CM RFP 20015 .pdf

1-17

REQUEST FOR PROPOSALS

for

CONSTRUCTION MANAGEMENT SERVICES

(Authority PA 431 of 1984)

TECHNICAL AND COST PROPOSALS

DEPARTMENT OF NATURAL RESOURCES

NEWBERRY CUSTOMER SERVICE CENTER

File No. 751/20015.TAP

PROPOSAL DUE DATE: Thursday, March 9, 2022, 2:00 p.m., EASTERN Time

ISSUING OFFICE

Department of Technology, Management & Budget

State Facilities Administration Design and Construction Division

3111 W. St. Joseph Street Lansing, MI, 48917

2-17

REQUEST FOR PROPOSAL

Construction Management Services for

DEPARTMENT OF NATURAL RESOURCES

NEWBERRY CUSTOMER SERVICE CENTER

File No. 751/20015.TAP

SECTION I – INSTRUCTIONS

I-1 Purpose

This Project Specific Request for Proposal (RFP) for Construction Management Services is issued to Construction Management (CM) firms to provide comprehensive construction management services throughout preconstruction, construction, and post construction phases. The complete RFP is a joint RFQ and RFP submission. Although this varies slightly from previous SOM CM processes, we have elected to combine them within this RFP to expedite the process.

I-2 Selection Process

Interested CM firms with relevant experience and/or qualifications must respond to the requirements included herein. This technical proposal, as well as the interview (if needed), will be evaluated to determine the best value, most responsive construction management firm to provide construction management services for this project. If interviews are deemed necessary, shortlisting to not less than 3 firms will be conducted, but all firms may not be interviewed. The owner reserves the right to reject any and all applicants and may stop the selection process for the project at any time.

Pre-Proposal Site Visit 1:00 p.m., EASTERN February 16, 2023 Cutoff for Questions 2:00 p.m., EASTERN February 24, 2023

RFP Questions/Answers Posted March 2, 2023 RFP Due @ 2pm EASTERN Time, SIGMA VSS March 9, 2023 VIRTUAL Interviews (if needed) March 20-24, 2023 State Administrative Board Submission March 13 or 27, 2023 State Administrative Board Approval March 28 or April 11, 2023

3-17

I-3 Instructions for Proposals and Deadline

The professional must submit a complete, straightforward response to this Request for Proposal. The proposal should describe the professional’s ability to meet the requirements of the Request for Proposal.

The proposal must be submitted electronically through the State of Michigan Procurement System (SIGMA VSS). No other distribution of proposals will be made by the Professional. To be considered responsible and responsive, proposals must be uploaded to SIGMA VSS on or before 2:00 p.m., EASTERN time (ET), on Thursday, March 9, 2023. Proposal must be signed by an official authorized to bind the professional firm to its provisions. NO FACSIMILES OR E-

MAILS OF THE REQUEST FOR PROPOSAL WILL BE ACCEPTED.

The proposal and attachments must be fully uploaded and submitted prior to the proposal deadline. Please do not wait until the last minute to submit a proposal, as the SIGMA VSS system will not allow a proposal to be submitted after the proposal deadline identified in the solicitation, even if a portion of the proposal has been uploaded.

SIGMA has a maximum size limit on file uploads. When uploading, your attachment(s) each attachment must be 6MB or less.

Also, when entering proposal amount, please enter the total cost amount as the bid amount.

Bidder’s failure to submit a proposal as required may result in being deemed nonresponsive.

Questions on vendor registration, proposal submissions, or navigation in the SIGMA VSS system can be answered by contacting the SIGMA Help Desk either by telephone at 517.284.0540 or toll free at 888.734.9749 or by email at sigma-procurement-helpdesk@michigan.gov.

I-4 Contract Award

Contract award will be undertaken by the State of Michigan through DTMB with the construction management firm whose proposal the issuing office determines to be in the state’s best interest.

Firms must complete and sign the attached Certification of Michigan Based Business and Responsibility Certification forms.

The interview, if needed, may be conducted in person in Lansing or in a virtual format.

mailto:sigma-procurement-helpdesk@michigan.gov mailto:sigma-procurement-helpdesk@michigan.gov

4-17

Evaluation and selection will be by an Ad Hoc Committee and will be based on the content of the submitted technical proposal, cost proposal and if conducted, the interview. Each proposer will be evaluated on the thoroughness of the project understanding, the written response to the RFP, cost proposal and any interview presentation.

