Attachment 4 - SF 28 - Affidavit of Individual Surety.pdf
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AFFIDAVIT OF INDIVIDUAL SURETY
(See instructions on reverse)
STATE OF COUNTY OF SS.
I, the undersigned, being duly sworn, depose and say that I am: (1) the surety to the attached bond(s); (2) a citizen of the United States; and of full age and legally competent. Where the sureties are acting as co-sureties, we, the Sureties, bind ourselves in such 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. I recognize that statements contained herein concern a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious or fraudulent statement may render the maker subject to prosecution under Title 18, United States Code Sections 1001 and 494. This affidavit is made to induce the United States of America to accept me as surety on the attached bond.
1. NAME
(First, Middle, Last) (Type or Print)
2A. HOME ADDRESS
(Number, Street, City, State, ZIP Code)
2B. TELEPHONE NUMBER
4B. EMPLOYER EMAIL ADDRESS
3. TYPE AND DURATION OF OCCUPATION
4A. NAME AND ADDRESS OF EMPLOYER
(Number, Street, City, State, ZIP Code) (If self-employed, so state)
5A. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED
(Number, Street, City, State, ZIP Code)
5C. HOME TELEPHONE NUMBER 5D. BUSINESS TELEPHONE NUMBER
7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND. (LIST THE COMMITTEE ON UNIFORM SECURITIES IDENTIFICATION PROCEDURES (CUSIP) NUMBER AND PAR (FACE) AMOUNT OF
EACH SECURITY).
AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is NOT usable
STANDARD FORM 28 (REV. 2/2021)
Prescribed by GSA-FAR (48 CFR) 53.228(e)
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0001. We estimate that it will take 0.3 hours to read the instructions, gather the facts, and answer the questions.
Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S.
General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
6A. NAME AND ADDRESS OF FINANCIAL INSTITUTION SUBMITTING
THE PLEDGE OF SECURITIES ON BEHALF OF INDIVIDUAL SURETY
(Number, Street, City, State, ZIP Code)
OMB Control Number: 9000-0001 Expiration Date: 3/31/2024
5B. SURETY BROKER EMAIL ADDRESS
6B. FINANCIAL INSTITUTION
EMAIL ADDRESS
6C. ROUTING TRANSIT NUMBER (RTN)
6D. CONTACT PERSON NAME
6F. CONTACT PERSON EMAIL ADDRESS
6E. CONTACT PERSON TELEPHONE
NUMBER
2C. EMAIL ADDRESS
12. SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:
a. DATE OATH ADMINISTERED
MONTH DAY YEAR
b. CITY AND STATE (or other jurisdiction)
Official Seale. MY COMMISSION
EXPIRES
d. SIGNATUREc. NAME AND TITLE OF OFFICIAL ADMINISTERING
OATH (type or print)
DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.
11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (where appropriate) 10. SIGNATURE
8. IDENTIFY ALL LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS.
9. IDENTIFY ALL BONDS, INCLUDING BID GUARANTEES, FOR WHICH THE SUBJECT ASSETS HAVE BEEN PLEDGED WITHIN THREE YEARS PRIOR
TO THE DATE OF EXECUTION OF THIS AFFIDAVIT.
STANDARD FORM 28 (REV. 2/2021) PAGE 2
INSTRUCTIONS
1. Individual sureties on bonds executed in connection with Government contracts must complete and submit this form with the bond. (See Federal Acquisition Regulation (FAR) 28.203, 53.228(e).) The surety must have the completed form notarized.
2. No corporation, partnership, or other unincorporated association or firm, as such, is acceptable as an individual surety (i.e. must be a natural person). Likewise, members of a partnership are not acceptable as sureties on bonds that a partnership or an association, or any co-partner or member thereof, is the principal obligor. An individual surety will not include any financial interest in assets connected with the principal on the bond that this affidavit supports.
3. United States citizenship is a requirement for individual sureties for contracts and bonds when the contract is awarded in the United States. However, when the Contracting Officer is located in an outlying area or a foreign country, the individual surety is only required to be a permanent resident of the area or country in which the contracting officer is located.
4. All signatures of the affidavit submitted must be originals. Affidavits bearing reproduced signatures are not acceptable. An authorized person must 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 a firm, partnership, or joint venture, or an officer of the corporation involved.
STANDARD FORM 28 (REV. 2/2021) PAGE 3
AFFIDAVIT OF INDIVIDUAL SURETY
(See instructions on reverse)
STATE OF
COUNTY OF
SS.
I, the undersigned, being duly sworn, depose and say that I am: (1) the surety to the attached bond(s); (2) a citizen of the United States; and of full age and legally competent. Where the sureties are acting as co-sureties, we, the Sureties, bind ourselves in such 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. I recognize that statements contained herein concern a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious or fraudulent statement may render the maker subject to prosecution under Title 18, United States Code Sections 1001 and 494. This affidavit is made to induce the United States of America to accept me as surety on the attached bond.
