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22650 County Highway 6 PO Box 1708 Detroit Lakes, MN 56502-1708 USA
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22650 County Highway 6 PO Box 1708 r Detroit Lakes, MN 56502-1708 USA
Item
Description
Unit
Estimated
Quantiles
Unit Price
Total Amount
1
Upgrade to Instrumentation and Controls
LS
1.0
$ 7(14 2, 3.,,
$ 7 76),),..3C, --,c
TOTAL BID
$ 7 q ( g,,3 a , <3 U
FORM OF BID OR PROPOSAL
FY 2016 WATER POLLUTION CONTROL FACILITIES
UPGRADE TO INSTRUMENTATION AND CONTROLS SYSTEMS
CITY OF WATERLOO, IOWA
CITY CONTRACT NO. 929
Honorable Mayor and City Council
Waterloo, Iowa
Gentlemen:
1. The undersigned, being a Corporation existing under the laws of the State of M , a
Partnership consisting of the following partners: WA
having familiarized (himself) (themselves) (itself) with the existing conditions on the project area
affecting the cost of the work, and with all the contract documents listed in the Table of Contents and
Addenda (if any), as prepared by the City Engineer of the City of Waterloo now on file in the office of
the City Clerk, City Hall, Waterloo, Iowa, hereby proposes to furnish all supervision, technical
personnel, labor, materials, machinery, tools, appurtenances, equipment, and services, including
utility and transportation services required to construct and complete this FY 2016 WATER
POLLUTION CONTROL FACILITIES, UPGRADE TO INSTRUMENTATION AND CONTROLS
SYSTEMS, CITY CONTRACT NO. 929, all in accordance with the above -listed documents and for
the unit prices for work in place for the following items and quantities:
FY 2016 WATER POLLUTION CONTROL FACILITIES
UPGRADE TO INSTRUMENTATION AND CONTROLS SYSTEMS
CITY OF WATERLOO, IOWA
CITY CONTRACT NO. 929
2. It is understood that the quantities set forth are approximate only and subject to variation and that the
unit bid price for the work done shall govern in the actual payment to Contractor.
3. In submitting this bid, the bidder understands that the right is reserved by the City of Waterloo, Iowa,
to reject any or all bids. If written notice of the acceptance of this bid is mailed, telegraphed, or
delivered to the undersigned within thirty (30) days after the opening thereof, or at any time thereafter
before this bid is withdrawn, the undersigned agrees to execute and deliver an agreement in the
prescribed form and furnish the required bond and certificate of the insurance within ten (10) days
after the agreement is presented to him for signature, and start work within ten (10) days after
"Notice to Proceed" is issued.
4. Security in the sum of S /0 Dollars ($ ) in the
form of b13D
, is submitted herewith in accordance with the INSTRUCTIONS
TO BIDDERS.
5. Attached hereto is a Non -Collusion Affidavit of Prime Contractor.
FORM OF BID
AECOM 60438627
CONTRACT NO. 929 BF -1 OF 2
6. Attached hereto is a Resident Bidder Certification ( ) or Non -Resident Bidder Certification
). (Mark one.)
7. The bidder is prepared to submit a financial and experience statement upon request.
8. The Prime Contractor and Subcontractor(s), which have performed an aggregate of $10,000.00 in
work for the City in the current calendar year, are prepared to submit an AAP or Update and an
EOC, within ten (10) days of notification that the bid submitted is lowest and acceptable.
9. The bidder has received the following Addendum or Addenda:
Addendum No. Date n/e, j7
10. The bidder shall list the MBE/WBE subcontractor(s), amount of subcontracts and bid items on the
City of Waterloo Minority and/or Women Business Pre-bid Contact Information Form submitted with
this Form of Bid or Proposal. The apparent low Bidder shall submit a list of all other Subcontractor(s)
to be used on this Project to the City of Waterloo by 5:00 p.m. the business day following the day
Bids on this Project are due along with the Non -Collusion Affidavits of All Subcontractor(s).
The Contractor shall submit information on subcontractors on "SUBCONTRACTOR REQUEST AND
APPROVAL" Form to be provided by City prior to approval of contract.
The subcontractors listed on this proposal and/or submitted to the Contract Compliance Officer
cannot be changed except for the following reasons:
1) The City of Waterloo does not approve the subcontractors.
2) The subcontractors submit in writing that they cannot fulfill their subcontracts.
11. The bidder has filled in all blanks on this proposal. Those blanks not applicable are marked "none"
or "NA".
12. The bidder has attached all applicable forms.
13. The Owner reserves the right to select alternates, delete line items, and/or to reduce quantities
prior to the award of a contract due to budgetary limitations.
S
laaln SY4nS, ►Ilei v1 1- Pkin46x
( -m. •f Biso- r r
r im 1,411101 1
Vk►"
Official Address: (Including Zip Code):
qi
(Date)
Title 1 f7 t'1 N// wtUK-ce f C ler ettoidoli,orw
1,4o trukr' 01611v✓i Y /
IT LAi Y111I '$t)1
I.R.S. No. I/ — i%Zq I yi 4'
FORM OF BID
AECOM 60438627
*** END OFSECTION ***
CONTRACT NO. 929 BF -2 OF 2
Attachment 1
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and
submitted with the bid.)
U.S. Environmental Protection Agency
Certification of Non -Segregated Facilities
(Applicable to contracts, subcontracts, and agreements with applicants who are themselves
performing Federally assisted construction contracts, exceeding $10,000 which are not exempt
from the provisions of the Equal Opportunity clause.)