I-5 Rejection of Proposals

The State reserves the right to reject any or all proposals, in whole or in part, received as a result of this Request for Proposal.

I-6 Incurring Costs

The State is not liable for any cost incurred by the Professional prior to acceptance of a proposal and the award and execution of a contract and issuance of the state's contract order.

I-7 Responsibilities of Construction Manager

The construction management firm is responsible for all construction management services, disciplines and management services of the contract during the design, preconstruction phase and the construction phase to permit owner occupancy at the earliest possible dates and to assure that the project costs will remain within the project budget. The construction management services shall include but are not necessarily limited to cost estimating, coordinating design modifications, assembling contract bidding documents, taking bids, and entering into contracts for all required construction phase services. Responsibilities also include the supervision of trade construction contractors in the performance of their contracts assuring efficient use of materials to provide quality construction at the lowest responsive, responsible cost in accordance with the architectural/engineering contract documents, drawings and specifications with owner approved modifications.

I-8 Responsibilities for DTMB Contractors

The State of Michigan may contract with certain suppliers/installers for materials and services, referred to as DTMB contractors. The construction management firm will be required to coordinate their construction tasks with the DTMB contractors. Examples of possible DTMB contractors may include (if later determined to exclude these items from the CM contract):

• State system furniture contractor for office and administrative office furniture.

• State system carpet contractor for carpet, vinyl floor tile as well as base selection, supply, and installation.

5-17

• State IT / telecom services for installation of data/telecom cabling, racks, etc.

I-9 Inquiries

Questions must be in writing and directed to Tom Pawlowski at pawlowskit@michigan.gov. All inquiries must be submitted no later than 2:00 p.m.

EASTERN time on Friday, Feb 24, 2023. Questions will be responded to in writing and posted via addenda on SIGMA. Include a signed Acknowledgement of any Addenda as part of your proposal response.

SECTION II – PROJECT DETAILS

II-1 Project Description

The Michigan Department of Natural Resources (MDNR) – Finance and Operations Division has taken the lead for multiple MDNR divisions to initiate with the Michigan Department of Technology, Management and Budget (DTMB) to engage firms to design and construct a new Customer Service Center (CSC) building in Newberry, Michigan. MDNR’s vision is for this new state-of-the-art facility to utilize sustainable mass timber panel, beam and column technology.

This project is necessary to construct a CSC that meets the agency's complete program and operational needs and will result in eventual discontinuation of leasing the current insufficient and outdated space nearby.

The MDNR Finance and Operations Division has to-date worked with professional services consultants (PSCs) to complete programming and conceptual schematic and phasing as a platform for design, and to complete preliminary, and more recently 50% final design. The effort is currently on track to complete final design with the documents undergoing plan review by LARA in mid-to late Feb 2023.

The new facility is to be sited on a portion of MDNR property that currently operates as a Forest Resources Division field office and storage facility located just north of the existing leased Newberry CSC building. The new facility was originally designed as an integral CSC building with adjoining storage and operations building. Those structures have more recently been dis-joined and construction of each building separately under distinct phases is planned. Phase I being constructed here is for the CSC building. Elements related to the future phase (e.g., sitework, etc.) may be contained within the Phase I scope.

The CSC building is presently sized at 10,140 square feet and is comprised of -

a. a Reception Area and Community Meeting Room.

b. an MDNR Customer Service Center and MDNR FRD Field Offices.

See the attachments provided for location, a prospective layout, and site features, and related useful documents.

mailto:pawlowskit@michigan.gov

6-17

DTMB and MDNR are interested in receiving CM proposals from firms with experience and qualifications particularly and strongly suited for working closely with their agencies, the PSC, mass timber suppliers and contractors to implement and facilitate timely and quality construction for this state-of-the-art mass-timber frame and featured building. Proposals should demonstrate and highlight all particularly relevant experience, skills, tools, aptitude, and initiative being proposed for the CM firm to successfully complete this work. Proposals should identify the CM firm’s understanding as it relates to the overall site location (i.e., centric Eastern UP), resource availability in the area, potential supply route constraints (i.e. Mackinac Bridge), brevity of seasonal construction window, and other related factors, and how the CM firm will manage those factors.

