Technical English Part AAAAA

Technical English at WizIQ by St. George’s Academy of Dragon Slaying and Spoken English www.myESLfriends.com AGREEMENT THIS AGREEMENT is dated as of the day of in the year 2009 by and between the City of xxxxxxxx, Indiana, (hereinafter called OWNER) and xxxxxxxxxxxx(hereinafter called CONTRACTOR). OWNER and CONTRACTOR, in consideration of the mutual covenants hereinafter set forth, agree as follows: Article 1. WORK. CONTRACTOR shall complete all Work as specified or indicated in the Contract Documents. The Work is generally described as follows: Site Preparation for Water Treatment Plant No. 1 Contract 76 Article 2. ENGINEER. The Project has been designed by xxxxxxxxxxxxx., who is hereinafter called ENGINEER and who is to act as OWNER's representative, assume all duties and responsibilities, and have the rights and authority assigned to ENGINEER in the Contract Documents in connection with completion of the Work in accordance with the Contract Documents. Article 3. CONTRACT TIMES. 3.1 The Work will be completed within the following schedule: 3.1.1 The excavation and fill shall be complete and all Work related to the installation of the storm drainage system shall be completed within 120 days after the date when the Contract Time commences to run as provided in paragraph 2.3 of the General Conditions. 3.1.2 All remaining Work shall be completed and ready for final payment in accordance with paragraph 14.13 of the General Conditions within 150 days after the date when the Contract Time commences to run. 3.2 Liquidated Damages: OWNER and CONTRACTOR recognize that time is of the essence of this Agreement and that OWNER will suffer financial loss if the Work is not completed within the times specified in paragraph 3.1 above, plus any extensions thereof allowed in accordance with Article 12 of the General Conditions. They also recognize the delays, expense and difficulties involved in proving the actual loss suffered by OWNER if the Work is not completed on time. Accordingly, instead of requiring any such proof, OWNER and CONTRACTOR agree that as liquidated damages for delay (but not as a penalty) CONTRACTOR shall pay OWNER Five Hundred Dollars ($500.00) for each day that expires after the time specified in paragraph 3.1 for Substantial Completion until the Work is substantially complete. After Substantial Completion if CONTRACTOR shall neglect, refuse or fail to complete the remaining Work within the time specified in paragraph 3.1 for completion and readiness for final payment or any proper extension thereof granted by OWNER, CONTRACTOR shall pay OWNER Five Hundred Dollars ($500.00) for each day that expires after the time specified in paragraph 3.1 for completion and readiness for final payment. Article 4. CONTRACT PRICE. OWNER shall pay CONTRACTOR for completion of the Work in accordance with the Contract Documents in current funds based on the bid prices as set forth in the conformed copy of the CONTRACTOR's Bid hereto attached. Article 5. PAYMENT PROCEDURES. CONTRACTOR shall submit Applications for Payment in accordance with Article 14 of the General Conditions. Applications for Payment will be processed by ENGINEER as provided in the General Conditions. 5.1 Progress Payments; Retainage: OWNER shall make progress payments on account of the Contract Price on the basis of CONTRACTOR's Applications for Payment as recommended by ENGINEER, no more often than monthly during construction as provided in paragraphs 5.1.1. and 5.1.2. below. All such payments will be measured by the schedule of values established in paragraph 2.9 of the General Conditions (and in the case of Unit Price Work based on the number of units completed) or, in the event there is no schedule of values, as provided in the General Requirements. 5.1.1 Prior to Substantial Completion, progress payments will be made in an amount equal to the percentage indicated below, but, in each case, less the aggregate of payments previously made and less such amounts as ENGINEER shall determine, or OWNER may withhold, in accordance with paragraph 14.7 of the General Conditions. Progress payment will be made for 90% of Work completed (with the balance being retainage). If Work has been 50% completed as determined by ENGINEER, and if the character and progress of the Work have been satisfactory to OWNER and ENGINEER, OWNER on recommendation of ENGINEER, may determine that as long as the character and progress of the Work remain satisfactory to them, there will be no additional retainage on account of Work completed in which case the remaining progress payments prior to Substantial Completion will be in an amount equal to 100% of the Work completed. Progress payment will be made for 90% of invoice price for materials and equipment not incorporated in the Work (but delivered, suitably stored and accompanied by documentation satisfactory to OWNER as provided in paragraph 14.2 of the General Conditions). 