Gentry BrothersBIDDER: GENTRY BROTHERS, INC
SECTION 1- BID SCHEDULE
A�
BIDDER: GENTRY BROTHERS, INC
CONTRACT BID FORMS
TABLE OF CONTENTS
SECTION 1
BID SCHEDULE ........................ ...............................
SECTION 2
BID DATA FORMS .................... ...............................
2.A
BID BOND .................................. ...............................
2.13
LIST OF PROPOSED SUBCONTRACTORS..........
SECTION 3
NON - COLLUSION AFFIDAVIT . ...............................
�� it :r• r �
{. BID SCHEDULE
f SCHEDULE OF PRICES FOR
ANNUAL RESIDENTIAL RESURFACING PROJECT
MUSCATEL AVENUE
FROM GRAND AVENUE TO MARSHALL AVENUE
PROJECT No. 21846
BASE BID SCHEDULE
CBF -1
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
1
Clearing & Grubbing per plans
LS
1
and specifications. See technical
N L/ 6
(1 L.I o 6
provisions TP -2, TP -3 & TP4.
2
Disposal of Waste Materials.
LS
5 60 c
3
Cold mill 2.0- inches thick existing
SF
208,172
.
31 S
pavement.
4
Construct 1.5 inches thick
TONS
1,950
pavement overlay ARHM -GG-C
(PG 64 -16) as indicated on the
7 9
S `( U S�
plans.
5
Construct 0.5 inches thick
TONS
655
Asphaltic Leveling course D1
p �%
(PG 64 -10) as indicated on the
lj D
N y
plans.
6
Remove, Dispose and Construct
SF
6,755
4- inches thick PCC Sidewalk per
Y ` 6
7/ O �
SPPWC Std. Plan 113 -1,
1
7
Remove, Dispose and Construct
SF
2,350
ab
PCC Driveway Approaches per
SPPWC Std. Plan 110 -2.
r
8
Remove, Dispose and Construct
LF
1,214
8- Inches Curb and 24- inches
Gutter SPPWC Std. Plan
3 U
3
per
120-2.
9
Remove, Dispose and Construct
LF
200
_
84nches PCC Curb Only per
SPPWC Std. Plan 120 -2.
� =
`/ O C 0
J
10
Remove, Dispose and Construct
PCC Cross Gutter per SPPWC
SF
416
u
C�
Std. Plan 123 -2.
3 3
CBF -1
t � 8i
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 17 �J O ( 3
Dollar amount in written form
Note: The City of Rosemead reserves the right to reduce or increase the quantities of any items in
the schedule of bid items above, within the limits define in Section 3 -2.2.1 of the Standard
Specifications, to stay within the budgeted amount of this project.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amount shall be considered the Total
Bid Price for the Project.
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
Attached hereto is a certified check, a cashier's check or bid bond in lie amount of
oI Dollars ($ ) said amount being not less than n (10 %) of the Total
CBF -2
UNIT OF
EST.
UNIT
ITEM
NO.
ITEM DESCRIPTION
MEASURE
QTY.
PRICE
COST
11
Remove, Dispose and Construct
E4
20
PCC Curb Ramps per SPPWC
Std. Plan
1 -760
3 jpo0
11114.
12
Double Adjust Sewer Manhole to
EA
30
Grade per APWA Std. Plan 205-
1 206
� G O
f), 0 0 0
and -1.
13
Adjust Water Valve /Gas Valve to
Grade.
EA
29
14
Install Survey Well Monument
EA
16
per City of Rosemead Std, Plan
SOB -001. See Section 2 -9
Surveying of the General
4 s'6
Provision -7 per details (Cover,
Sleeve & Dome will be provided
by the City at no cost).
15
Install Traffic Striping, Traffic
LS
1
Signal Loops and Pavement
S 7 d
Markers per the Striping Plans
S 7 066.
and Specifications Complete.
t � 8i
TOTAL BASE BID PRICE (SCHEDULE BID PRICE):$ 17 �J O ( 3
Dollar amount in written form
Note: The City of Rosemead reserves the right to reduce or increase the quantities of any items in
the schedule of bid items above, within the limits define in Section 3 -2.2.1 of the Standard
Specifications, to stay within the budgeted amount of this project.
