AMS-Form-025.docx

PROCUREMENT AND PROPERTY MANAGEMENT DIVISION

BROOKHAVEN NATIONAL LABORATORY

Managed by Brookhaven Science Associates, LLC under contract to the U.S. Department of Energy

ACQUISITION MANAGEMENT SYSTEM FORM

Form No. AMS-Form-025

Revision No. 0.1

APPROVED BY:

A. Guadagni / 01/11/2017

PPM Manager/Date

Payment Bond

State of Incorporation:

Thousand(s) Hundred(s) Cents

OBLIGATION:

We, the Principal and Surety(ies) are firmly bound to the Brookhaven Science Associates L.L.C. and any successor Contractor to operate Brookhaven National Laboratory, (hereinafter called the Obligee) in the above penal sum. For payment of the penal sum, we bind ourselves, our heirs, executors, administrators, and successors, jointly and severally. However, where the Sureties are corporations acting as co-sureties, we, the Sureties, bind ourselves in sum “jointly and severally” as well as “severally” only for the purpose of allowing a joint action or actions against any or all of us. For all other purposes, each Surety binds itself, jointly and severally with the Principal, for the payment of the sum shown opposite the name of the Surety. If no limit of liability is indicated, the limit of liability is the full amount of the penal sum.

CONDITIONS:

The Principal has entered into the contract identified above.

THEREFORE:

The above obligation is void if the Principal promptly makes payment to all persons having a direct relationship with the Principle or a subcontractor of the Principle for furnishing labor, materials or both in the prosecution of the work provided for in the contract identified above and any authorized modifications of the contract that are subsequently made. Notice of those modifications to the Surity(ies) are waived.

WITNESS:

The Principal and Surety(ies) executed this bid bond and affixed their seals on the above date.

PRINCIPAL

Seal

Payment Bond (Continued)

INDIVIDUAL SURETY(IES)

(Seal)

CORPORATE SURETY(IES)

Address:

City, St. Zip:

Liability Limit ($)

Corporate Seal

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Payment Bond (Continued)

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Address:

City, St. Zip:

Liability Limit ($)

Corporate

Instructions

1. This form is authorized for use when a payment bond is required. Any deviation from this form will require the written approval of the Procurement and Property Management Division Manager.

2. Insert the full legal name and business address of the Principal in the space designated “Principal” on the Page 1 of the form. An authorized person shall sign the bond. Any person signing in a representative capacity (e.g., an attorney-in-fact) must furnish evidence of authority if that representative is not a member of the firm, partnership, or joint venture, or an officer of the corporation involved.

3. a. Corporations executing the bond as sureties must appear on the Department of Treasury’s list of approved sureties and must act within the limitations listed therein. Where more than one corporate surety is involved, their names and addresses shall appear in the spaces (Surety A, Surety B, etc.) headed “CORPORATE SURETY(IES).” In the space designated “SURETY(IES)” on the face of the form, insert only the letter identification of the sureties.

b. Where individual sureties are involved, a completed Standard Form 28 - Affidavit of Individual surety, for each individual surety, shall accompany the bond. The Obligee may require the surety to furnish additional substantiating information concerning its financial capability.

4. Corporations executing the bond shall affix their corporate seals. Individuals shall execute the bond opposite the word “Corporate Seal”, and shall affix an adhesive seal if executed in Maine, New Hampshire, or any other jurisdiction requiring adhesive seals.

5. Type the name and title of each person signing this bond in the space provided.

Date Printed 5/11/2017 3 of 3 Date Approved 05/11/2017