CONTRACT 3948 CLOSEDCity of El Segundo
Mor-
Residential Sound Insulation Program
Contract Number 3948
Residential Sound Insulation Program Contract
between
The City of El Segundo
and
Professional Building Contractors, Inc.
This Contract is entered into this 3`d day of June, 2009, by and between the City of El Segundo, a
general law city and municipal corporation ( "City ") and Professional Building Contractors, Inc.
( "Contractor ").
1. Work
A. The Contractor and the City agree to abide by the terms and conditions contained
in the Contract Documents;
B. The Contractor must furnish all of the labor; supplies and materials; equipment;
printing; vehicles; transportation; office space and facilities; all tests, testing and
analyses; and all matters whatsoever (except as otherwise expressly specified to
be furnished by the City) needed to install all products and provide all services
required of the Contractor by the Contract Documents (the "Work ").
C. The Contractor agrees to do additional work arising from changes ordered by the
City in accordance with the Contract Documents.
D. "Contract Documents" means the Notice Inviting Sealed Bids; Instructions to
Bidders; the accepted Bidding Documents; this Contract; Specifications; Plans;
Addenda; Notice of Award; Notice to Proceed; Requests for Information;
Requests for Change Orders; Change Orders; Notice of Completion; and all other
documents identified in the Contract Documents which together form the Contract
between the City and the Contractor for the Work. The Contract Documents
constitute the complete agreement between the City and the Contractor and
supersede any previous agreements or understandings.
2. Contract Sum
The City agrees to pay the Contractor a sum not to exceed Eight hundred, twenty -six
thousand, three hundred and seventy -five dollars ($826,375) for the Work in the manner
set forth in the Contract Documents. The City may adjust this amount as set forth in the
Contract Documents.
3. Time for Performance
A. The Contractor will fully complete the Work in accordance with the Construction
Schedule (the "Contract Time ").
K51 ug -ug (croup sz)
City of El Segundo
AMMOM Residential Sound Insulation Program
Contract Number 3948
B. City may, but is not required to, allow time extensions or alterations to the
Construction Schedule if Contractor causes a delay in City issuing a Notice to
Proceed.
C. The Construction Schedule will supersede any conflicting provisions included on
the notice to proceed issued pursuant to this Contract.
D. The Contractor must not perform any Work until:
i. The Contractor furnishes proof of insurance as required by the Contract
Documents; and
ii. The City gives the Contractor a Notice to Proceed.
E. By signing this Contract, the Contractor represents to the City that the Contract
Time is reasonable for completion of the Work and that the Contractor will
complete the Work within the Contract Time.
F. Should the Contractor begin the Work before receiving written authorization to
proceed, any such Work is at the Contractor's own cost and risk.
4. Disputes
Disputes arising from this contract will be determined in accordance with the Contract
Documents and Public Contracts Code §§ 10240 - 10240.13.
5. Taxpayer Identification Number
The Contractor will provide the City with a Taxpayer Identification Number.
6. Permits and Licenses
Unless otherwise provided, the Contractor, at its sole expense, will obtain and maintain
during the Contract Time, all necessary permits, licenses, and certificates that may be
required in connection with the Work.
7. Ownership of Documents
All documents, data, studies, drawings, maps, models, photographs and reports prepared
by the Contractor under the Contract Documents are the City's property. The Contractor
may retain copies of said documents and materials as desired, but will deliver all original
materials to the City upon the City's written notice.
8. Indemnification
The Contractor agrees to indemnify and hold the City harmless as set forth in the Contract
Documents. The requirements as to the types and limits of insurance coverage to be
2 RSI 09 -09 (Group 32)
Agglillhk City of El Segundo
MPWO Residential Sound Insulation Program
Contract Number 3948
MW
maintained by the Contractor as required by the Contract Documents, and any approval of
such insurance by the City, are not intended to and will not in any manner limit or qualify
the liabilities and obligations otherwise assumed by the Contractor pursuant to the
Contract Documents, including, without limitation, to the provisions concerning
indemnification.