If the Bid Documents specify alternate bid items, the following Alternate Bid amounts shall
be added to or deducted from the Total Bid Price entered above. The owner can choose to
include one or more of the alternates in the Total Bid Price of the Project. If any of the
Alternate Bids are utilized by the Owner, the resulting amount shall be considered the Total
Bid Price for the Project.
The undersigned agrees that these Contract Bid Forms constitute a firm offer to the Owner which
cannot be withdrawn for the number of Working Days indicated in the Notice Inviting Bids from and
after the bid opening date, or until a Contract for the Work is fully executed by the Owner and a third
party, whichever is earlier. The undersigned also agrees that if there is a discrepancy between the
written amount of the Bid Price and the numerical amount of the Bid Price, the written amount shall
govern.
Attached hereto is a certified check, a cashier's check or bid bond in lie amount of
oI Dollars ($ ) said amount being not less than n (10 %) of the Total
CBF -2
BIDDER: GENTRY BROTHERS, INC
Bid Price. The undersigned agrees that said amount shall be retained by the Owner if, upon award,
we fail or refuse to execute the Contract and furnish the required bonds, certificates and
endorsements of insurance and other certifications within the time provided.
If awarded a Contract, the undersigned agrees to execute the formal Contract, which will be
prepared by the Owner for execution, within five (5) Calendar Days following the Letter of Award for
the Contract, and will deliver to the Owner within that same period the necessary original Certificates
of Insurance, Endorsements of Insurance, Performance Bond, Payment Bond and all other
documentation and certification required by the Contract.
The undersigned offers and agrees that if this bid is accepted, it will assign to the purchasing body
all rights, title, and interest in and to all causes of action it may have under Section 4 of the Clayton
Act (15 U.S.G. Section 15) or under the Cartwright Act (Chapter 2 of Part 2 of Division 7 of the
„- Business and Professional Code), arising from purchases of goods, materials or services by the
Bidder for sale to the purchasing body pursuant to the bid. Such assignment shall be made and
become effective at the time the purchasing body tenders final payment to he Contractor.
Bidder understands and agrees that, when requested by Owner, he shall provide: (1) evidence
satisfactory to the Owner of Bidder's California contractor's license(s) in good standing; (2) evidence
that the person signing this Bid is authorized to bind Bidder to this Bid and to a contract resulting
therefrom; and (3) any other information and documentation, financial or otherwise, needed by
Owner to award a Contract to the lowest responsible and responsive bidder.
The undersigned acknowledges receipt, understanding and full consideration of the following
addenda to the Contract Documents.
Addenda Nos.
The Bidder understands and agrees that the Total Bid Price is inclusive of all labor, materials, and
equipment or supplies necessary to complete the Work as described in the Bid Documents. If this
bid is accepted, the undersigned Bidder agrees to enter into and execute the Contract with the
necessary bonds and accept the Total Bid Price as compensation in full for all Work under the
contract.
CBF -3
Bidder acknowledges that data submitted with its Contract Bid Forms which it requires to be
incorporated into a Contract arising out of this Submittal has been so identified by Bidder. Bidder
further acknowledges that the Owner may, at its discretion, incorporate any of the remaining data
submitted herewith into a contract arising out of this Bid.
By:
Signature 1
C,/ t/ —.Cs ,✓ I - ham/
Type or Print Name
/
Title
BIDDER: GENTRY BROTHERS, IN
384 LIVE OAK AVE.
IRWINDALE CA 91706
Business Street Address
City, State and Zip Code
(v 3,� 96
Telephone Number
Bidder's /Contractor's State of Incorporation: C4 (,
Partners or Joint Venturers:
Bidder's License Number(s): 3 1 - 2 (oe ) -
NOTES:
1) By its signature on this Bid, the Bidder certifies under penalty of perjury the accuracy of the
representations made on the Contract Bid Forms.