By the submission of this bid, the bidder, offeror, applicant, or subcontractor certifies that
he does not maintain or provide for his employees any segregated facilities at any of his
establishments, and that he does not permit his employees to perform their services at any
location, under his control, where segregated facilities are maintained. He certifies further that
he will not maintain or provide for his employees any segregated facilities at any of his
establishments, and that he will not permit his employees to perform their services at any
location, under his control, where segregated facilities are maintained. The bidder, offeror,
applicant, or subcontractor agrees that a breach of this certification is a violation of the Equal
Opportunity clause in this contract. As used in this certification, the term "segregated facilities"
means any waiting rooms, work areas, restrooms and washrooms, restaurants and other eating
areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking
fountains, recreation or entertainment areas, transportation, and housing facilities provided for
employees which are segregated by explicit directive or are in fact segregated on the basis of
race, creed, color, or national original, because of habit, local custom, or otherwise. He further
agrees that (except where he has obtained identical certifications from proposed subcontractors
for specific time periods) he will obtain identical certifications from proposed subcontractors prior
to the award of subcontracts exceeding $10,000 which are not exempt from the provisions of
the Equal Opportunity clause; that he will retain such certifications in his files; and that he will
forward the following notice to such proposed subcontractors (except where the proposed
subcontractors have submitted identical certifications for specific time periods):
NOTICE TO PROSPECTIVE SUBCONTRACTORS OF REQUIREMENT FOR
CERTIFICATIONS OF NON -SEGREGATED FACILITIES
A Certification of Non -segregated Facilities, as required by the May 9, 1967, order (33
F.R. 7808, May 28, 1968) on Elimination of Segregated Facilities, by the Secretary of Labor,
must be submitted prior to the award of a subcontract exceeding $10,000 which is not exempt
from the provisions of the Equal Opportunity clause. The certification may be submitted either
for each subcontract or for all subcontracts during a period (i.e., quarterly, semiannually, or
annually
tiN wkegr ell HAN'61M etiL
Name and Title of Signer (Please Type)
Date
NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
EPA -7 5720-4.2
SRF -2 May 2015
Attachment 2
SRF Required Front -End Specifications
(This form must be completed and signed by the Prime Contractor and
submitted with the bid.)
Debarments and Suspensions
Any bidder or equipment supplier whose firm or affiliate is listed in on the U.S. General Services
Administration Excluded Parties List System web site at http://www.epls.gov/ will be prohibited
from the bidding process. Anyone submitting a bid who is listed on this web site will be
determined to be a non-responsive bidder in accordance with 40 CFR Part 31.
United States Environmental Protection Agency Washington, DC 20460
Certification Regarding Debarment, Suspension, and
Other Responsibility Matters
The prospective participant certifies to the best of its knowledge and belief that it and the
principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any Federal department or
agency;
(b) Have not within a three year period preceding this proposal been convicted of or had a
civil judgment rendered against them for commission o f fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (Federal, State,
or local) transaction or contract under a public transaction: violation of Federal or
State antitrust statutes or commission of embezzlement, theft, forgery, bribery,
falsification or destruction of records, making false statements, or receiving stolen
property;
(c) Are not presently indicted for otherwise criminally or civilly charged by a government
entity (Federal, State, or local) with commission of any of the offenses enumerated in
paragraph (1) (b) of this certification; and
(d) Have not within a three-year period preceding this application/proposal had one or
more public transaction s (Federal, State, or local) terminated or cause or default.
I understand that a false statement on this certification may be ground for rejection of this
proposal or termination of the award. In addition, under 18 U SC Sec. 10 01, a false statement
ma y result in a fine of up to $10,000 or imprisonment for up to 5 years, or both.
Nuik r, CN1eF@NflVU irr44 trfc.
Typed Name & T'tle of Authorized Representative
J2f1
igri- urs o`$'1ut :rite. Representative
Date
❑ 1 am unable to certify to the above statements. My explanation is attached.
EPA Form 5700-49 (11-88)
SRF -3 May 2015
Attachment 3
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and
submitted with the bid.)
Disadvantaged Business Enterprise (DBE) Solicitation
It is EPA's policy that recipients of EPA financial assistance through the State Revolving Fund
programs award a "fair share" of subagreements to small, minority and women -owned
businesses, collectively know as Disadvantaged Business Enterprises (DBEs). Iowa's Fair
Share goals are:
Only work performed by certified DBEs can be counted toward the goals. In Iowa, DBEs must
be certified through the Iowa Department of Transportation (IDOT). Information on certification
requirements and a list of certified DBEs is on the IDOT website at
http://www.iowadot.gov/contracts/contracts eeoaa.htm.
Prime contractors' DBE requirements for SRF projects include:
• Taking affirmative steps for DBE participation
• Documenting the efforts and the proposed utilization of certified DBEs
PROJECT INFORMATION
SRF Applicant:
Minority -Owned Business
Enterprise (MBE) Goal
Women -Owned Business
Enterprise (WBE) Goal
Construction
1.7%
2.2%
Supplies
0.6%
5.6%
Services
2.5%
11.3%
Goods/Equipment
2.5%
10.4%
Average
1.8%
7.4%
Only work performed by certified DBEs can be counted toward the goals. In Iowa, DBEs must
be certified through the Iowa Department of Transportation (IDOT). Information on certification
requirements and a list of certified DBEs is on the IDOT website at
http://www.iowadot.gov/contracts/contracts eeoaa.htm.
Prime contractors' DBE requirements for SRF projects include:
• Taking affirmative steps for DBE participation
• Documenting the efforts and the proposed utilization of certified DBEs
PROJECT INFORMATION
SRF Applicant:
Bidder:
SJ,,. �i 6gie W-?RJ1i1ti�1
Address:
�G'!�!�1fJ%
,0-kk M'01-/-1/1/21-No pp-, ` r l m 5"
1,1
Contact Person:
/40 1 /giva,di.'" (--
Signature:
OF
/ .1 , 410
rig, •. ,,
Phone Number:
- l f-• , 7 --/5/7
E -Mail Address:
-Tit)rJii4 .5ockER1 SJr IOM S CO",
Check if Prime Contractor is: ❑ Minority -Owned ❑ Women -Owned
SRF -4
May 2015
GOOD FAITH EFFORTS CHECKLIST
Please complete the checklist to determine if you have complied with the requirement to make
good faith efforts to ensure that certified DBEs have the opportunity to compete for
procurements funded by EPA financial assistance funds. Bidders/offerers must make good faith
efforts prior to submission of bids/proposals.