Project Budget

For the purpose of this proposal, the construction budget, including contingency, should be $7,100,000.00, exclusive of PSC fees and DTMB administration fees.

II-2 Design Professional – The Design Professional for the Project is:

Lord Aeck Sargent 213 S. Ashley St., Ste 200 Ann Arbor, MI 48104

II-3 DTMB Project Director – All inquiries are to be submitted in writing via e-mail to:

Tom Pawlowski Design and Construction | State Facilities Administration Department of Technology, Management and Budget Email: pawlowskit@michigan.gov Phone: 517-242-0973

SECTION III – PROPOSAL INSTRUCTIONS

III-1 Proposal Preparation

The tables provided in Attachment A will assist you in determining the projected total cost for your company to provide the services that are outlined within this

RFP.

The total cost is to include not-to-exceed costs for CM fees, reimbursable expenses including project direct staffing and CM site/project operations expenses, CM liability insurance expenses, Performance and Payment bond expenses for the full CM construction cost, builders risk insurance and any other CM general condition expenses.

mailto:pawlowskit@michigan.gov

7-17

The initial contract will also include an allowance for trade contracts, construction general conditions items and construction contingency allowance (owner must approve all contingency allowance use). The allowance for trade contracts, construction general conditions items and construction contingency shall be part of the initial not-to-exceed CM contract award but shall not constitute a guaranteed maximum cost; provided however that the CM recognizes the Owner’s fixed Project Budget and shall endeavor in a relationship of trust with the Owner and Design Professional to monitor and make recommendations to accomplish the project within the fixed Project Budget. All the terms listed on the tables must be included in your projected total cost and costs for each category must be completed.

If we have failed to include a category or item in Attachment A that you deem pertinent, please include, and note that in your proposal.

III-2 Proposal Signature

Proposal must be signed by an official authorized to bind the company to its provisions.

III-3 Prime Responsibilities

The CM selected will be required to assume responsibility for all services offered in the proposal, regardless of who produces them. The selected company shall be the sole point of contact regarding contractual matters, including payment of any and all charges resulting from the contract. In the event of a joint proposal, such firms shall be jointly and severally responsible for all services offered in the proposal, regardless of who provides/produces them.

III-4 Proposal Preparation Costs

All costs incurred for proposal preparation presentation, or contract negotiations are the responsibility of the CM. The State shall not be responsible for, and will not pay, the cost for any information solicited or received.

III-5 Acceptance of Proposal Contents

The contents of the proposal of the selected company will become contractual obligations when a contract is issued, except regarding particular contents which may be rejected by the State or conflicts with articles of the contract. Failure of the successful firm to abide by such obligations without the express consent of the State will result in cancellation of the award.

8-17

III-6 Proposed Project Schedule

The State and all consultants recognize that this schedule may be modified once the Construction Manager is selected, and the CM and Architect (A/E) firms have jointly reviewed project requirements.

• Preliminary Design Completed May 2022

• Final Design 50% Complete July 2022, revised and will be 90% complete Feb 13, 2023

• NTP Projected (as early as) March 29 or April 12, 2023

• Substantial Completion Spring 2024

• Move In Date June 1, 2024

III-7 Scope of Services

It is assumed that any proposal submitted will include, but may not be limited to, performance of all the activities listed below and in the Form of the Contract Agreement (Attachment B of this RFP). The State may consider alternate proposals; however, to submit an alternate proposal; CM’s must first respond to all requirements of the base RFP and then separately identify its alternate proposal in writing, identifying it as such. Further, if a CM objects to any aspect of this RFP, including but not limited to the proposed agreement (Attachment B), the CM must separately identify the objection, the basis for the objection, and a reasonable alternative in a separate written document attached to the RFP response and identified as "Exceptions to the RFP." Failure of any proposal to identify exceptions as required herein shall be an express and binding acknowledgment that all requirements of the RFP will be satisfied and have been included within the proposal. Exceptions to basic terms and conditions of the SOM contract (e.g.

payment terms, etc.) should not be proposed, as they will be perceived as a lack of understanding of what the Contract contains (a significant faux paus), or a lack of understanding of the ability of the SOM to modify its momentum as a large institution to accommodate one vendor (another significant faux pas).

The Construction Manager's services will include, but are not necessarily limited to, the services identified below, and any other services described in the modified agreement and general conditions (Attachment B) attached hereto.