2) If Bidder is a corporation, enter State of Incorporation in addition to Business Address
3) If Bidder is a partnership or joint venture, give full names of all partners or joint
venturers.
As further discussed in the Instructions to Bidders, Bidder will be required
to provide evidence that the person signing on behalf of the corporation,
oartnershio or iomt venture has the authority to do so.
CBF -4
CALIFORNIA ALL- PURPOSE CERTIFICATE OF AKNOWLEDGMENT
State of California
Countyof: Los Angeles
On August 7, 2013 before me , N. Smith, Notary-----------------------
(name and fitle of the officer)
personally appeared
Rodney J. Gentry --------------- ---------------------
who proved to me on the basis of satisfactory evidence to be the person (t9) whose name(g) is/m
subscribed to the within instrument and acknowledged to me that he/ key executed the same in
his7ft OKWauthorized capacity Wand that by hisithBrlwk signature(t) on the instrument the person(W
or the entity upon behalf of which the person (S�acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS,mv hand and official seal
(Notary Seal)
- :.. -•... _ � -- OPTIONAL INFORMATIONS ...,.,..,
Information below is NOT required by law however may deter fraudulent removal of this form.
Description of Attached Document
Number of Pages 1
Document Date: nT /
Bid Schedule------------- - - - - --
type of document
Capacity Claimed by Signer(s)
• Individual(s)
• Corporate Officer
❑ Partner
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
information
BIDDER: GENTRY BROTHERS, INC
SECTION 2
BID DATA FORMS
CBF -5
BIDDER. Gentry Brothers, Inc.
Bidder shall submit its Bid data in accordance with the format shown on each of the following Bid
Data Forms. Bidders shall prepare and use as many sheets as are necessary to adequately provide
the information required. Bidder shall ensure that every page of its Bid Data Forms are properly
identified with the Bidder's name and page number.
2.A BID BOND
KNOW ALL MEN BY THESE PRESENTS:
THAT Gentry Brothers, Inc. , as
Principal, and Federal insurance Company
as Surety, are held firmly bound unto the
CITY OF ROSEMEAD (hereinafter called the OWNER) in the sum of
Ten percent of the total amount of the bid
($ 10% ) , being not less than ten percent (I0°A6) of the Total
Bid Price; forthe payment of which sum will and truly to be made, we bind ourselves,
our heirs, executors administrators, successors, and assigns, jointly and severally,
firmly by these presents.
WHEREAS, said Principal has submitted a bid to the OWNER to perform all Work
required for the Annual Residential Resurfacing Project — Muscatel Avenue
From Grand Avenue to Marshall Avenue as set forth in the Notice Inviting Bids
and accompanying Bid Documents, dated August 7, 2013
NOW, THEREFORE, if said Principal is awarded a Contract for the Work by the
OWNER and, within the time and in the manner required by the above- referenced
Bid Documents, enters into the written form of Contract bound with said Bid
Documents, furnishes the required bonds (one to guarantee faithful performance
and the other to guarantee paymentfor labor and materials) furnishes the required
insurance certificates and endorsements, and furnishes any other certifications as
may be required by the Contract, then this obligation shall be null and void; otherwise
it shall remain in full force and effect. In the event suit is brought upon this bond by
the OWNER and judgment is recovered, said Surety shall pay all costs incurred by
the OWNER in such suit, including reasonable attorneys' fees to be fixed by the
court.
SIGNED AND SEALED, this 22nd day of July 20 13
Gentry Brothers, Inc. (SEAL) Federal Insurance Company (SEAL)
Principal Surety
By: 4�� ��ny By: 4
_
Sig ature dev f Signature m tthew J. Coats,, Attorney -in -Fact
CBF -6
CALIFORNIA
ALL - PURPOSE ACKNOWLEDGEMENT
State of California
County of Orange
On Jul 2 2 2013 before me, Adelaide C. Hunter, Notary Public
(insert name and title.of the of
personally appeared Matthew J. Coats
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is /are
subscribed to the within instrument and acknowledged to me that he/sheftheq executed the
same in his,ther/th£tr authorized capacity(ies), and that by hisflter/their signature(s) on the
instrument the person(s), or the entity upon behalf ofwhich the person(s) acted, executed the
instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal. '
Signature A.