1. NAME
(First, Middle, Last) (Type or Print)
2A. HOME ADDRESS
(Number, Street, City, State, ZIP Code)
2B. TELEPHONE NUMBER
4B. EMPLOYER EMAIL ADDRESS
3. TYPE AND DURATION OF OCCUPATION
4A. NAME AND ADDRESS OF EMPLOYER
(Number, Street, City, State, ZIP Code) (If self-employed, so state)
5A. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED
(Number, Street, City, State, ZIP Code)
5C. HOME TELEPHONE NUMBER
5D. BUSINESS TELEPHONE NUMBER
7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND. (LIST THE COMMITTEE ON UNIFORM SECURITIES IDENTIFICATION PROCEDURES (CUSIP) NUMBER AND PAR (FACE) AMOUNT OF
EACH SECURITY).
AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is NOT usable
STANDARD FORM 28 (REV. 2/2021)
Prescribed by GSA-FAR (48 CFR) 53.228(e) Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0001. We estimate that it will take 0.3 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
6A. NAME AND ADDRESS OF FINANCIAL INSTITUTION SUBMITTING
THE PLEDGE OF SECURITIES ON BEHALF OF INDIVIDUAL SURETY
(Number, Street, City, State, ZIP Code) OMB Control Number: 9000-0001 Expiration Date: 3/31/2024
5B. SURETY BROKER EMAIL ADDRESS
6B. FINANCIAL INSTITUTION
EMAIL ADDRESS
6C. ROUTING TRANSIT NUMBER (RTN)
6D. CONTACT PERSON NAME
6F. CONTACT PERSON EMAIL ADDRESS
6E. CONTACT PERSON TELEPHONE
NUMBER
2C. EMAIL ADDRESS
12. SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:
a. DATE OATH ADMINISTERED
MONTH
DAY
YEAR
b. CITY AND STATE (or other jurisdiction) Official Seal
e. MY COMMISSION
EXPIRES
d. SIGNATURE
c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH (type or print)
DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.
11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (where appropriate)
10. SIGNATURE
8. IDENTIFY ALL LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS.
9. IDENTIFY ALL BONDS, INCLUDING BID GUARANTEES, FOR WHICH THE SUBJECT ASSETS HAVE BEEN PLEDGED WITHIN THREE YEARS PRIOR
TO THE DATE OF EXECUTION OF THIS AFFIDAVIT.
STANDARD FORM 28 (REV. 2/2021) PAGE 2
INSTRUCTIONS
1. Individual sureties on bonds executed in connection with Government contracts must complete and submit this form with the bond. (See Federal Acquisition Regulation (FAR) 28.203, 53.228(e).) The surety must have the completed form notarized.
2. No corporation, partnership, or other unincorporated association or firm, as such, is acceptable as an individual surety (i.e. must be a natural person). Likewise, members of a partnership are not acceptable as sureties on bonds that a partnership or an association, or any co-partner or member thereof, is the principal obligor. An individual surety will not include any financial interest in assets connected with the principal on the bond that this affidavit supports.
3. United States citizenship is a requirement for individual sureties for contracts and bonds when the contract is awarded in the United States. However, when the Contracting Officer is located in an outlying area or a foreign country, the individual surety is only required to be a permanent resident of the area or country in which the contracting officer is located.
4. All signatures of the affidavit submitted must be originals. Affidavits bearing reproduced signatures are not acceptable. An authorized person must 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 a firm, partnership, or joint venture, or an officer of the corporation involved.
STANDARD FORM 28 (REV. 2/2021) PAGE 3
8.2.1.3144.1.471865.466429 Standard Form 28 - Affidavit of Individual Surety
| Enter the State.: |
| Enter the County.: |
| 1. Enter the Undersigned's Name (First, Middle, Last) (Type or Print).: |
| 2A. Enter the Undersigned's Home Address (Number, Street, City, State, Zone Improvement Plan (ZIP) Code). : |
| 3. Enter the Type and Duration of Occupation. : |
| 4A. Enter the Name and Address of the Employer (If self-employed, so state). : |
| 6A. Enter the Name and Address of the Financial Institution submitting the pledge of securities on behalf of the Individual Surety (Number, Street, City, State, Zone Improvement Plan (ZIP) Code).: |
| 5C. Enter the Surety Broker's Home Telephone Number.: |
| 2C. Enter the Undersigned's Email Address. : |
| 7. Enter a True Representation of the Assets the undersigned has pledged to the United States in support of the attached bond (list the Committee on Uniform Securities Identification Procedures (CUSIP) number and Par (Face) amount of each security). : |
| 5B. Enter the Surety Broker's Email Address.: |
| 12a. Enter the Month, Day, and Year the Oath was administered (enter 2 digit month, 2 digit day and 4 digit year).: |
| 12b. Enter the City and State (or other jurisdiction).: |
| 12e. Enter the Date the Official Administering the Oath's Commission Expires (enter 2 digit month, 2 digit day and 4 digit year).: |
| 10. Sign here if you are the Undersigned.: |
| 12c. Enter the Name and Title of the Official Administering the Oath (type or print).: |
| 11. Enter the Bond and Contract info to which this Affidavit relates (where appropriate).: |
| 8. Identify all Liens, Judgements, or any other Encumbrances involving subject assets. : |
| 9. Identify All Bonds including Bid Guarantees, for which the Subject Assets have been pledged within 3 years prior to the Date of Execution of this Affidavit.: |
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