9-17

A. Pre-Construction Phase Services including bidding/award (DTMB Phase 500)

1. Provide as-needed value engineering and construction advice regarding materials, methods, systems, and other conditions as they affect the project’s constructability and cost.

2. Review drawings and documents and prepare estimates of Phase 500 so the scope of work and project costs can be aligned by the completion of that phase.

3. Work with the project team to identify acceptable bid alternates and provide budget estimates for the alternates for the project team’s review.

4. The CM will primarily be responsible for cost estimating. The PSC will coordinate and provide information to the CM for costing. The CM will lead the value engineering effort, if needed, but both the CM and PSC will work together to provide potential value engineering options to meet budget and schedule constraints.

5. Provide project support and coordination with governmental agencies having jurisdictional authority over the project.

6. Prepare a construction schedule including recommendations for appropriate bidding categories and phases, as well as contract coordination and sequencing.

7. Prepare and maintain a cash flow schedule for the project.

8. Provide as needed services in applying for, tracking, securing, and serve as the permit holder whenever possible for all required project permits. Pay all required permit and inspection fees necessary (reimbursable) for a fully permitted project.

9. Develop proposal forms and write work scope descriptions for each separate bidding category and trade.

10. Qualify contractors, as required, to ensure financial solvency and manpower availability.

11. Qualify subcontractors, as required, to ensure financial solvency and manpower availability.

12. Conduct, joint Pre-bid conference(s) with all bidders for all divisions of work.

10-17

13. Evaluate bids.

14. Conduct post-bid interviews for each bid package and make award recommendations to the project team for their review.

15. Prepare all trade contracts and associated documents, considering project specific issues including but not limited to dispute resolution and insurance matters as required the CM contract.

16. Provide a certificate of insurance for the coverage required for the project by the CM contract.

17. Secure building permits and other governmental agency approvals and advise the State of the same.

B. Construction Phase Services (DTMB Phases 600 & 700)

1. Maintain current, detailed construction and occupancy schedules.

2. Provide full-time, on-site staff to plan, manage, and coordinate trade contractors' activities. The CM firm’s Superintendent shall be the first line of defense for recognizing non-compliant and defective work and requiring correction. An underperforming Superintendent is subject to replacement at the written request of DTMB showing cause.

3. Coordinate and monitor all safety programs.

4. Monitor the schedule daily and take appropriate action with trade contractors that need encouragement to maintain schedule. Schedule shall be a critical path schedule, updated not less than monthly, and shall be managed in close conjunction with the budget to mitigate schedule slippage and cost overruns. Unmitigated budget and schedule slippage is not to be tolerated.

5. Coordinate and hire material testing services as required by the documents, recommended by the CM, and / or requested by the Owner.

6. Provide project support and coordination with governmental agencies having jurisdictional authority over the project for trade inspections.

7. At a minimum, conduct weekly trade contractor’s foremen meetings to review safety and project progress.

a. Update the project team of any activities which may affect operations/schedule.

11-17

b. Provide copies of meeting minutes and distribute to appropriate staff, contractors, and project team within 24 hours of the conclusion of the meeting.

8. Conduct, in collaboration with the Design Professional, project progress meetings for planning, coordination, and payments.

a. Meetings with project team which will include status reports on the project, budget, change orders, and allowances for reimbursable expenses, etc. to be held every other week through substantial completion.

b. Design Professional will be responsible to prepare, with CM review and input, and provide copies of meeting minutes distributed to appropriate staff and project team within 5 days of the conclusion of the meeting.

c. The CM will be responsible for review and validation of sub-contractor payment requests.

d. This project will require State of Michigan Prevailing Wage Rates and the CM must include those provisions in all subcontracts and will be responsible for assuring all payment requests meet SOM Prevailing Wage Rate requirements. Provisions for requesting the appropriate rates are on the DTMB-DCD website.

9. Monitoring and reporting on trade contractor performance and contract compliance.

10. Coordinate and report construction interfaces, methods, techniques, and sequences.

11. Coordinate and monitor implementation of change orders.

12. Review shop drawings for compliance with construction documents prior to distributing to the A/E for their review.

13. Expedite high priority shop drawing with A/E.

14. Collect, assemble, and provide to the State as-built drawings and records, operating and maintenance manuals, warranties, guarantees, and project directories.