ADELAIDE C. HUNTER
,o" "• Commission IX 1994447 Z
t,g Nolary Public • California Y
tt
": Orango County
w1y Comm. Expires Ocl 19, 2016
1r7, Chubb POWER Federal Insurance Company Attn: Surety Department
OF Vigilant Insurance Company IS Mountain View Road
S urety ATTORNEY Pacific indemnity Company Warren, NJ 07059
OF+Uu
Know All by These Presents, That FEDERAL INSURANCE COMPANY, an Indiana corporation, VIGILANT INSURANCE
COMPANY, a New York corporation, and PACIFIC INDEMNITY COMPANY, a Wisconsin corporation, do each hereby constitute and
appoint Linda D. Coats and Matthew J. Coats of Laguna Hills, California
each as their true and lawful Aturn ey- in. Fact to execute under such designation in their names and to affix: their corporate seats to and deliver for and on their behalf as surety
thereon or otherwise. bonds and undertakings and other writings obligatory in the nature thereof (other than bail bonds) given or executed in the course of business, and any
instruments amending or altering the same, and consents to the modifioation or alteration of any Instrument referred to in said bonds or obligations.
In Witness Whereof, said FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY have each executed and attested
these presents and affixed their corporate seals on this ISt day of December, 2011.
Kenneth C. Wendel, ssls ant aebry David S s, Jr., Lice President
STATEOF NEW JERSEY
County of Somerset $s.
On this 1 St day of December, 2011 before me, a Notary Public of New Jersey, personally came Kenneth C. Wendel, to me
known to be Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY, the companies which
executed the foregoing Power of Attorney, and the said Kenneth C. Wendel, being by me duly sworn, did depose end say mat he is Assistant Secretary of FEDERAL
INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY and knows the Corporate seals thereof, that the seals affixed to the
foregoing Power of Attorney are such corporate seals and were thereto affixed by authority of the By. Laws of said Companies; and that he signed said Power of Attorney as
Assistant Secretary of said Companies by like authority; and that he is acquainted with David B. Norris, Jr., and knows him to be Vice President of said Companies; and that the
signature of David B. Noms, Jr., subscribed to said Power of Attorney is in the genuine handwriting of David B. Norris, Jr., and was thereto subscribed by authority of said By-
Laws and in deponent's presence.
Notarial Seal KATHERINE J. ADELAAR
NOTARY PUBUC OF NEW 1FRSF1
�. NOTARY Nn. 23 Whim July Commi l
� wee a efion rxpileeJuly 16, 2019
PUBLIG
Notary Public
9;s1er 1CAS�,
CERTIFICATION
Extract from the By- Laws of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY:
"AIL powers of attorney for and on behalf of the Company may and shall be executed In the name and on behalf of the Company, either by the Chairman or the
President or a Vise President or an Assistant Vice President, jointly with the Secretary or an AWStant Secretary; under their respective designations. The
signature of such officers may be engraved, printed or lithographed. The signature of each of the tollowing offrceri Chairman, President, any Vice President, any
Assistant Vice President, any Secretary, any Assistant Secretary and the seal of the Company may be affixed by facsimile to any power of attorney or to any
certificels relating thereto appointing Assistant Secretaries or Attorneys In- Fact for purposes only of executing and attesting bonds and undertakings and other
writings obligatory In the nature thereof, and any such power of attorney or cedlficate bearing such facsimile signature or facsimile seal shall be valid and binding
upon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding upon the Company
with respect to any bond or undertaking to which it is attached."