1. Did you ensure that DBEs are made aware of contracting opportunities to the fullest extent
practicable through outreach and recruitment activities? Yes ❑ No
2. Did you make information on forthcoming opportunities available to DBEs and arrange time
frames for contracts and establish delivery schedules, where the requirements permit, in a way
that encourages and facilitates participation by DBEs in the competitive process? This includes,
whenever possible, posting solicitation for bids or proposals for a minimum of 30 calendar days
before the bid or proposal closing date. ❑ Yes No
3. Did you consider in the contracting process whether firms competing for large contracts
could subcontract with DBEs? This will include dividing total requirements, when economically
feasible, into smaller tasks or quantities to permit maximum participation by DBEs in the
competitive process. R. Yes ❑ No
4. Did you encourage contracting with a consortium of DBEs when a contract is too large for
one of these firms to handle individually? ❑ Yes N,g, No
5. Did you use the services of the Small Business Administration and the Minority Business
Development Agency of the Department of Commerce to identify potential subcontractors?
❑ Yes � No
6. List the potential DBE subcontractors that were contacted. Only list those that are certified
through the Iowa Department of Transportation.
Name
How Contacted
(e.g. letter, phone
call, fax, e-mail)
Response (e.g. did not respond,
not interested, not competitive)
CrC,P.Mg CLEC, -r gi
•P wi 4 Liter
i o
NOT
g -S Pe,D
Cuu PERPE R. Clkci,et c
F", .t 141-er
bi o
No -r
Q spit r0
1.. C - C.oRpb eA-T oto
VA --A .t LcT7F.2
b»
r
P.E Stot 0
ACtAs ?A n-,n1hNE
f 1.6-1%*-
-lith
NoF
- .5P0ND
'VAT Co C,blac t?.Uc.T)1
L.
&1 \i- ir.etce
1b)0
NOT
,SPOan
)
PROPOSED UTILIZATION OF DBE SUBCONTRACTORS
Please include Attachments 4 and 5 to document the proposed utilization of certified DBE
subcontractors.
SRF -5 May 2015
Attachment 4
SRF Required Front -End Specifications
(This form must be completed and signed by Prime and DBE Subcontractor
for each subcontract and submitted with the bid.)
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
This form is intended to capture the DBE' subcontractor's2 description of work to be performed and the price of the work
submitted to the prime contractor. An EPA Financial Assistance Agreement recipient must require its prime contractor to
have its DBE subcontractors complete this form and include all completed forms in the prime contractor's bid or proposal
package.
Subcontractor Name
P-V�
Project Name
2 Oi � W A PoL ctioM j eoL. clad 1 --MES
tkPbeAttE, 'lb -13S-reiliA61.514(1 tbt3 VI Want, sip
Bid/Proposal No.
NIA
Assistance Agreement ID No.
(if known)
PI A
Point of Contact
W1\
Address
1')(11
Telephone No.
Email Address
Prime Contractor Name
Ste' c.t rcz•a..o SVSi► t5/X. +e. J PEI iv\EX
Issuing/Funding Entity
S C '
Contract Item
Number
Description of Work Submitted to the Prime Contractor Involving
Construction, Services, Equipment or Supplies
Price of Work Submitted to
the Prime Contractor
UD "PROPOSALS C,Gi V _e.
DBE Certified by DOT SBA
Meets/exceeds EPA certification standards?
YES NO Unknown
Other:
1A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts
certification as described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that meet or exceed
EPA certification standards as described in 40 CFR 33.202.
2Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance.
EPA Form 6100-3 (DBE Subcontractor Performance Form) — Page 1
SRF -7 May 2015
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Performance Form
certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a
commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a subcontractor, I will
adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
Prime Con tac_ or Signature
Print Name
�11i'
OW/iii �l % I-
fide
Date
e/W OW/kb OM-- —
th// /
Subcontractor Signature
Print Name
Title
Date
The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates,
and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
• Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.
EPA Form 6100-3 (DBE Subcontractor Performance Form) — Page 2
SRF -8 May 2015
Attachment 5
SRF Required Front -End Specifications
(This form must be completed and signed by Prime Contractor and submitted with the bid
if utilizing DBE subcontractors.)
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
This form is intended to capture the prime contractor's actual and/or intended use of identified certified DBE1
subcontractors2 and the estimated dollar amount of each subcontract. An EPA Financial Assistance Agreement Recipient
must require its prime contractors to complete this form and include it in the bid or proposal package. Prime contractors
should also maintain a copy of this form on file.
Prime Contractor Name
5_3 ,€ucr; o 5y ST€,MS l'iB>A NIX
Project Name
W2'I(v WAR ft-I.Afr rJ
WE, e ate -it, Jsi .ui cro-
C0f5TPL.. FACIL(TnE S
T1t7N Nkicc ROt- Stisf
rTOC
Bid/Proposal No.
cA0-112.Ac-t n,)v. q20
Assistance Agreement ID No.
(if known)
0+.+
Point of Contact
?-AkweA SOCtLE.12:1
Address
galas a C.00NTy N 16}Il&)A IN le b iur r.1 --A► :s ,1vt+,! 565V 1
Telephone No. }
21S- eAri - t3 )-7
Email Address
AVMA . Su(,K6itz, - e-SzeKNoMBus ,CzM&
Issuing/Funding Entity
51ZF.
have identified potential DBE certified subcontractors
If yes, please complete the table below. If no, please explain:
YES X
NO
t,t a IZ�S c S E
C 1P..*` D S' DSO W" +
Subcontractor
Name/Company
Name
Company Address/Phone/Email
Estimated Dollar
Amount
Currently DBE
Certified?
Continue on back if needed
1A DBE is a Disadvantaged, Minority, or Woman Business Enterprise that has been certified by an entity from which EPA accepts
certification as described in 40 CFR 33.204-33.205 or certified by EPA. EPA accepts certifications from entities that meet or exceed
EPA certification standards as described in 40 CFR 33.202.
2Subcontractor is defined as a company, firm, joint venture, or individual who enters into an agreement with a contractor to provide
services pursuant to an EPA award of financial assistance.
EPA Form 6100-4 (DBE Subcontractor Utilization Form) — Page 1
SRF -9
May 2015
OMB Control No: 2090-0030
Approved 8/13/2013
Approval Expires 8/31/2015
United States Environmental Protection Agency Disadvantaged Business Enterprise Program
DBE Subcontractor Utilization Form
certify under penalty of perjury that the forgoing statements are true and correct. Signing this form does not signify a
commitment to utilize the subcontractors above. I am aware of that in the event of a replacement of a subcontractor, I will
adhere to the replacement requirements set forth in 40 CFR Part 33 Section 33.302 (c).