9. Independent Contractor
The City and the Contractor agree that the Contractor will act as an independent
contractor and will have control of all work and the manner in which is it performed. The
Contractor will be free to contract for similar service to be performed for other employers
while under contract with the City. The Contractor is not an agent or employee of the
City and is not entitled to participate in any pension plan, insurance, bonus or similar
benefits the City provides for its employees. Any provision in this Contract that may
appear to give the City the right to direct the Contractor as to the details of doing the
work or to exercise a measure of control over the work means that the Contractor will
follow the direction of the City as to end results of the work only.
10. Audit of Records
The Contractor will maintain full and accurate records with respect to all services and
matters covered under this Contract. The City will have free access at all reasonable
times to such records, and the right to examine and audit the same and to make transcript
therefrom, and to inspect all program data, documents, proceedings and activities. The
Contractor will retain such financial and program service records for at least three (3)
years after termination or final payment under the Contract Documents.
11. Notices
All communications to either party by the other parry will be deemed made when
received by such party at its respective name and address as follows:
City
RSI Program
City of El Segundo
City Hall
350 Main Street
El Segundo, CA 90245
Contractor
Professional Building Contractors, Inc.
125 Sheldon Street
El Segundo, CA 90245
Any such written communications by mail will be conclusively deemed to have been
received by the addressee three (3) days after deposit thereof in the United States Mail,
postage prepaid and properly addressed as noted above. In all other instances, notices
will be deemed given at the time of actual delivery. Changes may be made in the names
or addresses of persons to who notices are to be given by giving notice in the manner
prescribed in this paragraph.
KNI uy -VY �Uruup .)/-)
City of El Segundo
Residential Sound Insulation Program
Contract Number 3948
ISIMEEM
12. NO THIRD PARTY BENEFICIARY
This Contract and every provision herein are for the exclusive benefit of the Contractor
and the City and not for the benefit of any other party. There will be no incidental or
other beneficiaries of any of the Contractor's or the City's obligations under this Contract.
13. INTERPRETATION
This Contract was drafted in, and will be construed in accordance with the laws of the
State of California, and exclusive venue for any action involving this Contract will be in
Los Angeles County.
14. EFFECT OF CONFLICT
In the event of any conflict, inconsistency, or incongruity between any provision of the
Contract Documents, precedence will be as follows:
A. This Contract;
B. Precedence of documents as determined in the Conditions of the Contract.
15. SEVERABILITY
If any portion of the Contract Documents are declared by a court of competent
jurisdiction to be invalid or unenforceable, then such portion will be deemed modified to
the extent necessary in the opinion of the court to render such portion enforceable and, as
so modified, such portion and the balance of this Contract will continue in full force and
effect.
16. AUTHORITY/MODIFICATION
The Parties represent and warrant that all necessary action has been taken by the Parties to
authorize the undersigned to execute this Contract and to engage in the actions described
herein. This Contract may be modified by written amendment. The City's city manager,
or designee, may execute any such amendment on the City's behalf.
17. ACCEPTANCE OF FACSIMILE SIGNATURES
The Parties agree that this Contract, agreements ancillary to this Contract, and related
documents to be entered into in connection with this Contract will be considered signed
when the signature of a party is delivered by facsimile transmission. Such facsimile
signature will be treated in all respects as having the same effect as an original signature.
4 Kul ug -ug (kiroup 3z)
City of El Segundo
AMPMEM Residential Sound Insulation Program
Contract Number 3948
18. COVENANTS AND CONDITIONS
The parties agree that all of the provisions hereof will be construed as both covenants and
conditions, the same as if the words importing such covenants and conditions had been
used in each separate paragraph.
19. CAPTIONS
The captions of the paragraphs of this Contract are for convenience of reference only and
will not affect the interpretation of this Contract.
20. Time is of Essence
Time is of the essence for each and every provision of the Contract Documents.
[Signatures on next page]
KJl uv -uv wroup .3z)
City of El Segundo
Residential Sound Insulation Program
Contract Number 3948
IN WITNESS WHERE OF the parties hereto have executed this contract the day and year first
hereinabove written.
