Standard Form 28 - Affidavit Of Individual Surety - 2003

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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
MONTH
DAY
YEAR
Official
Seal
c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH
d. SIGNATURE
e. MY COMMISSION
(Type or print)
EXPIRES
STANDARD FORM 28
AUTHORIZED FOR LOCAL REPRODUCTION
(REV. 6/2003)
Previous edition is not usable
Prescribed by GSA-FAR (48 CFR) 53.228(e)

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