The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates,
and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.
EPA Form 6100-4 (DBE Subcontractor Utilization Form) - Page 2
SRF -10 May 2015
Prime ontractor Signature
Print Name
X01 /1.°1{'
- OAN-1e-tai
itle
Date
el
8/1/4-0/9
t
g/I%7
The public reporting and recordkeeping burden for this collection of information is estimated to average three (3) hours
per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates,
and any suggested methods for minimizing respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send
the completed form to this address.
EPA Form 6100-4 (DBE Subcontractor Utilization Form) - Page 2
SRF -10 May 2015
Mayor
QUENTIN M.
HART
COUNCIL
MEMBERS
TOM
POWERS
Ward 1
BRUCE
JACOBS
Ward 2
PATRICK
MORRISSEY
Ward
JEROME
AMOS, JR.
Ward 4
RON
WELPER
Ward 5
TOM
LIND
At -Large
STEVEN
SCHMITT
At -Large
SALES TAX EXEMPTION
AECOM 60438627
CITY OF WATERLOO, IOWA
WATERLOO ENGINEERING DEPARTMENT
715 Mulberry St. Waterloo, IA 50703 • (319) 291-4312 Fax (319) 291-4262
ERIC THORSON, P.E. • City Engineer
INFORMATION NEEDED
FOR
IOWA CONSTRUCTION SALES TAX EXEMPTION CERTIFICATE
CONTRACTOR NAME: 5.1, &at& _i Sfr/ / JIL I' t)
ADDRESS:440 f , %A/U71� I" 1 hinA/74 V G,
/Weir MV3) 7.1cS1?
(Check One) PRIME: X SUBCONTRACTOR:
FEDERAL ID#: LH -1,o 70 4
V -logo vJATeR ft)wtTeaz,13-Titou q�fl 4
PROJECT NAME: i1it:.IZAr ' Th xv.. 1 elm #ri • A Anon c n ea- gT'eMS
PROJECT CONTRACT NO.: 2q
DESCRIPTION OF WORK:
❑ Brickwork ❑ Landscaping
❑ Carpentry 0 Painting
❑ Concrete 0 Paving
❑ Drywall -Plaster -Insulation 0 Plumbing
Electrical 0 Roofing -Siding -Sheet Metal
❑ Excavation/Grading 0 Windows
O Flooring 0 Wrecking -Demolition
❑ Heavy Construction 0 Other (Please Specify)
O Heating -Ventilating -Air Cond. 0
WE'RE WORKING FOR YOU!
An Equal Opportunity/Affirmative Action Employer
CONTRACT NO. 929 Page STE-1 OF 1
NON -COLLUSION AFFIDAVIT OF PRIME BIDDER
State of tflIWAJ6 D TA" )
)ss
County of Pi„dC—
% I'Al /11 5ldG i 'r
1. He is
pPP
, being first duly sworn, deposes and says that:
Owner Partner •ffice :Re •resentative orA•ent , of 5.J, area D sig61/41r1,
, the Bidder that as submitted the attached Bid;
2. He is fully informed respecting the preparation and contents of the attached Bid and of all
pertinent circumstances respecting such Bid;
3. Such Bid is genuine and is not a collusive or sham Bid;
4. Neither the said Bidder nor any of its officers, partners, owners, agents, representatives,
employees, or parties in interest, including this affiant, has in any way colluded, conspired,
connived or agreed, directly or indirectly, with any other Bidder, firm or person to submit a
collusive or sham Bid in connection with the Contract for which the attached Bid has been
submitted or to refrain from bidding in connection with such Contract, or has in any manner,
directly or indirectly, sought by agreement or collusion or communication or conference with any
other Bidder, firm or person to fix the price or prices in the attached Bid or of any other Bidder, or,
to fix any overhead, profit or cost element of the bid price or the bid price of any other Bidder, or to
secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage
against the City of Waterloo, Iowa, or any person interested in the Proposed Contract; and
5. The price or prices quoted in the attached Bid are fair and proper and are not tainted by any
collusion, conspiracy, connivance or unlawful agreement on the part of the Bidder or any of its
agents, representatives, owners, employees, or pa s i � audi g this'ffiant.
(Sig _ / ,41///�����; l// I�
Title
Subscribed and sworn to before me this J 1 day of
fithled.i111.
My commission expires � _� ��' 3 1 C% 99
,_0�
Title
, 20n
RENAE M. TWIGG
NOTARY PUBLIC•MINNESOTA
My Comm. Exp. Jan. 31 2022
NON -COLLUSION CONTRACT NO. 929 NCA -1 OF 2
AECOM 60438627
NON -COLLUSION AFFIDAVIT OF SUBCONTRACTOR
State of --I:ovJa. )
)ss:
County of Pack Ac(c)k_ )
gr'&K f,)-cVv' -e 5 , being first duly sworn, deposes and says that:
1. He is (Owner Partner, fficer Representative, or Agent) , of
1<tW El etf-r,c v.C. hereinafter referred to as the
"Subcontractor;"
2, He is fully informed respecting the preparation and contents of the subcontractor's proposal
submitted by the subcontractor to P Rrni O.
contract pertaining to the project
in F Y ,2a/& LJ s. -f -e pot/vit.-co,. Co.,a.'o ( Fac i l t}i <S Up nide_
-t-n .*,.-s. 1 ”ii u,..,e,...1-n4;a co..m( Co (.44-.zat 55}rc'l-e,-••--S tAteel-ev- lot. tH,
(City or County and State)
3. Such subcontractor's proposal is genuine and is not a collusive or sham proposal;
4. Neither the subcontractor nor any of Its officers, partners, owners, agents, representatives,
employees, or parties in interest, including this affiant, has in any way colluded, conspired,
connived, or agreed, directly or indirectly, with any other bidder, firm or person to submit a
collusive or sham proposal in connection with such contract or to refrain from submitting a
proposal in connection with such contract, or has in any manner, directly or indirectly, sought by
unlawful agreement or connivance with any other bidder, firm or person to fix the price or prices in
said subcontractor's proposal, or to fix any overhead, profit or cost element of the price of prices
in said subcontractor's proposal, or to secure through collusion, conspiracy, connivance or
unlawful agreement any advantage against the City of Waterloo, Iowa, or any person interested in
the proposed contract; and
5, The price or prices quoted in the subcontractor's proposal are fair and proper and are not tainted
by any collusion, conspiracy, connivance or unlawful agreement on the part of the bidder or any of
its agents, representatives, owners, employees, or parties in interest, including this affiant.