City: Contractor:
Attest:
By: <
Cindy rt
City Clerk
APPROVED A
MARK D. HE)
• V ,4 •
K01 H. )Berger,
Assistant City A
By: Z��
Richard J. Willi
President
Taxpayer ID Number: 91- 1947933
State License Number: 3852
City Business License Number: 02906
6 RSI 09 -09 (Group 32)
City of El Segundo
Residential Sound Insulation Program
' w
1
FAITHFUL PERFORMANCE BOND
Bond No, SSB397165
Bond Fee: $11,764.00
Professional Building Contractors, Inc. _,as principal ( "PRINCIPAL ") and
RLI Insurance Company , a corporation incorporated under
the laws of the State of Illinois and licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ( "SURETY'), are held and
firmly bound unto the City of El Segundo ( "CITY") in the sum of
Eight Hundred Twenty -Six Thousand Three
Hundred Seventy -Five & No /100 dollars ($ 826, 375.00 _ ),
(words)
lawful money of the United States, which away be increased or decreased by a rider hereto
executed in the same manner as this bond, for the payment of which sum PMCIPAL and
SURETY bind themselves, their successors, and assigns, jointly and severally, by this
instrument.
PRINCBAL or SURETY will apply this bond for the faithful performance of any and all of the
conditions and stipulations set forth in this bond, Contract Documents for Group 32 (RSI
09.09 of the City of El Segundo's Residential Sound Insulation Program ( "PROJECT ' ) and
Contract 3948 executed for such Project. In the case of any default in the performance of
the conditions and stipulations of this undertaking, it is agreed that PRINCIPAL or SURETY
will apply the bond or any portion thereof, to the satisfaction of any damages, reclamation,
assessments, penalties, or deficiencies arising by reason of such default.
Bond Conditions
1. PRINCIPAL will construct the improvements identified in the Contract Documents for
the PROJECT, copies of which are on file in the CITY's Residential Sound Insulation
program offices. Such performance will be in accordance with the requirements of the
Contract Documents which are made a part of this bond by reference.
1 PRINCIPAL's work on the PROJECT will be done in accordance with the requirements
of the Contract Documents for the PROJECT and with permits issued by the CITY,
Should PRINCIPAL fail to complete all required work within the time allowed, CITY
may, at its sole discretion, cause all required work to be done and the parties executing
the bond will be firmly bound for the payment of all necessary costs therefor.
3. PRINCIPAL will guarantee its work against any defective work, labor, or materials on
the PROJECT for a period of one (1) year following the PROJECT's completion and
acceptance by the CITY.
4. PRINCIPAL will pay for all materials and other supplies, for equipment used in, on, for
or about the performance of the Project, and will pay for all work and labor thereon.
Faithful Performance Bond l Last Modified: April 22, 2009
City of El Segundo 3948
,
Residential Sound Insulation Pra am
5. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code ( "ESMC').
6. SURETY, for value received, agrees that no changes, extensions of tinge, alteration or
modification of the Contract Documents, or of the obligation to be performed will in any
way affect its obligation on this bond, and it waives notice of any such change, extension
of time, alteration or modification of the contract documents or of the obligation to be
performed.
7. This bond consists of this instrument-, the Contract Documents identified above; and the
following two (2) attached exhibits all of which are incorporated herein by reference:
A. A certified copy of the appointment, power of attorney, bylaws or other
instrument entitling or authorizing the persons executing this bond to do so; and
B. A, certificate issued by the county clerk for the county in which SURETY's
representative is located conforming with California Code of Civil Procedure
§995.640 and stating that SURETY's certificate of authority has not been
surrendered, revoked, cancelled, annulled, or suspended, or in the event that it
bas, that renewed authority has been granted.
8. Should PRINCIPAL perform its obligations within the time allowed, PRINCIPAL's
obligations will be void upon the acceptance of the performance by CITY; otherwise this
obligation will remain in full force and effect.
• .
SIGNED AND SEALED this 4th _ day of June , 20 09 _
Profe al Buil ng Contr ctors, Inc. RLI Insurance Company
i
By: A, .. By ;
PRINCIPAL'S a dent UgE 's F�1 � Attorney -in -Fact
Bonny Smith
PRINCIPAL'S Secretary SURETY's StIHiy Witness
NOTE: ALL signatures must be acknowledged by a notary public.