12-17

15. Coordinate completion of punch lists, final inspections, State acceptance and occupancy.

16. Acquisition and set-up of necessary construction support items, all in compliance with required bidding procedures and otherwise subject to the State's approval.

17. Manage and coordinate the commissioning process; assist the commissioning agent and project team with commissioning of the building.

18. Provide coordination of all construction trades/activities with any, and all “owner” provided Fixtures, Furniture and Equipment.

C. Post-Construction Phase Services (DTMB Phases 600 & 700)

1. Conduct training sessions for appropriate employees regarding the operation and maintenance of technical equipment. Video record all training sessions for the State's future use.

2. Prepare and deliver 1 paper and 1 electronic copy of all closeout materials, O&M manuals, etc. Provide 1 paper and 1 .pdf as-built markup set of documents to Design Professional; Design Professional is responsible to prepare final corrected Record Documents delivered to the Owner in CAD and PDF formats.

3. Provide follow-up at eleven (11) months after Substantial Completion in order identify and correct any warranty items prior to the one-year (unless notified otherwise) Labor and Materials Warranty expiring.

PART 1 – TECHNICAL PROPOSAL

The proposal must be submitted in the format outlined below. Paginate proposals and ensure that the proposals refer specifically to the project at hand. Proofread proposals for language and mathematical errors. The items shown below are considered in the Ad Hoc Committee proposal review of technical qualifications.

III-8 Business Organization

State the full name, address, and federal I.D. number of the organization and, if applicable, the branch office, consultants or other subordinate elements that will provide or assist in providing the service. Indicate whether you operate as an individual, partnership, or corporation. If a corporation, include the state in which you are incorporated. State whether you are licensed to operate and practice in the State of Michigan.

13-17

Complete RFQ form included in Attachment F.

III-9 Statement of the Problem

State in succinct terms your understanding of the problem presented by this RFP.

III-10 Project Team/Personnel

The Construction Management Firm must be able to staff a project team that has the qualifications and expertise necessary to undertake the project. Include the full names of all personnel by classification that will be employed in the project.

Indicate which of these individuals you consider to be "Key Personnel" for the successful completion of the project, identify them by name and position/classification, and provide their resumes. Each resume should include, at minimum: a) title and project assignment or role that person will be expected to fulfill for this project; b) educational background and professional registrations;

c) a synopsis of experience, training or other qualities which reflect the individual’s potential contribution to the project, with specific emphasis or highlight to relevant and similar project experience/success.

Provide an organization chart outlining authority and communication lines for each

Key Personnel, including client agencies and DTMB.

III-11 Project Approach, Management Summary, Work Plan

Describe in narrative form your unique project approach for this project. CM firm should also outline your work plan and methodology to ensure the success of this project. Describe what services and deliverables will be provided, quality of services and deliverables and unique aspects of your services which will add value to the project.

III-12 Schedule Plan

Describe your project execution plan, including your recommended phasing/sequencing of bid packages to best benefit the project team, budget, and schedule. Provide, at minimum, a summary level critical path schedule based upon your understanding of the project and the program/design provided. Describe how you will develop this initial schedule with the project team from notice to proceed through design to detailed construction schedule. Describe the process and procedures you will use to monitor and control the schedule during construction.

Identify and challenges or opportunities related to the Owner target schedule.

14-17

III-13 Cost Estimating and Control

Provide a preliminary cost estimate or cost model for the project (Refer to Attachments C) as you deem appropriate per your understanding of the project and the program/design provided. Provide your analysis of the proposed project budget project program/design; identify any key items/conditions/areas of challenge and describe your initial suggestions and recommendation to mitigate each; describe potential value engineering opportunities and your process for evaluating the initial suggestions and developing additional opportunities with the team throughout the remaining design/construction process.

III-14 Project Risk Management

The CM will provide Performance and Payment bond covering the full value of the CM/Construction Cost contract. Describe your recommended approach to management of subcontract performance and payment risk and the estimated cost to the project associated with that approach.

III-15 Sustainability

The State endeavors to provide responsible sustainable construction with a goal of documenting the ability to achieve LEED-Silver (not registering or certifying).

Describe your construction waste minimization and/or recycling approaches you would recommend and implement. Describe any other energy conservation or sustainable measures you recommend as value added pursuits.