(Signed)
VP
Title
'.nn
Subscribed and sworn to before me this `� day of �Y"CIAatASt- 201"1.
(X/4Titl
My commission expires "7-13- tr6
.ENDOR
Commission •Number 161F482
c My Commission E Aires
July 23, 20 ( V
NON -COLLUSION CONTRACT NO. 929 NCA -2 OF 2
AECOM 60438627
EQUAL OPPORTUNITY CLAUSE
(As provided in Executive Order No. 11246)
All contractors, subcontractors, vendors and suppliers of goods and services doing business with the City
and value of said business equals or exceeds ten thousand dollars ($10,000.00) annually agree as
follows:
1. The contractors, subcontractor, vendor and supplier of goods and services will not discriminate
against any employee or applicant for employment because of race, color, creed, sex, national
origin, economic status, age, mental or physical handicap, political opinions or affiliations. The
contractor, subcontractor, vendor and supplier will develop an Affirmative Action program to
ensure that applicants are employed and that employees are treated during employment without
regard to their race, creed, color, sex, national origin, religion, economic status, age, mental or
physical disability, political opinions or affiliations. Such actions shall include but not be limited to
the following:
a. Employment
b. Upgrading
c. Demotion or Transfer
d. Recruitment and Advertising
e. Layoff or Termination
f. Rates of Pay or Other Forms of Compensation
g. Selection for Training Including Apprenticeship
2. The contractor, subcontractor, vendor and supplier of goods and services will, in all solicitations or
advertisements for employees, state that all qualified applicants will receive consideration for
employment without regard to race, creed, color, sex, national origin, religion, economic status,
age, mental or physical disabilities, political opinion or affiliations.
3. The contractor, subcontractor, vendor and supplier or his/her collective bargaining representative
will send to each labor union or representative of workers which he/she has a collective bargaining
agreement or other contract or understanding, a notice advising said labor union or workers'
representative of the contractor's commitment under this section.
4. The contractor, subcontractor, vendor and supplier of goods and services will comply with all
published rules, regulations, directives, and order of the City of Waterloo Affirmative Action
Program Contract Compliance Provisions.
5. The contractor, subcontractor, vendor and supplier of goods and services will furnish and file
compliance reports within such time and upon such forms as provided by the Affirmative Action
Officer. Said forms will elicit information as to the policies, procedures, patterns, and practices of
each subcontractor as well as the contractor himself/herself and said contractor, subcontractor,
vendor and supplier will permit access to his/her employment books, records and accounts to the
City's Affirmative Action Officer, for the purpose of investigation to ascertain compliance with this
contract and with rules and regulations of the City's Affirmative Action Program—Contract
Compliance Provisions relative to Resolution No. 24664.
6. In the event of the contractor's non-compliance with the non-discrimination clauses of this contract
or with any of such rules, regulations and orders, this contract may be canceled, terminated or
suspended in whole or in part and the contractor may be declared ineligible for further contracts in
accordance with procedures authorized by the City Council.
7. The contractor, subcontractor, vendor and supplier of goods and services will include, or
incorporate by reference, the provisions of the non-discrimination clause in every contract,
EQUAL OPPORTUNITY CLAUSE
AECOM 60438627
CONTRACT NO. 929 EOC-1 of 2
subcontract or purchase order unless exempted by the rules, regulations or orders of the City's
Affirmative Action Program, and will provide in every subcontract, or purchase order that said
provisions will be binding upon each contractor, subcontractor, or supplier.
8. We, the undersigned, recognize that we are morally and legally committed to non-discrimination in
employment. Any person who applies for employment with our company will not be discriminated
against because of race, creed, color, sex, national origin, economic status, age, mental or
physical disabilities.
EQUAL OPPORTUNITY CLAUSE
AECOM 60438627
(Title)
(Date)
CONTRACT NO. 929 EOC-2 of 2
NON-RESIDENT BIDDER CERTIFICATION
CONTRACT NO.: I2A
PROJECT NAME: 9 zot uk-f ? oLLUCI'►D 1.1 (Dare% cAAG►LfriES tkpaAw. "10 .ziFGS Fs
DATE OF LETTING: 4‘1.16UST ID, 2Oi 7
I hereby certify that I am an Iowa non-resident bidder.
COMPANY NAME: • ttidiw �K2L l Nt , /7M- Pie/f/
CORPORATE OFFICER: low-
TITLE: &fief RAMA A, L if�GIC.
DATE: gl //
STATE/COUNTRY OF RESIDENCY:l%l/Af[ Qll7-
Stated below are the preference(s) to resident bidders in the state/country of
(Preference to bidders, labor force, or other preferential treatment to bidders or laborers, etc.
RESIDENT BIDDER
AECOM 60438627
CONTRACT NO. 929 RB -3 OF 3
Revised February 2003
CONTRACTOR'S OR SUBCONTRACTOR'S AFFIRMATIVE ACTION PROGRAM
Check box that applies to party completing program:
(
) General Contractor
) Subcontractor
I. Section A to be completed by GENERAL CONTRACTORS only:
A. /rte
Name of Company C,J. Ut W SYS►�`'i?S, /AI& VA- Y/1f1 EX
Address of Company th62 (DMnfTY 1-116//W4' 69 Zip
Telephone Number ( > ) J / 5 17
Federal ID Number (if no Federal ID Number, Owner/President's Social Security
Number)
w - l »77&-J b'
Name of Projecfc* to tJk - p(1t1 aJC1l t CCaT'rOL4AU ants tiP6k1w."1 z'I-C Sys MS
Project Contract Number Cit3r e.Art M?. 129
Estimated Construction Work Dates Will I `1 / 7l 18
�Sfart Finish
Section B to be completed by SUBCONTRACTORS only:
B.
