Site Maintenance and Repair (Monday-Friday, 7:00 AM - 5:00 PM)

500 Hrs $____ $________

3-3 Emergency Response Rate (24-hour response for repairs/maintenance outside normal business hours)

100 Hrs $____ $________

3-4 Annual Service - 3 Units (ASP-652, ASP-654, ASP-583) per Section 7.1

1 Year $____/Year $________

3-5 Freight Allowance $2,500 N/A $2,500

Total Cost Calculation: Estimated Quantity × Unit Price = Total Cost

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 4 of 15

EXPLANATION OF BID ITEMS

YEARS ONE AND TWO - INITIAL TERM

ITEMS 1-1, 2-1, & 3-1 -- Parts Contingency Allowance

Bidder shall provide a material markup percentage not to exceed 15% for parts. All parts must be

OEM replacement parts or approved equivalent.. See Technical Specification Section 3.0 for detailed requirements and pricing formulas. Late delivery penalties apply as specified in the

Supplemental Terms and Conditions.

ITEMS 1-2, 2-2, & 3-2 -- Regular Hourly Rate

Labor services for maintenance and repair work on an as-needed basis. Regular hourly rate applies Monday through Friday, 7:00 AM - 5:00 PM, excluding holidays. Rate includes all costs for tool usage/rental, travel time, mileage, and environmental charges. Technician must arrive within two (2) work days of notification per Supplemental Terms and Conditions. Late response penalties apply as specified. See Technical Specification Section 4.0.

ITEMS 1-3, 2-3, & 3-3 -- Emergency Response Rate

The contractor shall initiate work within twenty-four (24) hours after notification from Authority staff of the emergent event. The cost is based on hourly rate for repairs/maintenance outside of normal business hours (including weekends and holidays) and outside of the regular hourly rate.

The emergency hourly rate shall be the cost of a single technician working onsite and shall include all costs for performing the requested work along with all associated costs for tool usage and/or rental costs, travel time to and from site, mileage, and environmental or casual charges that may result from the performance of the requested task. Payment will be made only for the number of hours performed onsite working at the emergency hourly bid amount. No separate payment will be made for associated costs such as travel time, vehicle mileage costs, tolls, tool usage and/or rental costs etc. The contractor shall also provide the Authority with a 24-hour emergency telephone number that will serve as the notification and dispatch center for service calls from the Authority.

ITEMS 1-4, 2-4, & 3-4 -- Annual Service

Complete annual inspection and maintenance of three Rolls-Royce® 501KB Turbine Power

System Allison Power Generators (Serial #ASP-652, ASP-654, and ASP-583). Includes complete mechanical and electrical inspection, borescope inspection, fuel nozzle inspection, filter changes, functional testing, and comprehensive reporting. See Technical Specification

Section 7.1 for detailed scope of work.

ITEMS 1-5, 2-5, & 3-5 -- Freight Allowance

Arbitrary allowance for freight costs for bid comparison purposes. All shipments must be F.O.B.

destination, freight prepaid and charged back. Standard shipping methods only unless specifically authorized for overnight/air freight. Actual freight charges will be reimbursed based on written freight invoices with no markup. Initial term allowance is $5,000; option year allowances are $2,500 each.

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METHOD OF AWARD

The awarded Bidder will be based on the TOTAL COST of the BASE BID PROPOSAL of the initial contract year and the OPTION YEARS.

CONTRACT TERM

The initial Contract will commence on January 1, 2026, and will be for a term of two (2) years, with an expiration date of December 31, 2027. The Owner shall have the sole discretion to extend the Contract for up to two (2) additional one-year terms at the cost specified in the awarded Bidder's BCUA Contract No. 25-10 Bid Proposal Form submission.

SECURITY REQUIREMENTS

Bid Guarantee: Not required for this bid

Consent of Surety: Not required for this bid

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 6 of 15

STATEMENT ON BID DOCUMENT

SUBMISSION CHECKLIST

For this procurement the Bergen County

Utilities Authority is utilizing the Euna

Solutions E-Procurement Portal via

BergenBids.com through a shared service with the County of Bergen. When preparing your bid, the system will alert you to those documents which are labeled as "Mandatory Forms Which

Shall Cause Your Submission to be Rejected" and "Other Requested Documents Due Before

Contracting". The system will not allow you to submit your bid without including an attachment in each of the mandatory criteria or forms.

Therefore, it is the position of the Authority in consultation with the NJ Department of

Community Affairs Division of Local

Government Services that this format satisfies as a checklist properly delineating those documents needed to be returned at time of bid.

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 7 of 15

BUSINESS REGISTRATION CERTIFICATE

In accordance with P.L. 2009, c.315, all business organizations doing business with any governmental agency (including the Bergen County Utilities Authority hereafter known as

Owner) are required to be registered with the State of New Jersey and provide proof of registration before the Owner may enter into a contract. Therefore, all bidders must submit prior to the time of contract award a copy of the bidder's "BUSINESS REGISTRATION

CERTIFICATE" issued by the Division of Revenue. Bidders can contact the Division of

Taxation, Regulatory Services Branch, at 609-292-5995 for information on the required form.