III-16 BIM and/or 3D clash detection

Describe how important you believe BIM and/or 3D clash detection is to this project and your recommendation for what, if any, level to which it should be implemented to provide best value and why. Is this managed with in house staff or via a trade contract/consultant and what is the estimated expense for the investment.

III-17 Commissioning

Describe how your company will manage the commissioning of the building systems and provide examples of similar projects and processes.

III-18 Additional Information and Comments

Include any other information, references of similar projects displaying your cost estimating, scheduling or other CM services that is believed pertinent but not specifically asked for elsewhere.

15-17

III-19 Insurance and Bond Coverage

Prior to beginning work, the selected firm will be required to provide copies of Surety Bonds and insurance certificates for liability and umbrella coverages as identified in Attachment B.

III-20 Payment of Fees

All fees, reimbursable expenses and general conditions expenses must be itemized on one invoice so that the State may issue one monthly check to the CM.

Design Professional shall certify the AIA 702 cover page of each invoice prior to delivery to DTMB. The specific day of the month on which invoices are to be received and checks released will be determined during contract negotiations with the selected CM.

III-21 Architect and Engineering Team

Architect/Engineer (A/E) of Record: Lord Aeck Sargent

SECTION IV – ATTACHMENTS

Attachment A: Staffing and General Conditions Tables

Attachment B: Sample Owner/Construction Manager Contract and General Conditions

Attachment C: Existing Plans, Pictures, Schedule, Study Plans, Study Report

Attachment D: Acknowledgment of Addendums

Attachment E: Scope of Work Outline

Attachment F: RFQ

16-17

PART 2 – COST PROPOSAL

For purposes of this cost proposal, assume that the budget for Phase 1 construction is

$7,100,000.00 which is inclusive of all CM fees, general conditions, overhead and profit. Note that the $7,100,000.00 construction cost includes the construction contingency. CM costs & % fees will be subject to negotiation and mutual agreement should the final approved scope increase substantially.

It is the intent of this cost proposal to obtain proposals that are priced utilizing the same criteria so an accurate evaluation can be performed. Please assume the schedule provided will be the schedule required to complete the project, do not make alternate schedule assumptions in the preparation of your proposal, accuracy will be as important as cost in the evaluation of your proposal.

Please provide the following breakdown of your cost proposal and include Attachment A to provide a further breakdown of fees requested:

Preconstruction Services total (from Attachment A) $______________

Bidding Phase Services total (from Attachment A) $______________

Construction Services total (from Attachment A)

Post Construction Services total (from Attachment A) $______________

CM General Conditions total (from Attachment A) $______________

Bond cost $AMOUNT X ______% = $______________

CGL Insurance $AMOUNT X ______% = $______________

(Refer to Attachment B & C for coverage requirements)

Builders Risk Insurance $AMOUNT X ______% = $______________

Fee for Overhead & Profit $AMOUNT X ______% = $______________

Total CM Cost Proposal (sum of all costs above) (A) $______________

Trade Contract, Construction General Condition & Contingency Allowance (Equals Total CM Contract (C) LESS CM Cost Proposal (A)) (B) $_______________

Total CM Not-to-Exceed Contract Amount (C) $ 7,100,000.00

Any adjustments to the total project cost varying from the $7,100,000.00 assumed above or variances from the schedule provided in this RFP through no fault of the CM will be adjusted utilizing the information and rates provided in this cost proposal as mutually agreed upon in writing.

Adjustments will be made after trade contracts have been awarded and the final project cost has been established.

Construction General Conditions will be reimbursed to the CM at cost with no mark-up.

17-17

PART 3 – PROPOSAL CERTIFICATION

This proposal has been prepared to provide the State with all the information requested in the RFP for Construction Management Services. The undersigned certifies that the proposal contained herein meets or exceeds the scope of services as outlined in the RFP, and associated addenda. The proposal acknowledges the anticipated budget and anticipated schedule for the Project, which is acceptable to the bidder except unless otherwise noted in the Proposal.

The projected total cost (from Part 2) for our firm to provide the services outlined within the RFP are:

WRITTEN AMOUNT and 0/100 dollars. ($00,000,000.00)

Signed this ____ day of ______________, 202x.

Name Firm

Address:

Phone Number: ____________________ Email: _________________________

If a corporation, indicate state of incorporation and affix seal.

Attest:

By:

Signature/Title