Name of General or Prime Contractor
Name of Subcontractor
Subcontractor's Address Zip
Subcontractor's Telephone Number (
Subcontractor's Federal ID Number (if no Federal ID Number Owner/President's Social
Security Number)
Name of Equal Employment Officer
C. Remainder of program to be completed by party completing program, either
Prime or Subcontractor.
-1 -
1. The Owners and/or Principals of your company:
Ethnic
Name Address Position Sex Origin
Pkv/ 111091 o (mrnWI1fimt)A '10 WOW* i j'YI GIPi yml
wIH Sial( ?,26 f Oust 'IIi6/h UAY/ (!PO r l'.kl{ iih\I
2. Other Areas of Interest:
If your company has branches or subsidiaries, or if your company is a branch or
subsidiary of a parent organization, give the following information:
Name
t If
Type of
Address Affiliation Degree
II. EMPLOYER'S POLICY (Please read carefully.)
A. We, the undersigned, recognize that we are morally and legally committed to
nondiscrimination in employment. Any person who applies for employment with
our company will not be discriminated against because of race, color, creed, sex,
national origin, economic status, age, mental or physical handicap.
B. The employment policies and practices of the undersigned are to recruit and hire
employees without discrimination, and to treat them equally with respect to
compensation and opportunities for advancement, including training, upgrading,
promotion, and transfer. However, we realize the inequities associated with
employment training, upgrading, contracting and subcontracting for minorities
and women and we will direct our efforts to correcting any deficiencies to the
maximum extent possible. The same will be required of our
SUBCONTRACTORS and suppliers.
C. We submit this program to assure compliance with Executive Order 11246, as
amended, and other subsequent orders that may pertain to equal employment
opportunity and merit employment policies, fully realizing that our qualification
and/or merit system should be evaluated and revised, if necessary.
D. We agree to put forth the maximum effort to achieve full employment and
utilization of capabilities and productivity of all our citizens without regard to race,
creed, color, sex, national origin, economic status, age, and mental or physical
handicap.
E. S:_�,earn4 INC . 'DM )i/)1 �( will give training
(Name of Company)
-2 -
and employment opportunities to local residents of Waterloo, Iowa, to the
greatest extent feasible.
III. AFFIRMATIVE ACTION
A. 5,J, CZCf 7 ..D W , /1Ve , AA- P12117?f ( recognizes that the
(Name of Company)
effective application of a policy of merit employment involve more than just a
policy statement, and 5,J, wra SYS A J ?ifr7&k
(Name of Company)
will, therefore, re-evaluate our Affirmative Action Program to ensure that equal
employment opportunities are available on the basis of individual merit, and to
actively encourage minorities, women and local residents to seek employment
with our company on this basis.
B. 77 L) Sym -J115 P T)/W& will undertake the
(Name of Company)
following six (6) steps to improve our Affirmative Action Program:
1. Minority Recruitment and Employment;
2. Local Recruitment and Employment;
3. Disabled Veteran and Vietnam Era Veteran Recruitment and
Employment;
4. Handicapped Recruitment and Employment;
5. Female Recruitment and Employment; and
6. r Training,;��nUpgrading and Promotional//1�Opportunities.
C. S.J. LEWt!T D '91-(444C,1101`. Dpi- PelMr . will take
(Name of Company)
whatever steps are necessary to ensure that our total work force has adequate
minority, female, and local representation. We will utilize the following methods
in our recruitment attempts:
1. Local advertising media (newspapers, radio, TV);
2. Community organizations (churches, clubs, schools);
3. Public and private institutions in the area (UNI, Hawkeye Community
College);
4. Job Service of Iowa; and
5. Other.
D. 5,J. 0, /JRG SY i 3 tS nye, pp- ?I , ill seek qualified minority,
(Name of Company)
female, and local group applicants for all job categories and will make asserted
efforts to increase minority, female and group representation in occupations at
the higher levels or skill and responsibility.
E. All sources of employment used shall be aware that we are an Equal
Employment Opportunity Employer. Labor organizations representing our
employees will be notified of our Equal Employment Opportunity Policy and
Affirmative Action Program.
-3 -
F. Training, upgrading, promotion and transfer activities at all levels will be
monitored to ensure that full consideration has been given to qualified minority,
female, and local group employees. yy,,p,,�
G. 5..1. k Syvv14 , //ii1 1 &4 J I4I A will encourage other
(Name of Company)
companies with whom we are associated and/or do business, to do the same
and we will assist them in their efforts. ;gyp`
H. 6J. SY T 1'IS /AIC- 1 ?1t f IMtx has taken the following
(Name ofCompany)
Affirmative Action to ensure that minority, female, local contractors and/or
suppliers were provided opportunities to negotiate and/or bid on this project: (if
none, write "NONE")
2.
As a result of the above efforts, we have involved minority, female, and local
contractors and/or suppliers in the following areas of subcontracting: (if none,
write "NONE")
1. ))00-e
2.
J. `7, J, Ct7 SYf 7Mf /IJ(', DM- PRirtiA will require approved
(Name of Company)
Affirmative Action Programs from all nonexempt contractors who propose to work
on this project and will take whatever steps are necessary to ensure that non -
minority contractors have adequate representation of minority, female and local
persons in their total work force.
K. In further accordance with rules and guidelines issued pursuant to Executive
Order 11246 as amended, we establish the goals for our company, based on
parity percentages supplied by the City, and we realize these goals will be
reviewed on an annual basis.
L. SJ, MI -1;) 6Y-0273/
)NC Wyk ?/e)/fl will keep records of
(Name of Company)
specific actions relative to recruitment, employment, training, upgrading and
promotion and will provide the City of Waterloo with any information relative to
same, including activities of our SUBCONTRACTORS and suppliers as
necessary or when requested.
M. Parity figures for companies located in Waterloo are as follows:
Minority Parity = I' .08 (8%) N. SJ, e ) 7 `M%�'J, /ke • PM- PRIMORAffirmative Action
(Name of Company)
-4 -
Employment Goals:
The definition of Affirmative Action Goals is as follows: "Goals may not be rigid
and inflexible quotas which must be met, but must be targets, reasonably
attainable by means of applying every good faith effort to make all aspects of the
entire Affirmative Action Program work."