5.1.2 Upon Substantial Completion, in an amount sufficient to increase total payments to CONTRACTOR to 98% of the Contract Price (with the balance being retainage), less such amounts as ENGINEER shall determine, or OWNER may withhold, in accordance with paragraph 14.7 of the General Conditions. 5.2 Final Payment. Upon final completion and acceptance of the Work in accordance with paragraph 14.13 of the General Conditions, OWNER shall pay the remainder of the Contract Price as recommended by ENGINEER as provided in said paragraph 14.13. Article 6. INTEREST. The CONTRACTOR is entitled to receive interest on all monies not paid when due as provided in Article 14 of the General Conditions. The CONTRACTOR must initiate the request to establish an escrow account and an escrow agent with the City’s Utility Director. If no request is made by the CONTRACTOR, the right to receive interest on all monies not paid when due is waived by the CONTRACTOR. Article 7. CONTRACTOR'S REPRESENTATIONS. In order to induce OWNER to enter into this Agreement CONTRACTOR makes the following representations: 7.1 CONTRACTOR has examined and carefully studied the Contract Documents (including the Addenda listed in paragraph 8) and the other related data identified in the Bidding Documents including "technical data." 7.2 CONTRACTOR has visited the site and become familiar with and is satisfied as to the general, local and site conditions that may affect cost, progress, performance or furnishing of the Work. 7.3 CONTRACTOR is familiar with and is satisfied as to all federal, state and local Laws and Regulations that may affect cost, progress, performance and furnishing of the Work. 7.4 CONTRACTOR has carefully studied all reports of explorations and tests of subsurface conditions at or contiguous to the site and all drawings of physical conditions in or relating to existing surface or subsurface structures at or contiguous to the site (except Underground Facilities) which have been identified in the Supplementary Conditions as provided in paragraph 4.2.1 of the General Conditions. CONTRACTOR accepts the determination set forth in paragraph SC-4.2 of the Supplementary Conditions of the extent of the "technical data" contained in such reports and drawings upon which CONTRACTOR is entitled to rely as provided in paragraph 4.2 of the General Conditions. CONTRACTOR acknowledges that such reports and drawings are not Contract Documents and may not be complete for CONTRACTOR's purposes. CONTRACTOR acknowledges that OWNER and ENGINEER do not assume responsibility for the accuracy or completeness of information and data shown or indicated in the Contract Documents with respect to Underground Facilities at or contiguous to the site. CONTRACTOR has obtained and carefully studied (or assumes responsibility for having done so) all such additional supplementary examinations, investigations, explorations, tests, studies and data concerning conditions (surface, subsurface and Underground Facilities) at or contiguous to the site or otherwise which may affect cost, progress, performance or furnishing of the Work or which relate to any aspect of the means, methods, techniques, sequences and procedures of construction to be employed by CONTRACTOR and safety precautions and programs incident thereto. CONTRACTOR does not consider that any additional examinations, investigations, explorations, tests, studies or data are necessary for the performance and furnishing of the Work at the Contract Price, within the Contract Times and in accordance with the other terms and conditions of the Contract Documents. 7.5 CONTRACTOR is aware of the general nature of work to be performed by OWNER and others at the site that relates to the Work as indicated in the Contract Documents. 7.6 CONTRACTOR has correlated the information known to CONTRACTOR, information and observations obtained from visits to the site, reports and drawings identified in the Contract Documents and all additional examinations, investigations, explorations, tests, studies and data with the Contract Documents. 7.7 CONTRACTOR has given ENGINEER written notice of all conflicts, errors, ambiguities or discrepancies that CONTRACTOR has discovered in the Contract Documents and the written resolution thereof by ENGINEER is acceptable to CONTRACTOR, and the Contract Documents are generally sufficient to indicate and convey understanding of all terms and conditions for performing and furnishing of the Work. Article 8. CONTRACT DOCUMENTS. The Contract Documents which comprise the entire agreement between OWNER and CONTRACTOR concerning Work consist of the following: 8.1 This Agreement (pages A-1 to A-6, inclusive). 8.2 Exhibits to this Agreement (pages -A-7 through A-16). 8.3 Performance and other Bonds, identified as Exhibits B and C and consisting of 4 pages. 8.4 Notice to Proceed identified as Exhibits F. 8.5 General Conditions (pages B-GC-1 to B-GC-42, inclusive). 8.6 Supplementary Conditions (pages B-SC-1 to B-SC-14, inclusive) and Additional Supplementary Conditions (Pages B-ASC-1 to B-ASC- 7.) 8.7 Specifications bearing the title Site Preparation for Water Treatment Plant No. 1, Contract 76A, consisting of all sections listed in Table of Contents thereof. 