Fillable Standard Form 28 - Affidavit Of Individual Surety

AFFIDAVIT OF INDIVIDUAL SURETY

OMB No.: 9000-0001

(See instructions on reverse)

Public reporting burden for this collection of information is estimated to average 3 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 (MVA), Office of Acquisition Policy, GSA, Washington,

DC 20405.

STATE OF

SS.

COUNTY OF

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.

2. HOME ADDRESS (Number, Street, City, State, ZIP Code)

1. NAME (First, Middle, Last) (Type or Print)

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 (If any)

6. TELEPHONE NUMBER

(Number, Street, City, State, ZIP Code)

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:

b. CITY AND STATE (Or other jurisdiction)

a. DATE OATH ADMINISTERED