Attachment Q_ SF28 03d Affidavit of Individual Surety.pdf
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- Attached to
- Champlain Administration Lobby Federal contract opportunity
- Solicitation number
- 47PC0220R0019
About this file
This document contains a federal contract opportunity for renovations to the Champlain Administration Lobby. The solicitation requests furnishing and installing all work and labor required to renovate approximately 5,400 square feet of the existing passenger administration building at the Land Port of Entry in Champlain, New York. The interior renovation project includes finish work, ballistic protections, electrical work, minor mechanical work, limited fire protection work, and temporary facilities. As shown in the project documents, the work will require installation of temporary facilities for U.S. Customs and Border Protection, demolition of the existing administration area, construction of the new facility, and removal of the temporary facilities. The solicitation was issued by the General Services Administration Public Buildings Service Region 2.
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Text version
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. I also depose and say that, concerning any stocks or bonds included in the assets listed below, that there are no restrictions on the resale of these securities pursuant to the registration provisions of Section 5 of the Securities Act of 1933. 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) 2. HOME ADDRESS (Number, Street, City, State, ZIP Code)
3. TYPE AND DURATION OF OCCUPATION 4. NAME AND ADDRESS OF EMPLOYER (If Self-employed, so State)
5. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED
(Number, Street, City, State, ZIP Code)
6. TELEPHONE NUMBER
HOME -
BUSINESS -
7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND:
(a) Real estate (Include a legal description, street address and other identifying description; the market value; attach supporting certified documents including recorded lien; evidence of title and the current tax assessment of the property. For market value approach, also provide a current appraisal.)
(b) Assets other than real estate (describe the assets, the details of the escrow account, and attach certified evidence thereof).
8. IDENTIFY ALL MORTGAGES, LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS INCLUDING REAL ESTATE TAXES DUE AND
PAYABLE.
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.
DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.
10. SIGNATURE 11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate)
12. SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:
a. DATE OATH ADMINISTERED
MONTH DAY YEAR
b. CITY AND STATE (Or other jurisdiction)
Official Sealc. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH
(Type or print)
d. SIGNATURE e. MY COMMISSION
EXPIRES
AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is NOT usable
STANDARD FORM 28 (REV. 6/2003)
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: General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
OMB Control Number: 9000-0001 Expiration Date: 2/28/2021
INSTRUCTIONS
1. Individual sureties on bonds executed in connection with Government contracts must complete and submit this form with the bond. (See 48 CFR 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. 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. However, stockholders of corporate principals are acceptable provided (a) their qualifications are independent of their stockholdings or financial interest therein, and (b) that the fact is expressed in the affidavit of justification. 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. 6/2003) BACK
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. I also depose and say that, concerning any stocks or bonds included in the assets listed below, that there are no restrictions on the resale of these securities pursuant to the registration provisions of Section 5 of the Securities Act of 1933. 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)
2. HOME ADDRESS (Number, Street, City, State, ZIP Code)
3. TYPE AND DURATION OF OCCUPATION
4. NAME AND ADDRESS OF EMPLOYER (If Self-employed, so State)
5. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED
(Number, Street, City, State, ZIP Code)
6. TELEPHONE NUMBER
HOME -
BUSINESS -
7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND:
(a) Real estate (Include a legal description, street address and other identifying description; the market value; attach supporting certified documents including recorded lien; evidence of title and the current tax assessment of the property. For market value approach, also provide a current appraisal.)
(b) Assets other than real estate (describe the assets, the details of the escrow account, and attach certified evidence thereof).
8. IDENTIFY ALL MORTGAGES, LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS INCLUDING REAL ESTATE TAXES DUE AND PAYABLE.
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.
DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.
10. SIGNATURE
11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate)
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
c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH (Type or print)
d. SIGNATURE
e. MY COMMISSION
EXPIRES
AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is NOT usable STANDARD FORM 28 (REV. 6/2003) 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: General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW, Washington, DC 20405.
OMB Control Number: 9000-0001 Expiration Date: 2/28/2021
INSTRUCTIONS
1. Individual sureties on bonds executed in connection with Government contracts must complete and submit this form with the bond. (See 48 CFR 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. 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. However, stockholders of corporate principals are acceptable provided (a) their qualifications are independent of their stockholdings or financial interest therein, and (b) that the fact is expressed in the affidavit of justification. 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. 6/2003) BACK
8.2.1.3144.1.471865.466429
STATE OF
0,0,0
COUNTY OF
0,0,0 Social Security Number 0,0,0
1. NAME (First, Middle, Last) (Type or Print) 0,0,0
2. HOME ADDRESS (Number, Street, City, State, ZIP Code) 0,0,0
3. TYPE AND DURATION OF OCCUPATION
0,0,0
4. NAME AND ADDRESS OF EMPLOYER (If Self-employed, so State) 0,0,0
5. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED (Number, Street, City, State, ZIP Code) 0,0,0
6. HOME TELEPHONE NUMBER
0,0,0
6. BUSINESS TELEPHONE NUMBER
0,0,0
7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND:
(a) Real estate (Include a legal description, street address and other identifying description; the market value; attach supporting certified documents including recorded lien; evidence of title and the current tax assessment of the property. For market value approach, also provide a current appraisal.)
0,0,0
(b) Assets other than real estate (describe the assets, the details of the escrow account, and attach certified evidence thereof).
0,0,0
8. IDENTIFY ALL MORTGAGES, LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS INCLUDING REAL ESTATE TAXES DUE AND PAYABLE.
0,0,0 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
11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate) 0,0,0
12. b. CITY AND STATE (Or other jurisdiction) 0,0,0
12. c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH (Type or print) 0,0,0 0,0,0
e. MY COMMISSION EXPIRES. DATE. Enter 2 digit month, 2 digit day and 4 digit year.
0,0,0
12. a. DATE OATH ADMINISTERED. Enter 2 digit month, 2 digit day and 4 digit year.
10. Undersigned Signature Signature of Official Administering Oath
| STATE OF: |
| COUNTY OF: |
| Social Security Number: |
| 1. NAME (First, Middle, Last) (Type or Print): |
| 2. HOME ADDRESS (Number, Street, City, State, ZIP Code) : |
| 3. TYPE AND DURATION OF OCCUPATION: |
| 4. NAME AND ADDRESS OF EMPLOYER (If Self-employed, so State) : |
| 5. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED (Number, Street, City, State, ZIP Code): |
| 6. HOME TELEPHONE NUMBER: |
| 6. 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: |
(a) Real estate (Include a legal description, street address and other identifying description; the market value; attach supporting certified documents including recorded lien; evidence of title and the current tax assessment of the property. For market value approach, also provide a current appraisal.):
| (b) Assets other than real estate (describe the assets, the details of the escrow account, and attach certified evidence thereof).: |
| 8. IDENTIFY ALL MORTGAGES, LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS INCLUDING REAL ESTATE TAXES DUE AND PAYABLE.: |
| 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: |
| 11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate) : |
| 12. b. CITY AND STATE (Or other jurisdiction): |
| 12. c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH (Type or print): |
| e. MY COMMISSION EXPIRES. DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| 12. a. DATE OATH ADMINISTERED. Enter 2 digit month, 2 digit day and 4 digit year.: |
| Signature of Official Administering Oath: |
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