8.8 Drawings, consisting of a cover sheet and sheets numbered _1__ through _21 , inclusive with each sheet bearing the following general title: Site Preparation for Water Treatment Plant No. 1 Contract 76 (The drawings are not attached to this Agreement.) 8.9 Addenda numbers __1__ to __2__ , inclusive. 8.10 CONTRACTOR's Bid (pages B-1 to B-10, inclusive) marked Exhibit A. 8.11 The following which may be delivered or issued after the Effective Date of the Agreement and are not attached hereto: All Written Amendments and other documents amending, modifying, or supplementing the Contract Documents pursuant to paragraphs 3.5 and 3.6 of the General Conditions. The documents listed in paragraphs 8.2 et seq. above are attached to this Agreement (except as expressly noted otherwise above). There are no Contract Documents other than those listed above in this Article 8. The Contract Documents may only be amended, modified or supplemented as provided in paragraphs 3.5 and 3.6 of the General Conditions. Article 9. MISCELLANEOUS. 9.1 Terms used in this Agreement which are defined in Article 1 of the General Conditions will have the meanings indicated in the General Conditions. 9.2 No assignment by a party hereto of any rights under or interests in the Contract Documents will be binding on another party hereto without the written consent of the party sought to be bound; and, specifically but without limitation, moneys that may become due and moneys that are due may not be assigned without such consent (except to the extent that the effect of this restriction may be limited by law), and unless specifically stated to the contrary in any written consent to an assignment no assignment will release or discharge the assignor from any duty or responsibility under the Contract Documents. 9.3 OWNER and CONTRACTOR each binds itself, its partners, successors, assigns and legal representatives to the other party hereto, its partners, successors, assigns and legal representatives in respect of all covenants, agreements and obligations contained in the Contract Documents. 9.4 Any provision or part of the Contract Documents held to be void or unenforceable under any Law or Regulation shall be deemed stricken, and all remaining provisions shall continue to be valid and binding upon OWNER and CONTRACTOR, who agree that the Contract Documents shall be reformed to replace such stricken provision or part thereof with a valid and enforceable provision that comes as close as possible to expressing the intention of the stricken provision. IN WITNESS WHEREOF, OWNER and CONTRACTOR have signed 5 copies of this Agreement. One counterpart each has been delivered to OWNER, CONTRACTOR and ENGINEER. All portions of the Contract Documents have been signed or identified by OWNER and CONTRACTOR or identified by ENGINEER on their behalf. This Agreement will be effective on , 2009 (which is the Effective Date of this Agreement). City of xxxxxxx, Indiana xxxxxxxxxxxxxx Owner Contractor By It’s Board of Works & Public Safety By Mayor and Member Member Member Attest Attest xxxxxxxxxx, Clerk-Treasurer Address for giving notices Address for giving notices xxxxxxxxxxx xxxxxxxx, IN xxxxxxx License No. Agent for service of process: INSTRUCTIONS FOR EXECUTING AGREEMENT If the Contractor is a corporation, the following certificate should be executed by an officer of the firm other than the Agreement signee: I, _________________________________________ certify that I am the _________________________of the corporation named as Contractor hereinabove; that ________________________________ _______________________who signed the foregoing Agreement on behalf of the Contractor was then ___________________________ ____________________________ of said Corporation; that said Agreement was duly signed for and in behalf of said Corporation by authority of its governing body, and is within the scope of its corporate powers. _____________________________________ (Corporate Seal) If the Agreement is signed by the secretary of the corporation, the above certificate should be executed by some other officer of the corporation, under the corporate seal. In lieu of the foregoing certificate there may be attached to the Agreement copies so much of records of the corporation as will show the official character and authority of the officers signing, duly certified by the secretary or assistant secretary under the corporate seal to be true copies. The full name and business address of the CONTRACTOR should be inserted and the Agreement should be signed with his official signature. The name of the signing party or parties should be typewritten or printed under all signatures to the Agreement. If the CONTRACTOR should be operating as a partnership, each partner should sign the Agreement. If the Agreement be not signed by each partner, there should be attached to the Agreement a duly authenticated power of attorney evidencing the signer's (signers') authority to sign such contract for and in behalf