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8 1-16.901–25B Standard Form 25B: Continuation Sheet for Standard Forms 24, 25 and

25A

(a) Page 1 of Standard Form 25-B.

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22.

21.

TOTAL AMOUNT OF CONTRACT $
CONTRACTING OFFICER WILL COMPLETE BLOCK 22 OR 26 AS APPLICABLE
CONTRACTOR'S NEGOTIATED AGREEMENT (Controilor is required to sign 26. AWARD (Contractor is not required to sign this document.) Your other
this document and return copies to issuing office.) Contractor agrees

on Solicitation Number

including the to furnish and deliver all items or perform all the services so forth or otherwise

additions or changes mode by you which additions or chongos are set forth in full identified above and on any continuation sheets for the consideration stated herein.

above, in horoby occopted as to the items listed above and on any continuation shoot. The rights and obligations of the parties to this contred shall be subject to and gor.

This award consummates the contract which consist of the following documento: (o) wned by the following documents (0) this sword/ contract, (b) the sohcitation, if any,

the Government's solicitation and you her, and (b) this sword /contract. Me end (c) such provisions, representations, cortifications, and specifications, er

Iurther contractuel document is neconery, ortached or incorporated by reference heroin. (Alluchments are listed herein.) 23. NAME OF CONTRACTOR

27, UNITED STATES OF AMERICA

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8 1-16.901-28 Standard Form 28: Affidavit of Individual Surety.

(a) Page 1 of Standard Form 28.

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!, the undersigned, boing duly sworn, dopose ond say that I om one of the suroties to the attached bond; that I om o citizen of the United States lor a permanent resident of the place where the contract and bond are executed os provided in paragraph 3 of the Instructions on reverse), and of full age and legally competent; that I am not a partner in any business of the principal on the bond or bonds on which I appear as suretyo that the information herein below furnished is true and complete to the best of my knowledge. This affidavit is made to induce the United States of America to occopt me as surety on the attached bond. 1. NAME (First, middle, last) (Type or primi)

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

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7. THE FOLLOWNG IS A TRUE REPRESENTATION OF MY PRESENT ASSETS, LIABILITIES, AND NET WORTH AND DOES NOT INCLUDE ANY

ANANCIAL INTEREST I HAVE IN THE ASSETS OF THE PRINCIPAL ON THE ATTACHED MOND:

a. Fair value of solely owned real estate
b. All mortgages or other encumbrances on the real estate included in line a
c. Real estate equity (subtract Line b from Line al
d., Fair value of all solely owned property other than ret
e. Total of the amounts on Lines c and
f. All other liabilities owing or intre
g. Net worth (subtract Ligotron

EN

b

EG

Do not include property exemple execution and sale for any reason. Surely's interest in community property may be included if not so exemps. I, LOCATION AND DESCRIPTION OF REAL ESTATE OF WHICH I AM SOU OWNER, TME VALUE OF WHICH IS INCLUDED IN LINE (o). ITEM 7 ABOVE

Amount of assessed reluation of abere nal estate for lamation purposes:9. DESCRIPTION OF MOPERTY INCLUDED IN LINE (G). ITEM 7 ABOVE (Live ide rolwe of our do weregory of property separately)

10. ALL OTHER BONDS ON WHICH I AM SURETY (SMK character and amount of each bond; of nowe, so Hare)

11. SIGNATURE

12. KONO AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES

(bere appropriate)

DATE OATM ADMINISTERED

SUBSCRIDED AND SWORN TO DEPORI ME AS FOLLOWS:
CITY

STATE (Or orber jurisdiction)
YEAR

MONTH

DAT

official Seal

NAME AND TITLE OF OFFICIAL ADMINISTERING OATH (Type or print)

SIGNATURE

MY COMMISSION
EXPIRES

20-103

(b) Page 2 of Standard Form 28.

CERTIFICATE OF SUFFICIENCY I Hereby Certify, That the surety named herein is personally known to nie; char, in my judgment, said surely is responsible, and qualified to act as such; and that, to the best of my knowledge, the facis stated by said surely in the foregoing affidavit are truc.

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4. The individual surety shall show net worth in a sum not less than the penalty of the bond by supply. ing the information required on the face hereof, under oath beton dubited States commissioner, a clerk of Ghitachiavares Court, or notary public, or samo other office chain suduthority to administer oaths

A the culcer has an official seal, it shall Aftet obrerwise the proper certificate as to his isibleharacter shall be furnished.

generally

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2. A corporation, partnership, or other business association or firm, as such, will not be accepted as o surety, nor will a partner be accepted as a surety por co-partners or for a firm of which he is Stockholders of a corporate principal mat tedd cesteld as sureties provided their qualifications Byth arel independent of their stockholdings therein 1 Triv. ing at the net worth figure in Item 7 on the face of this affidavit an individual surely will not include any financial interest he may have in the assets of the principal on the bond which this affidavit supports.

SI

ECH

5. The certificate of sufficiency shall be signed by an officer of a bank or trust company, a judge or clerk of a court of record, a United States district of. torney or commissioner, a postmaster, a collector or deputy collector of internal revenue, or any other of. ficer of the United States acceptable to the departo ment or establishment concerned. Further certificates showing additional assets, or a new surety, may be required to assure protection of the Government's interest. Such certificates must be based on the personal investigation of the certifying officer of the time of the making thereof, and not upon prior certifications.

3. An individual surely shall be a citizen of the United States, except that if the contract and bond are executed in any foreign country, the Common. wealth of Puerto Rico, the Virgin Islands, the Canal Zone, Guam, or any other territory or possession of the United States, such surely need only be o perma.

(Back of SF 28 June 66)

(31 FR 15093, Dec. 1, 1966)

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