I, Kenneth C. Wendel, Assistant Secretary of FEDERAL INSURANCE COMPANY, VIGILANT INSURANCE COMPANY, and PACIFIC INDEMNITY COMPANY
(the 'Companies) do hereby certify that
(1) the foregoing extract of the By- Laws of the Companies is true and correct,
(ii) the Companies are duly licensed and authorized to transact surety business in all ee of the United States of America and the District of Columbia and are
authorized by the U.S. Treasury Department; further, Federal and Vigilant are licensed in Puerto Rim and the U.S. Virgin Islands, and Federal is licensed in
American Samoa, Guam, and each of the Provinces of Canada except prince Edward Island; and
(iii) the foregoing Power of Attorney is true, coned and in full force and effect.
Given under my hand and seals of said Companies at Warren,. NJ this 22nd day of
t
avnwtl• - r ` � ��Ir •
July, 2013
— Kenn�� entle nt Secretary
IN THE EVENT YOU WISH TO NOTIFY US OF A CLAIM, VERIFY THE AUTHENTICITY OF THIS BOND OR NOTIFY US OF ANY OTHER
MATTER, PLEASE CONTACT US AT ADDRESS LISTED ABOVE, OR BY Telephone (908) 903. 3493 Fax (908) 903- 3656
e -mail: surety (Mchubb.com
Form 15.10. 02258- U (Ed. 5.03) CONSENT
CALIFORNIA ALL - PURPOSE CERTIFICATE OF AKNOWLEDGMENT
State of: California
Countyof: Los Angeles
On August 7, 2013 , before me , N. Smith, Notary----------------- - - - - --
(name and fide of the officer)
personally appeared
Rodney J. Gentry - - - - - - - -
who proved to me on the basis of satisfactory evidence to be the person (9) whose name(9) is4w
subscribed to the within instrument and acknowledged to me that he/Aabloy executed the same in
hisMkfMKauthorized capacity Pal and that by hislbBc2mk signature(g) on the instrument the person(W
or the entity upon behalf of which the persono)�acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
hand and official seal
My
(Notary Seal)
F,�OPTIONAL INFORMATIONS ... _�
........ Information below is NOT required bylaw however may deter fraudulent removal of this form.
Description of Attached Document
Number of Pages 1
Document Date: M /n
Bid Bond
type of document
Capacity Claimed by Signer(s)
• Individual(s)
• Corporate Officer
❑ Partner
❑ Attorney -in -Fact
❑ Trustee(s)
❑ Other
BIDDER: GENTRY BROTHERS, INC
23 LIST OF PROPOSED SUBCONTRACTORS
In compliance with the "Subletting and Subcontracting Fair Practices Act," Sections 4100
through 4114 of the California Public Contract Code, and any amendments thereto, each
Bidder shall provide the information requested below for each subcontractor who will
perform work, labor or render service to Bidder in or about the construction of the Work in an
amount in excess of one -half of one percent (greater than 0.5 %) of the Bidder's Total Bid
Price, or, in the case of bids or offers for the construction of streets or highways, including
bridges, in excess of one -half of 1 percent of the Contractor's total bid or ten thousand
dollars ($10,000), whichever is greater, and shall further set forth the portion of the Work
which will be done by each subcontractor. Bidder shall list only one subcontractor for any
one portion of the Work.
Pursuant to Public Contract Code Section 4104, the Owner has determined that it will allow
Bidders twenty -four (24) additional hours after the deadline forsubmission of bids to submit
the information requested by the Owner about each subcontractor, otherthan the name and
location of each subcontractor.
If the Bidder fails to specify a subcontractor for any portion of the Work to be performed
under the Contract, it shall be deemed to have agreed to perform such portion itself, and
shall not be permitted to subcontract that portion of the Work except under the conditions
hereinafter set forth below.
Subletting or subcontracting of any portion of the Work in excess of one half of one percent
(greaterthan 0.5 %) of the Total Bid Price or, in the case of bids or offers for the construction
of streets or highways, including bridges, in excess of one -half of 1 percent of the
Contractor's total bid or ten thousand dollars ($10,000), whichever is greater, for which no
subcontractor was designated in the original bid shall only be permitted in cases of public
emergency or necessity, and then only after Owner approval.