of the partnership. If the CONTRACTOR be an individual, the trade name (if the CONTRACTOR be operating under a trade name) should be indicated in the Agreement and the Agreement should be signed by such individual. If signed by one other than the CONTRACTOR, there should be attached to the Agreement a duly authenticated power of attorney evidencing the signer's authority to execute such Agreement for and in behalf of the CONTRACTOR. EXHIBIT B Performance bond KNOW ALL MEN BY THESE PRESENTS, that xxxxxxxxxxxxxx, Contractor, as Principal and___________________ ______________________________________________________, as Surety, are held and firmly bound unto the City of xxxxxxxxxx, Indiana, hereinafter called the Owner, in the penal sum of Nine Hundred Sixty Two Thousand Two Hundred Forty Eight Dollars and No Cents ($962,248.00), good and lawful money of the United States of America to be paid to said Owner, its legal representatives and assigns, for which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, and each and every one of them jointly and severally, firmly by these presents. WHEREAS, the above-named Principal has entered into a certain written Agreement with the Owner, dated the _________________________________ day of ___________________ A.D. 20____, for construction of work entitled Site Preparation for Water Treatment Plant No. 1, Contract 76 (hereinafter called the Contract) which Contract and Specifications for said work shall be deemed a part hereof as fully as if set out herein. NOW THEREFORE, THE CONDITIONS OF THIS OBLIGATION IS SUCH, that if the said Principal shall well and faithfully do and perform the things agreed by him to be done and performed according to the terms of said Contract and shall pay all lawful claims of subcontractors, material suppliers, and laborers, for labor performed and materials furnished in carrying forward, performing or completing of the said Contract, we agreeing and assenting that this undertaking shall be for the benefit of any material supplier or laborer having a just claim as well as for the obligee herein, then this obligation shall be void, otherwise the same shall remain in full force and effect; it being expressly understood and agreed that the liability of the surety for any and all claims hereunder shall in no event exceed the penal amount of this obligation as herein stated. The said surety, for value received, hereby stipulates and agrees that no charge, extension of time, alteration or addition to the terms of the Contract or to the work to be performed thereunder or the Specifications accompanying the same shall in any wise affect its obligations on this bond, and it does hereby waive notice of any such change, extension of time, alteration, or addition to the terms of the Contract or to the work of the Specifications. WITNESS our hands and seals this ___________ day of ______________ A.D. 20____. Witnesses: Principal: Printed Printed (Seal) Witness Signature Principal Signature Surety: Printed Printed (Seal) Witness Signature Surety Signature I hereby approve the form and correctness of the foregoing Bond. Owner’s Legal Officer Date: EXHIBIT C payment bond KNOW ALL MEN BY THESE PRESENTS: that xxxxxxxxxxxxxxxx (Contractor) xxxxxxxxxxxxxxxxxxxxxxxx______________________ (Address) A Corporation, hereinafter called Principal, ________________________________________ (Corporation, Partnership, or Individual) and__________________________________________________________________________________ (Surety) _____________________________________________________________________________________ (Address) hereinafter called Surety, are held and firmly bound unto the xxxxxxxxxxxxxxxx xxxxxxx, Indiana xxxxxxxxx hereinafter called Owner, in the penal sum of Nine Hundred Sixty Two, Two Hundred Forty Eight Dollars and No Cents ($ 962,248.00), in lawful money of the United States, for the payment of which sum well and truly to be made, we bind ourselves, successors, and assigns, jointly and severally, firmly by these presents. THE CONDITION OF THIS OBLIGATION is such that whereas, the Principal entered into a certain Agreement with Owner, dated the ______ day of ______, 20______, (hereinafter called the Contract) a copy of which is hereto attached and made a part hereof for the construction of: Site Preparation for Water Treatment Plant No. 1 _________________________________Contract 76________________________________________ NOW, THEREFORE, if the Principal shall promptly make payment to all persons, firms, Subcontractors, and corporations furnishing materials for or performing labor in the prosecution of the Work provided for in said contract granted by the Owner with or without notice to the Surety, and during the one year guarantee period, including all amounts due for materials, lubricants, oil, gasoline, coal and coke, repairs on machinery, equipment, and tools, consumed or used in connection with the construction of such work, and for all insurance premiums on said Work, and for all labor performed in such Work whether by Subcontractor