Public reporting burden for this collection of information is estimated to average 0.4 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Regulatory Secretariat (M1V1CB), Office of Acquisition Policy, GSA, Washington, DC 20405.
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.[
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) |
2. HOME ADDRESS (Number, Street, City, State, ZIP Code[, email address])[ AND TELEPHONE NO.] |
3. TYPE AND DURATION OF OCCUPATION |
4. NAME AND ADDRESS OF EMPLOYER [(Number, Street, City, State, ZIP Code, Email address)] (If Self-employed, so State) |
5[A]. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED (Number, Street, City, State, ZIP Code[, email address]) |
HOME – BUSINESS - |
[6A. NAME AND ADDRESS OF FINANCIAL INSTITUTION SUBMITTING THE PLEDGE OF SECURITIES ON BEHALF OF INDIVIDUAL SURETY (Number, Street, City, State, ZIP Code[, email address) AND ROUTING TRANSIT NUMBER (RTN)] |
[6B. CONTACT PERSON NAME, TELEPHONE NUMBER, AND EMAIL]
|
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)]:
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.)
Assets
other than
real
estate
(describe
the
assets,
the
details
of
the
escrow account,
and
attach
certified
evidence
thereof).
IDENTIFY
ALL
MORTGAGES,
LIENS,
JUDGEMENTS,
OR
ANY
OTHER
ENCUMBRANCES
INVOLVING
SUBJECT
ASSETS
INCLUDING
REAL
ESTATE
TAXES
DUE
AND
PAYABLE.
IDENTIFY
ALL
BONDS,
INCLUDING
BID
GUARANTEES,
FOR
WHICH
THE
SUBJECT
ASSETS
HAVE
BEEN
PLEDGED
WITHIN
3[THREE]
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: |
Official Seal |
|||
a. DATE OATH ADMINISTERED |
b. CITY AND STATE (Or other jurisdiction) |
|||
MONTH DAY YEAR |
||||
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.
[DATE]6/2003)
Prescribed by GSA-FAR (48 CFR) 53.228(e)
INSTRUCTIONS
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.
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.
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.
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.
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.
[DATE]6/2003)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | ZenaidaDelgado |
File Modified | 0000-00-00 |
File Created | 2021-01-20 |