PRINCIPAL'S Mailing Address
125 Sheldon Street
El Segundo, CA 90245
SURETY's Mailing Address
14900 Interurban Ave. So.
Suite 275
Seattle, WA 98168
Faithful Performance Bond 2 Last Modified: April 22, 2009
Geer rr, -At-Ao purse ��lt %0 995.640(a) Code 0 C�vt; fdcetf
of ', C�cA�J L 'AS Cnu qty Clerk of the Count
'? Ccun__ mote of Caiifdrnia, in an�i for said Count
D EREUY CERTIFY THAT
has a certificate ofauthonty a ,a, dl �C{� Ovm ��
Insurance: Commissions r aUEnofl2ln trY:. insurer C is yue d by ti. C Califomi
the Sta; of C;aiiforn;a, sand that based on the recurur; snuwn !, I (fit, rt35p to nt ol
Insurance website that authority has not been surre;rdered, revoked, canceled,
annulled, or suspended.
In Ti timanY rrro% I e here t et my hand and affixed the seal of
said County on
&Ai L C
COUNTY CLERK
BY
Deputy County Clerk
j. JMENEZ
Ce
CPeVc�,-".; Puratogi;t to 995.640(a) Code of C" Via !7fj - dtfiv
DEAN C. LO GAIL , County Onrk of the County
of itofnia, in nano fur said Counq
DO ERESYC'ERTIFY THAT
PO' Gj
has a certificate of authority a,. �nadm ,,ex ' -Y iss.0 d by 100 CLIlifornij-
Insurance Commissionet utnonzin� U";;.- lflz�urar 10 SUP!atv insurance in
the State of Catifornia, and that bas d on the recow, , shown w tht- Ouparinient of
Insurance websrLe: that authority has not been surie,,ictrecj, revoked, canceled,
annulled, or suspended.
In Testimony it, I Tye here W-set my hand and atfixea the seal of
said County on l LQ
COUNTY CLERK
BY: Deputy County Clerk
LJ-JIMENr;k
City of Bl Segundo
Residential Sound Imulation
3546 - , ...
LABOR. AND MATERIALS BOND
Bond No. SSB397165
Bond Fee: $11,764.00
Professional Building Contractors, Inc. , as principal ( "PRINCIPAL") and
RLI Insurance Company , a corporation incorporated under
the laws of the State of Illinois and licensed by the State of
California to execute bonds and undertakings as sole surety, as surety ( "SURETY"), are held and
firmly bound unto the City of El Segundo ( "CITY ") in the sum of
Eight Hundred Twenty -Six Thousand Three 826,375.00
_ Hundred Seventy -Five & No /100 dollars ($
-- (words)
lawful money of the United States, which may be increased or decreased by a rider hereto
executed in the same manner as this bond, for the payment of which sure PRINCIPAL and
SURETY bind themselves, their successors, and assigns, jointly and severally, by this
instrument.
This bond is conditioned upon and guarantees payment by PRINCIPAL to contractors,
subcontractors, and ,persons renting equipment; payment by PRINCIPAL and all PRINCIPAL'S
subcontractors for all materials, provisions, provender, or other supplies, and equipment used in,
upon, for or about the performance of the work contemplated in the Contract Documents for
Crroup 32 (RSI 09 -09 ) of the City of El Segundo's Residential Sound Insulation Program
( "PROJECT ") and Contract 3 9 4 8 executed for such Project, and for all work or labor of
any kind performed for the Project. In the case of any default in the performance of the
conditions and stipulations of this undertaking, it is agreed that PRINCIPAL or SURETY will
apply the bond or any portion thereof, to the satisfaction of any damages, reclamation,
assessments, penalties, or deficiencies arising by reason of such default.
Bond Conditions
1. PRINCIPAL will construct the improvements identified in the Contract Documents for
the PROJECT, copies of which are on file in the CITY's Residential Sound Insulation
Program offices. Such perfomance will be in accordance with the requirements of the
Contract Documents which are made a part of this bond by reference.
2. PRINCIPAL will pay all contractors, subcontractors, and persons renting equipment.
3. PRJNCIPAL will pay for all materials and other supplies, for equipment used ins, on, for
or about the performance of the Project, and will pay for all work and labor thereon.
4. This bond is conditioned upon and guarantees due compliance with all applicable law
including, without limitation, the El Segundo Municipal Code (" ESMC ").