CBF -7
BIDDER: G ENTRY BROTHERS, INC
2.13 LIST OF PROPOSED SUBCONTRACTORS (continued)
("Duplicate Next 2 Pages if needed for listing additional subwntractors.* j
Name and Location Description of Work
of Subcontractor to be Subcontracted
Name: M S/ /- /ac�nrc
Address: A m h a i N t /4 .
Name and Location
of Subcontractor
Name: S• &nroc
f
Address: times .
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address:
Description of Work
to be Subcontracted
Name and Location
of Subcontractor
Name:
Address
Description of Work
to be Subcontracted
CBF -8
BIDDER: GENTRY BROTHERS, INC
2.0 REFERENCES
The following are the names, addresses and telephone numbers for three public agencies for which BIDDER
has performed similar work within the past two (2) years: )I (
Name and Address of Owner
2.
3.
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
Name and Address of Owner
Name and telephone number of person familiar with project
Contract amount Type of Work Date Completed
Address of Owner
and telephone number of person familiar with project
4.
Contract amount Type of Work Date Completed
Name and Address of Owner
Name and telephone number of person familiar with project
Contractamount Type of Work Date Completed
CBF -9
BIDDER: GENTRVaonr4[„
SECTION 3
NON - COLLUSION AFFIDAVIT
CBF - 10
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BIDDER:
NON - COLLUSION AFFIDAVIT
GENTRY BROTHERS, INC
In accordance with Public Contract Code Section 7106, the undersigned, being first duly
sworn, deposes and says that he or she holds the position listed below with the bidder, the
party making the foregoing bid, that the bid is not made in the interest of, or on behalf of, any
undisclosed person, partnership, company, association, organization, or corporation; that the
bid is genuine and not collusive or sham; that the bidder has not directly or indirectly induced
or solicited any other bidder to put in a false or sham bid, and has not directly or indirectly
colluded, conspired, connived, or agreed with any bidder or anyone else to put in a sham
bid, or that anyone shall refrain from bidding; that the bidder has not in any manner, directly
or indirectly, sought by agreement, communication, or conference with anyone to fix the bid
price of the bidder or any other bidder, or to fix any overhead, profit, or cost element of the
bid price, or of that of any other bidder, or to secure any advantage against the public body
awarding the contract of anyone interested in the proposed contract; that all statements
contained in the bid are true; and, further, that the bidder has not, directly or indirectly,
submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged
information or data relative thereto, or paid, and will not pay, any fee to any corporation,
partnership, company association, organization, bid depository, or to any member or agent
thereof to effectuate a collusive or sham bid.
Signature
Typed or Printed Name
�,c 5
Title
GENTRY BROTHERS, INC
Bidder
Subscribed and sworn before me
This _ day of 20_
(Seal)
Notary Public in and for
the State of California
My Commission Expires:
CBF -11
CALIFORNIA ALL- PURPOSE CERTIFICATE OF AKNOWLEDGMENT
State of: California
Countyof: Los Angeles
On August 7, 2013 , before me , N. Smith, Notary------- -
(name and title of the officer)
personally appeared Rodney J. Gentry------------------------------ - - - - --
who proved to me on the basis of satisfactory evidence to be the person (9) whose name(g) is/RM
subscribed to the within instrument and acknowledged to me that he/ey executed the same in
hisMMNKauthorized capacity (3fXXand that by his/bar&wk signature(s on the instrument the person(W
or the entity upon behalf of which the person(S)�acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal
(Notary Seal)
OPTIONAL INFORMATION=.,.
Information below is NOT required by law however may deter fraudulent removal of this form.
Description of Attached Document
Number of Pages 1
Document Date: N / n
Non - Collusion Affidavit--- - - - - --
type of document
Capacity Claimed by Signer(s)
❑ Individual(s)
❑ Corporate Officer
❑ Partner
• Attorney -in -Fact
• Trustee(s)
❑ Other