or otherwise, then this obligation shall be void; otherwise to remain in full force and effect. PROVIDED, FURTHER, that the said Surety, for value received, hereby stipulates and agrees that no change, extension of time, alteration, or addition to the terms of the Contract or to the work to be performed thereunder or to the specifications accompanying the same shall in any wise affect its obligation on this Bond, and it does hereby waive notice of any such change, extension of time, alteration, or addition to the terms of the Contract or to the work or to the specifications. PROVIDED, FURTHER, that no final settlement between the Owner and the Contractor shall abridge the right of any beneficiary hereunder whose claim may be unsatisfied. IN WITNESS WHEREOF, this instrument is executed in 5 counterparts, each one of which shall be deemed an original, this, the ______ day of ______, 20______. ATTEST: Principal (Principal) Secretary By (SEAL) (Address) (Witness as to Principal) (Address) ATTEST: (Surety) (Surety) Secretary By Attorney-in-Fact (SEAL) (Address) (Witness as to Surety) (Address) NOTE: Date of Bond must not be prior to date of Agreement. If Contractor is Partnership, all partners should execute Bond. EXHIBIT D CONTRACTOR’S AFFIDAVIT Final Estimate STATE OF _______________________) )ss. COUNTY OF ) The undersigned, __________________________________________________________ hereby represents that on ____________________________________________________ it was awarded a contract by ______________________________________________ hereinafter called the Owner, to _________________________________________________________, in accordance with terms and conditions of Contract No. ______; and the undersigned further represents that the subject work has now been accomplished and the said Contract has now been completed. The undersigned hereby warrants and certifies that all of its indebtedness arising by reason of the said Contract has been fully paid or satisfactorily secured; and that all claims from Subcontractors and others for labor and material used in accomplishing the said project, as well as all other claims arising from the performance of the said Contract, have been fully paid or satisfactorily settled. The undersigned further agrees that, if any such claim should hereafter arise, he (it) shall assume responsibility for the same immediately upon request to do so by the Owner. The undersigned, for a valuable consideration, the receipt of which is hereby acknowledged, does further hereby waive, release and relinquish any and all claims or right of lien which the undersigned now has or may hereafter acquire upon the subject premises for labor and material used in accomplishing said project owned by the Owner. This affidavit is freely and voluntarily given with full knowledge of the facts, on this _____________ day of ________________, A.D. 20______. Contractor By: Title: Sworn and subscribed before me this _____________ day of ____________________ 20 _________. Notary Public in and for My Commission Expires: 20______ (Seal) EXHIBIT E CONTRACTOR’S AFFIDAVIT Current Estimate STATE OF _______________________) )ss. COUNTY OF ) The undersigned, ______________________________________________________ hereby represents that on ____________________________________________________ it was awarded a contract by ________________________________________________________________________ hereinafter called the Owner, to __________________________________________________________, in accordance with terms and conditions of Contract No. ______; and the undersigned further represents that the subject work has now been accomplished and the said Contract has now been completed. The undersigned hereby warrants and certifies that all of its indebtedness arising by reason of the said Contract has been fully paid or satisfactorily secured; and that all claims from Subcontractors and others for labor and material used in accomplishing the said project, as well as all other claims arising from the performance of the said Contract, have been fully paid or satisfactorily settled. The undersigned further agrees that, if any such claim should hereafter arise, he (it) shall assume responsibility for the same immediately upon request to do so by the Owner. The undersigned, for a valuable consideration, the receipt of which is hereby acknowledged, does further hereby waive, release and relinquish any and all claims or right of lien which the undersigned now has or may hereafter acquire upon the subject premises for labor and material used in accomplishing said project owned by the Owner. This affidavit is freely and voluntarily given with full knowledge of the facts, on this _____________ day of ________________, A.D. 20______. Contractor By: Title: Sworn and subscribed before me this _____________ day of ____________________ 20 _________. Notary Public in and for My Commission Expires: 20______ (Seal) EXHIBIT F NOTICE TO PROCEED Dated , 20_____ TO: xxxxxxx ADDRESS: xxxxxxxx xxxxxxxxxxx PROJECT: Site Preparation