For the year 2011, please submit percentage targets for employing minorities
and women. If you already have reached your target for hiring minorities and
women, please submit that percentage.
*Goals for Minorities:
Goals for Women:
p
"Your affirmative action goals should be between 1% and 10% or more for
minorities and 1% and 5% or more for women.
Please be advised that the goals or targets are purely your estimation of how
many women and minorities your company can reasonably expect to hire in 201
. Note, that none of the goals are rigid or inflexible. They are targets that your
company calculates as reasonably attainable. This will help the City in its
monitoring procedures as required by City of Waterloo Resolution No. 1984-
142(4).
-5 -
CONTRACTOR'S TOTAL WORK FORCE
(WATERLOO)
INDICATE:
DISABLED VETERAN: DV
VIETNAM ERA VETERAN: W
HANDICAPPED: H
-6
We hereby certify that we are in compliance with all City and Federal Affirmative Action
Regulations and agree to accept all liability for failure to comply.
Respectfully submitted,
411F
Equal Employment
Opportunity Officer
h7
Date
City of Waterloo Affirmative Action Officer
Approved
Disapproved Reason:
By:
Date:
7
MBE/WBE BUSINESS ENTERPRISE
p� ` �y�,,� PRE-BID CONTACT INFORMATION FORM
Prime Contractor Name: 5J, i J j?J 5)c tlY61 / Project:926'1(0 etL.Um iri. Letting Date: lb /101 r-7
7) r ,rn( paou t,UW'it s 1A%e40E- t :I. c SOTEMS
NO MBE/WBE SUBCONTRACTORS: If you 9re �fbb using any MBE/WBE subcontractors to complete this project, sign below. Attach a brief explanation as to
why subcontracting was not fe 'b wi t. If any MBE/WBE subcontractors will be used, please use the bottom portion of this form.
[57/li
Contractor .11p/y1-";!1A4,11 Title: alff FIJ(J (i/ i/,4t- brne Date:
SUBCONTRACTORS APPLICABLE: You are required, in order for your bid to be considered responsive, to provide the information on this form showing ALL of
your MBE/WBE subcontractor contacts made for your bid submission. This information is subject to verification. Any questions should be directed to Contract
Compliance Office 319-291-4429.
You are required, in order for your bid to be considered responsive, to provide the information on this Form showing your MBE/WBE Business Enterprise contacts
made prior to your bid submission. This information is subject to verifications and confirmation.
If you are unable to identify MBE/WBE firms to perform portions of the work, please contact Louis Starks, Contract Compliance Officer, for assistance at (319) 291-
4429.
In the event it is determined that the MBE/WBE Business Enterprise goals are not met, then before awarding the contract the City of Waterloo will make a
determination as to whether or not the apparent successful low bidder made good faith efforts to meet the goals.
TABLE OF INFORMATION SHOWING BIDDER'S PRE-BID
MBE/WBE BUSINESS ENTERPRISE CONTACTS
Quotes Received Quotation Used in Bid
MBE/WBE
Subcontractors
Dates
Contacted
Yes/No
Dates
Contacted
Yes/No
Dollar Amount Proposed to
be Subcontracted
(A rez. cI e.i+c
i tiii
8IrtO
1.i a
*DO
Cert e-cl '1 1
140
Gv�
g. E as C.
f Ill
VAXl-
€(2111
ie,-v4,E:4 ki,'1
No
-D- L 4"Xwait-T,UhJ
SI1/11
14x
140
®1si17
Co`KCiesi {t4n.r;1
00
f 1 A$ tail 031' I to (7
SIM/
ane.
.
(i - {: ed Kt i'
'JO
V P ra girriv , *�c,-
8 I h1��
'N"
, ciiiiii(,.ed , I
(Form CCO-4) Rev. 06-20-02
MBE/WBE PARTICIPATION
AECOM 60438627
CONTRACT NO. 929
M-6 OF 6
BID BOND
KNOW ALL MEN BY THESE PRESENTS, that we,
as Principal, and
as Surety are held and firmly bound unto the CITY OF WATERLOO , Iowa,
hereinafter called
"OWNER." In the penal sum
Dollars ($ ) lawful money of the United States, for the payment of which
sum will and truly be made, we bind ourselves, our heirs, executors, administrators, and successors,
jointly and severally, firmly by these presents. The condition of this obligation is such that whereas the
Principal has submitted the accompanying bid dated the day of , 20_,
for
NOW, THEREFORE,
(a) If said Bid shall be rejected, or in the alternate,
(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the form
specified and shall furnish a bond for his faithful performance of said contract, and for the payment of all
persons performing labor or furnishing materials in connection therewith, and shall in all other respects
perform the agreement created by the acceptance of said Bid,
Then this obligation shall be void, otherwise the same shall remain in 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.
By virtue of statutory authority, the full amount of this bid bond shall be forfeited to the Owner in
liquidation of damages sustained in the event that the Principal fails to execute the contract and provide
the bond as provided in the specifications or by law.
The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its
bond shall be in no way impaired or affected by any extension of the time within which the Owner may
accept such Bid or execute such contract; and said Surety does hereby waive notice of any such
extension.
IN WITNESS WHEREOF, the Principal and the Surety, have hereunto set their hands and seals, and
such of them as are corporations, have caused their corporate seals to be hereto affixed and these pres-
ents to be signed by their proper officers this day of , A.D. 20
(Seal)
Principal
By
(Title)
(Seal)
Witness Surety
By
Witness Attorney-in-fact
BID BOND
AECOM 6;0438627
CONTRACT NO. 929 BB -1 OF 1
BID BOND
KNOW ALL MEN BY THESE PRESENTS, that we, SJE Rhombus dba Primex
as Principal, and Western Suret COM an.
as Surety are held and firmly bound unto the CITY OF WATERLOOIowa,hereinafter called
Five Percent (5%) of the amount of the bid
"OWNER."In the penal sum _ .