Bidder's named subcontractors, at all levels, must also provide proof of registration to their contractors until they reach the direct contractor. The bidder has the obligation to obtain these certificates and file them with the Owner prior to the time of contract award. A "subcontractor" is described as a business organization that "knowingly" supplies goods or services to a contractor

(bidder) in fulfillment of a contract with the Owner. "Knowingly" means the subcontractor has affirmative and clear knowledge that the specific goods or services being provided are for the

Owner.

AMERICANS WITH DISABILITIES ACT OF 1990

Equal Opportunity for Individuals with Disability

The contractor and the OWNER do hereby agree that the provisions of Title 11 of the Americans

With Disabilities Act of 1990 (the "Act") (42 U.S.C. S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the owner pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the owner in any action or administrative proceeding commenced pursuant to this Act. The contractor shall indemnify, protect, and save harmless the owner, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The contractor shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the owner's grievance procedure, the contractor agrees to abide by any decision of the owner which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the owner, or if the owner incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the contractor shall satisfy and discharge the same at its own expense.

The owner shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim. If any action or

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 8 of 15 administrative proceeding is brought against the owner or any of its agents, servants, and employees, the owner shall expeditiously forward or have forwarded to the contractor every demand, complaint, notice, summons, pleading, or other process received by the owner or its representatives.

It is expressly agreed and understood that any approval by the owner of the services provided by the contractor pursuant to this contract will not relieve the contractor of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the owner pursuant to this paragraph.

It is further agreed and understood that the owner assumes no obligation to indemnify or save harmless the contractor, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor's obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

CERTIFICATION OF EQUAL EMPLOYMENT

OPPORTUNITY

The undersigned hereby agrees by the submission of this bid and in accordance with Executive

Order No. 11246, Section 202, dated September 24, 1965, the bidder, offeror, applicant, or subcontractor certifies that he shall not discriminate against any employee or applicant for employment because of race, color, creed, or national origin. This obligation not to discriminate in employment includes, but is not limited to, the following:

HIRING, PLACEMENT UPGRADING, TRANSFER OR DEMOTION, RECRUITMENT,

ADVERTISING, OR SOLICITATION OF EMPLOYMENT, TRAINING DURING

EMPLOYMENT, RATES OF PAY OR OTHER FORMS OF COMPENSATION, SELECTION

FOR TRAINING INCLUDING APPRENTICESHIP, LAYOFF, OR TERMINATION.

He further agrees that (except where he has obtained identical certifications from proposed subcontractors for specific time periods) he will obtain identical certifications from proposed subcontractors prior to the award of subcontractors exceeding $10,000, which are not exempt from the provision of Equal Opportunity clause: that he will retain such certifications in his files, and that he will post in a conspicuous place and forward Notice of Non-Discrimination to such proposed subcontractors (except where the proposed subcontractors have submitted identical certification for specific time periods).

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 9 of 15

EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L.1975, c.127)

N.J.A.C. 17:27 et seq.

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES

CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27-5.2.

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 10 of 15

The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable

Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable

Federal law and applicable Federal court decisions.

The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents: Letter of

Federal Affirmative Action Plan Approval; Certificate of Employee Information Report; or

Employee Information Report Form AA-302 (electronically provided by the Division and distributed to the public agency through the Division's website at:

http://www.state.nj.us/treasury/contract_compliance).

The contractor and its subcontractors shall furnish such reports or other documents to the

Division of Purchase & Property, CCAU, EEO Monitoring Program as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Purchase &

Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27-1.1 et seq.

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 11 of 15

BID SUBMISSION FORMATS

CONTRACT CONTACT INFORMATION

Contract Contact Name: _________________________________________________________________

Contract Contact Email: _________________________________________________________________

Contract Contact Cell Phone: _____________________________________________________________

Contract Contact Office Phone: ___________________________________________________________

BID SUBMISSION

Bid is submitted herewith if Bidder is:

AN INDIVIDUAL

Business Name: _______________________________________________________________________

Doing Business As: ____________________________________________________________________

Business Address: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Phone No.: __________________________________________________________________________

Federal Tax ID No.: __________________________________________________________________

BY: ________________________________________________________________________________

(Individual's Name - Print or Type)

Signature: ___________________________________________________________________________

Date: ______________________________________________________________________________

A PARTNERSHIP

Firm Name: __________________________________________________________________________

Business Address: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Phone No.: __________________________________________________________________________

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 12 of 15

Federal Tax ID No.: __________________________________________________________________

General Partner Name: _________________________________________________________________

(Print or Type)

Title: _____________________________________________________________________________

Signature: __________________________________________________________________________

Date: ______________________________________________________________________________

(Note: Address of bidder shall not be a post office box.)