for Water Treatment Plant No. 1 OWNER’s CONTRACT NO.: 76 CONTRACT FOR: City of xxxxxxxx Indiana You are notified that the Contract Times under the above contract will commence to run on ______, 20______. By that date, you are to start performing your obligations under the Contract Documents. In accordance with Article 3 of the Agreement the dates of Substantial Completion and completion and readiness for final payment are ______, 20______ and ______, 20______. Before you may start Work at the site, paragraph 2.7 of the General Conditions provides that you must deliver to the Owner (with copies to ENGINEER and other identified additional insureds) certificates of insurance which you are required to purchase and maintain in accordance with the Contract Documents. Also before you may start any Work at the site, you must City of xxxxxxx, Indiana xxxxxxxxx (OWNER) By: (Authorized Signature Utility Director (Title) EXHIBIT G confined space REQUIREMENT acknowledgement The undersigned hereby warrants and represents that they are familiar with and have reviewed the City of xxxxxxx Confined Space requirements concerning entry into a confined space including, but not limited to requirements for working in, on, or about the wastewater system or water system of the City of xxxxxxxx. The undersigned warrants and represents that they are familiar with and have reviewed the requirements of the City of xxxxxxxx and have made any and all employees, agents, or independent contractors including, but not limited to subcontractors employed by them and who will be working on the site familiar with these procedures. The undersigned hereby further warrants and represents that they will comply with any and all requirements including, but not limited to additional requirements which might be imposed pursuant to federal regulations and/or the City of xxxxxxx. In addition, the undersigned warrants and represents that any and all employees, agents, independent contractors working on projects will execute and provide a confined space entry permit form, said form incorporated into this Agreement and marked as Exhibit "F". Signature Company (Address) EXHIBIT H RIDER TO CONSTRUCTION AGREEMENT This Rider to the Construction Agreement (“Agreement”) executed by _____________________(“Vendor”) and the City of xxxxxxx, Indiana (“City”) on________________(City Contract No.76), is hereby entered into by and between the City, acting through its Board of Public Works and Safety, and Vendor on this ______day of _______,20____. WHEREAS, on January 1, 2001, the City instituted a mandatory “purchase order system” for the City’s purchase of all goods and services exceeding Two Hundred Fifty Dollars ($250.00) in value; and WHEREAS, in order to operate under this “purchase order system”, every City contract must contain an estimate of the cost of providing goods and services to the City pursuant to such contract, and the City must rely on this estimate when encumbering sufficient monies to pay for same. NOW, THEREFORE, THE PARTIES AGREE AS FOLLOWS: 1. The above Recitals are incorporated herein as though they were fully set below. 2. Vendor agrees that the total cost for all goods and services (“Goods and Services”) provided to City pursuant to the Agreement shall not exceed the Bid Amount, subject to change orders. 3. City agrees to prepare a purchase order setting aside the sum of the Bid Amount subject to change orders to pay for all Goods and Services provided pursuant to the Agreement, and to indicate budget appropriation number (N/A) as being that from which such Goods and Services are to be paid on said purchase order. 4. Vendor agrees to notify City, in writing, when the total cost for all Goods and Services provided to City by Vendor pursuant to the Agreement reaches the amount of the Bid Amount, subject to change orders. 5. Vendor agrees that it will not provide any Goods or Services to City if the provision of same would cause the total cost of the Goods and Services provided to City during such period to exceed the sum of the Bid Amount, subject to change orders. 6. This Rider shall continue in effect from year to year, unless earlier modified or terminated in writing by the parties hereto, except that this Rider shall automatically terminate on the date on which the Agreement itself is terminated. 7. The terms of this Rider shall supercede any contrary terms or conditions contained in the Agreement. All Agreement terms and conditions not so affected shall remain in full force and effect, are incorporated herein by this reference and shall apply to this Rider as well. 8. Upon proper execution by all parties hereto, the effective date of this Rider shall be the date of this Agreement. IN WITNESS WHEREOF, the parties hereto have made and executed this Rider as follows: __________________________________ (“VENDOR”) BY: _____________________________________ (Authorized Signature) ______________________________________ Printed Name ______________________________________ Title FID/SSN:_______________ Date:__________________