SURETY, for value received, agrees that no changes, extensions of time, alteration. or
Labor and Materials Bond 1 Last Modified: April 22, 2009
City of El Segundo 3948
.
Residential Sound Insulation Program
modification of the Contract Documents, or of the obligation to be performed will in any
way affect its obligation on this bond, and it waives notice of any such change, extension
of time, alteration or modification of the contract documents or of the obligation to be
performed,
6. This bond consists of this instr=eut; the Contract Documents identified above; and the
following two (2) attached exhibits all of which are incorporated herein by reference:
A. A ceilified copy of the appointment, power of attorney, bylaws or other
instrument entitling or authorizing the persons executing this bond to do so; and
B. A certificate issued by the county clerk for the county in which SURETY'S
representative is located conforming with California Code of Civil Procedure §
995,640 and stating that SURETY's certificate of authority has not been
surrendered, revoked, cancelled, annulled, or suspended, or in the event that it
has, that renewed authority has been granted.
7. Should PRINCIPAL perform its obligations within the time allowed, PRINCIPAL's
obligation will be void upon the acceptance of the performance by CITY; otherwise this
obligation will remain in full force and effect.
SIGNED AND SEALED this 4th day of June 20 09 .
Pro l uildin contractors, Inc.
By.
PRINCIPAL ident
1
By
PRINCIPAL's Secretary
RLI Insurance Company
By: C
SURE 's l MUW Attorney -in -Fact
Bonny ^Smith
By:
SURETY'S Swaft* Witness
NOTE: ALL signatures must be acknowledged by a notary public.
PRINCIPAL's Mailing Address
125 Sheldon Street
E1 Segundo, CA 90245
SURETY's Mailing Address
14900 Interurban Ave. So.
Suite 275
Seattle, WA 989168
Labor and Materials Bond 2 Last Modified: April 22, 2009
3 4 8
ATTORNEY -IN -FACT NOTARY ACKNOWLEDGMENT OF SURETY
State of Washington
County of King
On this 4th day of June , 2009 , before me, Roxana Pal acios
personally appeared Bonny Smith known to me to be the person
whose name is subscribed to the within instrument as the Attorney -In -Fact of
RLI Insurance Company
the corporation named as Surety in said instrument, and acknowledged to me that he/she
subscribed the name of said corporation thereto as Surety, and his/her own name as
Attorney -In -Fact. q px„
Witness and and offic' seal a•• iy �.o•; .
n7i 0A 2:
r
Notary Public in and for the State of Washington ' r? is ar
�y9•,. �9
Residing in Bothell ten'••
Commission Expires 9/2/09 �TC WA •••
s 0,A
C.) RLI Surety
RLI P.O. Box 3967 1 Peoria, IL 61612 -3967
Phone: (800)645 -2402 1 Fax: (309)689 -2036
www.rlicorp.com
Know All Men by These Presents:
3948 . , , ,4
POWER OF ATTORNEY
RLI Insurance Company
That this Power of Attorney is not valid or in effect unless attached to the bond which it authorizes executed, but may be detached by the
approving officer if desired.
That RLI Insurance Company, an Illinois corporation, does hereby make, constitute and appoint:
jay F i�lfers Steven W Palmer. Bonny Smith Roxana Palacios Mary A Dobbs Heather Allen iointly or severally.
in the City of Seattle-, State of Washineton its true and lawful Agent and Attorney in Fact, with full
power and authority hereby conferred, to sign, execute, acknowledge and deliver for and on its behalf as Surety, the following described
bond.
Any and all bonds, undertakings, and recognizances in an amount not to exceed Ten Million Dollars ($10,000,000) for
any single obligation.
The acknowledgment and execution of such bond by the said Attorney in Fact shall be as binding upon this Company as if such bond had been
executed and acknowledged by the regularly elected officers of this Company.
The RLI Insurance Company further certifies that the following is a true and exact copy of the Resolution adopted by the Board of Directors
of RLI Insurance Company, and now in force to -wit:
"All bonds, policies, undertakings, Powers of Attorney or other obligations of the corporation shall be executed in the corporate name of
the Company by the President, Secretary, any Assistant Secretary, Treasurer, or any Vice President, or by such other officers as the
Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint
Attorneys in Fact or Agents who shall have authority to issue bonds, policies or undertakings in the name of the Company. The
corporate seal is not necessary for the validity of any bonds, policies, undertakings, Powers of Attorney or other obligations of the
corporation. The signature of any such officer and the corporate seal may be printed by facsimile."