A CORPORATION

Corporation Name: ____________________________________________________________________

State of Incorporation: _______________________________________________________________

Business Address: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Phone No.: __________________________________________________________________________

Federal Tax ID No.: __________________________________________________________________

Name of Person Authorized to Sign: _____________________________________________________

(Print or Type)

Title: _____________________________________________________________________________

Signature: __________________________________________________________________________

Date: ______________________________________________________________________________

Attest: ____________________________________________________________________________

(Secretary)

(Corporate Seal)

(Note: Address of bidder shall not be a post office box.)

A JOINT VENTURE

Joint Venture Name: __________________________________________________________________

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 13 of 15

Business Address: _____________________________________________________________________

City, State, Zip: ______________________________________________________________________

Phone No.: __________________________________________________________________________

Federal Tax ID No.: __________________________________________________________________

Joint Venture Partner 1:

Name: ______________________________________________________________________________

Title: _____________________________________________________________________________

Signature: __________________________________________________________________________

Date: ______________________________________________________________________________

Joint Venture Partner 2:

Name: ______________________________________________________________________________

Title: _____________________________________________________________________________

Signature: __________________________________________________________________________

Date: ______________________________________________________________________________

Joint Venture Partner 3 (if applicable):

Name: ______________________________________________________________________________

Title: _____________________________________________________________________________

Signature: __________________________________________________________________________

Date: ______________________________________________________________________________

(Each joint venture partner must sign. The manner of signing for each individual, partnership, and corporation that is a party to the joint venture should be in the manner indicated above.)

(Note: Address of bidder shall not be a post office box.)

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 14 of 15

BID ACCEPTANCE

BERGEN COUNTY UTILITIES AUTHORITY

Contract No. 25-10

Solicitation Ref. # BCUA-BID-25-10

The undersigned hereby agrees to provide all services in accordance with the specifications and schedule set forth in the Procurement Documents. The Contractor agrees to furnish Turbine Generator

Maintenance, Inspection, and As-Need Repair & Replacement Parts at the dates and times coordinated with the Owner, and to provide qualified personnel and equipment to complete all maintenance, repair, and annual service work in accordance with manufacturer specifications.

The undersigned acknowledges that timely performance is essential to this contract and agrees to:

• Respond to regular maintenance and repair requests within five (5) work days of notification

• Respond to emergency response requests within twenty-four (24) hours of notification

• Maintain continuous work on-site until completion or as otherwise directed by the Authority

• Provide only manufacturer-trained and certified technicians for all work

• Comply with all service specifications and pricing formulas outlined in the Procurement

Documents

Upon request, the bidder will be expected to amplify the statements contained herein as necessary to satisfy the OWNER concerning their ability to successfully perform the services in a satisfactory manner.

The undersigned bidder submitting this proposal or bid certifies and affirms that such bid is genuine and not collusive or sham; that said bidder has not colluded, conspired, connived, or agreed, directly or indirectly, with any bidder or person, to put in a sham bid, or that such other persons shall refrain from bidding, and has not in any manner, directly or indirectly, sought by agreement or collusion, or communication or conference, with any person, to fix the bid price of said bidder or any other bidder or fix any overhead, profit or cost element of said bid price, or that of any other bidder, or to secure any advantage against the OWNER or any person interested in the proposed contract; and further, that such bidder has not, directly or indirectly, submitted this bid, or the contents thereof, or divulged information or data relative thereto to any association or to any member or agent thereof; and, that no member of the

OWNER'S Officials or Employees of said OWNER is interested directly or indirectly in the bid or in any portion of the bid, nor in the Contract or in any part of the Contract which may be awarded the undersigned on the basis of such bid.

Signed this ____________ day of _____________________, 20_______.

Print Name / Title: ___________________________ /______________________________

Signature: X____________________________________

BID ITEM KEY AND ACCEPTANCE BCUA-BID-25-10 Page 15 of 15

BIDDER'S AFFIDAVIT

BERGEN COUNTY UTILITIES AUTHORITY

Contract No. 25-10

Solicitation Ref. # BCUA-BID-25-10

STATE OF _________________________)

) ss.

COUNTY OF _______________________)

_________________________________ being duly sworn, deposes and says that he resides at and that he is the __________________________________________________

(Give Title) of ______________________________________________________________ who signed the above Bid acceptance, that he was duly authorized to sign and that the Bid is the true offer of the Bidder, that the seal attached is the seal of the Bidder and that all declarations and statements contained in the Bid are true to the best of his knowledge and belief.

He further deposes that he has submitted herewith a list of names and addresses of all stockholders and/or partners owning a 10 percent or greater interest therein in compliance with P.L. 1977, Chapter 33, effective March 8, 1977.

Affiant

Subscribed and Sworn to before me this ____________ day of________________, 20____.

X_________________________________