Dollars ($ 5% ) lawful money of the United States, for the payment of which
sum will and truly be made, we hind ourselves, our heirs, executors, administrators, and successors,
jointly and severally, firmly by these presents. The condition of this obligation is such that whereas the
Principal has submitted the accompanying bid dated the 10th day of August 2017,
for Upgrade Instrumentation and control s stems at Waterloo WPCF including replacement of PLCs, PCs
and outdated networking system running the plant control system witji industry standard equipment,
software platforms and Ethernet/fiber optics redundant communications network
NOW, THEREFORE,
(a) If said Bid shall be rejected, or in the alternate,
(b) If said Bid shall be accepted and the Principal shall execute and deliver a contract in the form
specified and shall furnish a boncl for his faithful performance of said contract, and for the payment of all
persons performing labor or furnishing materials in connection therewith, and shall in all other respects
perform the agreement created by the acceptance of said Bid, .
Then this obligation shall be void, otherwise the same shall remain in 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 eiy ount of this obligation as herein stated.
By virtue of statutory authority, the full amount of this bid bond shall be forfeited to the Owner in
liquidation of damages sustained in the event that the Principal falls to execute the contract and provide
the bond as provided in the specifications or by law,
The Surety, for value received, hereby stipulates and agrees that the obligations of said Surety and its
bond shall be in no way impaired or affected by any extension of the time within which the Owner may
accept such Bid or execute such contract; and said Surety does hereby waive notice of any such
extension,
IN WITNESS WHEREOF, the Principal and the Surety, have hereunto set their hands and seals, and
such of there as are corporations, have caused their corporate seals to be hereto affixed and these pres-
ents to be signed by their proper officers this 10th_ clay of August , A.D. 2017_ .
SJE Rhombus dba Primex
Witness
Witness
BID BOND
AECOM 6:0438627
Princ'pal
ealf
.4000, voitztivii
itle)
Western Surety Company
Surely
(Seal)
ENANSilidifek
(Seal)
By c /I'/, f- i" l ot- .
Attorney-in-fact, Melissa M. Nordin
CONTRACT NO. 92) BB -1 OF 1
INDIVIDUAL OR PARTNERSHIP ACKNOWLEDGMENT
STATE OF
COUNTY OF
On the day of
ss
, before me personally appeared
to me
known to be the person(s) described in and who executed the foregoing instrument, as
Principal(s), and acknowledged to me that he executed the same as his/her/their free act
and deed.
(Notary Seal)
CORPORATE ACKNOWLEDGMENT
STATE OF (V)_ 1J Ea1' i°f
COUNTY OF 'TJer�I4. -
ss
On the 10th day of August, 2017, before me personally appeared LA.0 pt 1. e EPS to
me known, who being by me duly sworn, did say that he/she is the C -YO of
SJE Rhombus dba Primex , the corporation described in and which executed the foregoing
instrument; that he/she knows the seal of said corporation; that the seal affixed to said instrument
is such corporate seal; that it was so affixed by order of the board of directors of said corporation;
and that he/she signed his/her name thereto by like order
RENAE M. TWIGG
NOTARY PUBLIC• MINNESOTA
MAM:SEx$i?J3N. 31 2022
ACKNOWLEDGMENT OF CORPORATE SURETY
STATE OF MINNESOTA
ss
COUNTY OF Hennepin
On the 10th day of August, 2017, before me personally appeared Melissa M. Nordin to me
known, who being duly sworn, did say that he/she is the aforesaid officer or attorney-in-fact of the
Western Surety Company a corporation; that the seal affixed to the foregoing instrument is the
corporate seal of said corporation, and that said instrument was signed and sealed in behalf of
said corporation by the aforesaid officer, by authority of its board of directors; and the aforesaid
officer acknowledged said instrument to be the free act and deed of said corporation.
(Notary Seal)
NAME ALEMDAR
NOTARY PUBLIC - MINNESOTA
My Commission Expires
January 31, 2021
Western Surety Company
POWER OF ATTORNEY APPOINTING INDIVIDUAL ATTORNEY-IN-FACT
Know All Men By These Presents, That WESTERN SURETY COMPANY, a South Dakota corporation, is a duly organized and existing corporation
having its principal office in the City of Sioux Falls, and State of South Dakota, and that it does by virtue of the signature and seal herein affixed hereby
make, constitute and appoint
Melissa M Nordin, Terry Starks, Robert E Clemants, Alan Starks, Name Alemdar,
Individually
of Saint Louis Park, MN, its tore and lawful Attorney(s)-in-Fact with full power and authority hereby conferred to sign, seal and execute for and on its behalf
bonds, undertakings and other obligatory instruments of similar nature
- In Unlimited Amounts -
and to bind it thereby as fully and to the same extent as if such instruments were signed by a duly authorized officer of the corporation and all the acts of said
Attomey, pursuant to the authority hereby given, are hereby ratified and confirmed.
This Power of Attorney is made and executed pursuant to and by authority of the By -Law printed on the reverse hereof, duly adopted, as indicated, by
the shareholders of the corporation.
In Witness Whereof, WESTERN SURETY COMPANY has caused these presents to be signed by its Vice President and its corporate seal to be
hereto affixed on this 5th day of January, 2017.
State of South Dakota
County of Minnehaha
}
SS
WESTERN SURETY COMPANY
aul T. Brunet, Vice President
On this 5th day of January, 2017, before me personally came Paul T. Bruflat, to me known, who, being by me duly sworn, did depose and say: that he
resides in the City of Sioux Falls, State of South Dakota; that he is the Vice President of WESTERN SURETY COMPANY described in and which executed
the above instrument; that he knows the seal of said corporation; that the seal affixed to the said instrument is such corporate seal; that it was so affixed
pursuant to authority given by the Board of Directors of said corporation and that he signed his name thereto pursuant to like authority, and acknowledges
same to be the act and deed of said corporation.
My commission expires
June 23, 2021
J. MOHR
�aorasrvuauca
6OM OM
suc
CERTIFICATE
J. Mohr, Notary Public
I, L. Nelson, Assistant Secretary of WESTERN SURETY COMPANY do hereby certify that the Power of Attomey hereinabove set forth is still in
force, and further certify that the By -Law of the corporation printed on the reverse hereof is still in force. In testimony whereof I have hereunto subscribed
my name and affixed the seal of the said corporation this 10TH day of AUGUST 2017
APpt
PVv`O
Form 84280-7-2012
WESTERN SURETY COMPANY
Cr. L. Nelson, Assistant Secretary