IN WITNESS WHEREOF, the RLI Insurance Company has caused these presents to be executed by its Vice President with its
corporate seal affixed this 13th day of __January_. 2009 .
?cc OoRPORAr.
—•-
SEAL.
State of Illinois 1 SS
County of Peoria J ''���; N,o�s``,�
On this 13th day of January 2009 , before me, a Notary
Public, personally appeared Roy C. Die , who being by me duly sworn,
acknowledged that he signed the above Power of Attorney as the aforesaid
officer of the RLI Insurance Company and acknowledged said instrument to be
the voluntary act and deed of said corporation.
BrC.
By. AZZ.
Notary Public
Jac eline M. Bock r n
E "OFFICIAL SEAL"
CQUELINE M. BOCKLER
MMISSION EXPIRES 03/01/10
, 11— j
RLI Insurance Company
By:
Roy C. Di Vice President
CERTIFICATE
I, the undersigned officer of RLI Insurance Company, a stock
corporation of the State of Illinois, do hereby certify that the attached
Power of Attorney is in full force and effect and is irrevocable; and
furthermore, that the Resolution of the Company as set forth in the
Power of Attorney, is now in force. In testimony whereof, I have
here Wtt my hnsurance Company
this ay of
RLI Insurance Company
By:
Roy C. Di Vice President
4665141030110 A0059207
39 `F V . a . of
California All- Purpose Acknowledgement
State of California }
County of Loos Angeles
On Jim 5, 2009 before me, Dam Norn m , a Notary Public
personally appeared Ridmrd J. WLUims and Charlotte Williams together
DANA NORMAN
Commission # 1597724
s Notary Kift - CaNfomia
t Los Angeles County
My Comm. Expkes Jul 28.2009
Notary Public Seal
Description of Attached Document
Title or Type of Document: Faithful Performance Bond
who proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) i are ubscribed to
the within instrument and acknowledged to me that he/
she 'executed the same in his /her eir authorized
capa rty(ies), and that by his /her/ e' gnature(s) on
the instrument the person(s), or th ntity 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.
0 �rjm/
Notary Public Signature
Document Date: June 1, 2009 Number of Pages: 4
Signer(s) Other than Named Above: Bomy Strdth and Holly E Ulfers
Capacity(ies) Claimed by Signer(s)
J Individual
• Corporate Officer:
• Partner - ❑ Limited ❑ General
• Attorney -in -Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer is Representing:
OPTIONAL
• Individual
• Corporate Officer:
a Partner - U Limited J General
❑ Attorney -in -Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer is Representing:
California All- Purpose Acknowledgement
State of California }
County of Los Angeles
On June 5, 2009 before me,
3948 • .. •`A
Dam Noman , a Notary Public
personally appeared
Richard J. William and Charlotte Williams together
DANA NORMAN
Coffpjv lon # 1897724
W5ff.MV Cantu. a pw Jul 28, 2009
Notary Public Seal
Description of Attached Document
Labor and Materials Bond
Title or Type of Document:
Document Date: June 1, 2009
who proved to me on the basis of satisfactory evidence
to be the person(s) whose name(s) i are ubscribed to
the within instrument and acknowledg to me that he/
she/ hey executed the same in his/ heir authorized
caps y(ies), and that by his /her/ eir signature(s) on
the instrument the person(s), 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 Public Signature
umber of Pages: 4
Signer(s) Other than Named Above: Bormy Stmth and Holly E. Ulfers
Capacity(ies) Claimed by Signer(s)
❑ Individual
❑ Corporate Officer:
U Partner - IJ Limited J General
❑ Attorney -in -Fact
❑ Trustee
❑ Guardian or Conservator
❑ Other:
Signer is Representing:
OPTIONAL
❑ Individual
❑ Corporate Officer: _-
❑ Partner - ❑ Limited Q General
❑ Attorney -in -Fact
❑ Trustee
U Guardian or Conservator
❑ Other:
Signer is Representing: