HomeMy WebLinkAboutWilson Custom TreeCITY OF WATERLOO, IOWA
WATERLOO LEISURE SERVICES COMMISSION
BID FORM
for
2018 RIGHT-OF-WAY MOWING
BIDDER: WI I Stir% 6 USftrm ire(_
COMPANY NAME n '
ADDRESS: �l� #t
Short ett
�f�SGc� , :m 13
PHONE: (.J(p3 ) 642 - q -a 35
1. The undersigned, being a Corporation existing under the laws of the State of N/A ,
a Partnership consisting of the following partners: /V/q
having been familiarized with the existing conditions on the project area affecting the
cost of the work, and with all the Contract Documents now on file in the offices of the
City Clerk, City Hall, Waterloo, Iowa, and the Waterloo Leisure Services Commission,
1101 Campbell Ave., Waterloo, Iowa, hereby proposes to furnish all supervision,
technical personnel, labor, materials, machinery, tools, equipment, and services,
including utility and transportation services required to complete the proposed RIGHT-
OF-WAY MOWING, in accordance with the contract documents and for the unit price in
place for the following amount:
OPTION A: provide all mowing services for:
• Broadway St. (22 acres) Parker St. to Airport Blvd.
• Dubuque Road (8.2 acres) Nevada St. to Evansdale city limits
• San Marnan Dr. (36.6 acres) W.4`h St. to Texas St.
• US 218 corridor (68.6 acres) US 63 interchange to San Marnan Dr.
• Highway 20 overpasses (7 acres) Hammond Ave., Kimball Ave.,
Ansborough Ave., WA ' St.
• Martin Luther King Jr. Dr. (23 acres) Franklin St to Idaho.
• Police Training Center (2.6 acres) Martin Luther King & Elk
Run Rd
Total 168 acres
Price Per Acre:
/JD PG dollars ($
OPTION B: provide all specified mowing services for
• University Ave. (13 acres) and
• Greenhill Road (28 acres)
Total 41 acres
Price Per Acre:
�tiy(t� (16-etetto Ana kW//tan
dollars ($ fro. 0� )
BID FORM page I of 3
OPTION C: provide all specified mowing services for Fairview Cemetery (8 acres)
Price Per Acre:
oUfLV, - (1 %/-&D dollars ($ 86,v_2
OPTION D: provide all specified mowing services for Virden Creek Waterway
(2 acres)
Price Per Acre: nn y
I,4>ti L4-uL �plt, 31.to,i1 GVH /lun--- dollars($ 515. 69z. )
OPTION E: provide all specified mowing services for Logan Ave/Hwy 63
(8.1 acres)
Price Per Acre:
StAgnit "4-4
Achim
dollars($ 70
2. It is understood that the quantities set forth are approximate only and subject to
variation and that the unit price for the work done shall govern the actual payment to the
Contractor.
3. In submitting this bid, the Bidder understands that the City reserves the right to reject
any or all bids and to award one or more contracts for a single Option, all Options
together, or any combination of Options. If written notice of acceptance of this Bid is
mailed or delivered to the undersigned within thirty (30) days after Bid Opening, of 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 certificate of
insurance within ten (10) days after the agreement is presented for signature, and start
work within ten (10) days after "Notice to Proceed" is issued.
4. Security in the sum of atvi & arms &iwt dollars ($ 5,000 )
in the form of 13-14 Pant., , is submitted herewith in accordance
with NOTICE TO BIDDERS.
5. Attached is a Non -Collusion Affidavit of Prime Contractor.
6. The Bidder is prepared to submit a financial and experience statement upon request.
7. 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 FOC, within ten (10) days of notification that the bid submitted is
lowest and acceptable.
8. The Bidder has received the following Addendum or Addenda:
Addendum No. -13- Date: -G / -9- l -6-
/ /
/ /
BID FORM page 2 of 3
9. The Bidder shall list the MBE/WBE subcontractors, amount of subcontracts and bid
items listed on the City of Waterloo Minority and /or Women Business Pre-bid Contract
Information Form submitted with this Bid Form. 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 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
10. The Bidder shall list all equipment available for this project:
(a)Trr Ftn Lttc-e v c mnb €n4' nv -tai,,
(.9) 5<'" en Lat it,
11-(o"J-&iun taw- I,l'kttc, Ar hu u
<P0'" J,s u tme . wn tophSti
pt,.t.t lo.c45,nd. 9/ dux
�l moi, ons
Jacky, aunt:nimo
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 alternatives, delete line items, and/or to reduce
quantities prior to the Award of Contract due to budgetary limitations.
SIGNED:
DATE: 11- / 3 1/8
BID FORM page 3 of 3
NON -COLLUSION AFFIDAVIT OF PRIME BIDDER
State of -rci )
Countyof14u ua&L )
, being first duly sworn, deposes and says that:
1. He is (Owner), (Partner), (Officer), (Representative), or (Agent) of YUikSson Cttstrrb 4 ttC_
the Bidder that has 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, film 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 parties in interest, including this affiant.
Title
Su.7rbcraYea'a.vy4Latuorwto- before/ meitliv>if
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NON -COLLUSION AFFIDAVIT OF SUBCONTRACTOR
State of N/Q )
County of ,V/.A )
W/4
that:
, being first duly sworn, deposes and says
1. He is (Owner), (Partner), (Officer), (Representative), or (Agent) of NAq
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 Au i4 , contract
pertaining to the 2018 RIGHT-OF-WAY MOWING CONTRACT in Waterloo, Black
Hawk County, Iowa;
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;
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.
id94 N/A
Signature Title
Sitorarhed,cm sworwto-before'wie th i
!/} day of NIA , 2018.
Stgvtature'
My co-winnlikkilory e4qiwed' N/4
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 contractor, 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 Tei,uination
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
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.
EQUAL OPPORTUNITY CLAUSE PAGE 1 OF 2
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,
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.
Signed:
Maar
Appropriate Official
¥/3 /J8
Title
Date
EQUAL OPPORTUNITY CLAUSE PAGE 2 OF 2
STATEMENT OF BIDDER'S QUALIFICATIONS
(To be submitted by the Bidder only upon request of the City of Waterloo, Iowa.)
All questions shall be answered and the data given must be clear and comprehensive. This
statement must be notarized. If necessary, questions may be answered on separate attached
sheets. The Bidder may submit any additional information desired.
1. Name of Bidder.
Jeff
2. Permanent main office address.
a. la Short P —
3. When organized. �eSGO' 5`L13(o
iqt
4. If a corporation, where incorporated. by/A
5. How many years have you been engaged in the contracting business under your present firs 1
or trade name? 01n �y s
6. Contracts on hand: (Schedule these amount of each contract and the appropriate
anticipated dates of completion.) VvaI-t,-ILn 7TxrL lee4-nzucLQ - (PS ryiGt-� • .
7. General character of work performed by your company.
—Tra SON tcc/ (loon MN/0;T
8. Have you ever failed to complete any work awarded to you? If so, where and why?
/✓L)
9. Have you ever defaulted on a contract? If so, where and why?
10. List the more important projects recently completed by your company, stating the
approximate cost for each, and the month and year completed. Gott Oh 114,06 •
W �-errloe) Sixt.p6 U
11. List your major equipment available for the contract. ry rYftnex �3
1~- tite A7/ 41--friviters9- swiopez.e. nee.Le,r>�'
12. Experience in landscape work similar in importance to the project.
i
J
13. Background and experience of the principal members of your organization, including the
officers. L( e rl1/23k fi.e.eo' w i 4I env 10 tai -3 i n Corr, nyj,
14. Credit available: $ (pb, bOO --101000
15. Give Bank reference: E i'fz en Skede. Admit. - Pr wc. s (u^2-
16. Will you, upon request, fill out a detailed financial statement and furnish any other
information that may be required by the City of Waterloo, Iowa? 145
17. The undersigned hereby authorizes and requests any person, firm, or corporation to furnish
any information requested by the City of Waterloo, Iowa, in verification of the recitals
comprising this Statement of Bidder's Qualifications.
STATEMENT OF BIDDERS QUALIFICATIONS PAGE 1 OF 2
Dated this day of (,P'(,t.-e✓ ,20/5 .
By:
Name of Bidder
• ..
11
Title: O w n er
State of Ioiack )
) ss
County of+ OlL trd
Vie# V1l �`1Q-,
, being duly sworn
deposes and says that she/he is Owner of
kron 6uSarm 1 ree_
Name of Organization
and that the answers to the foregoing questions and all statements therein contained are true and
correct. Subscribed and sworn to before me this ?5' "day of
god .e April D. Buls
Commission Numbe x783® 6
MY COMM. EXP. / l
OtyChti
Notary Public
My commission expires
, 20 /5 .
03/17/80 ,20
STATEMENT OF BIDDER'S QUALIFICATIONS PAGE 2 OF 2
Bid Bond
CONTRACTOR:
(Nance, legal status and address)
Jeff Wilson dba Wilson Custom Tree
212 Short Avenue
Cresco, IA 52136
Bond Number 41393487
SURETY:
(Name, legal status and prncipal place of business)
Platte River Insurance Company
P.O. Box 5900
Madison, WI 53705-0900
OWNER:
(Name, legal status and addivss)
City of Waterloo - Waterloo Leisure Services Commission
1101 Campbell Ave.
Waterloo, IA 50701
BOND AMOUNT: Three Thousand and No/100 Dollars
$3,000.00
PROJECT:
(Name, location or address, and PPnject number; if any)
2018 Right of Way Mowing
[Mowing of Open Areas]
Waterloo, IA
This document has important legal
consequences. Consultation with
an attorney is encouraged with
respect to its completion or
modification.
Any singular reference to
Contractor, Surety, Owner or
other party shall be considered
plural where applicable.
The Contractor and Surety are bound to the Owner in the amount set forth above, for the payment of which
the Contractor and Surety bind themselves, their heirs, executors, administrators, successors and assigns,
jointly and severally, as provided herein. The conditions of this Bond are such that if the Owner accepts the
bid of the Contractor within the time specified in the bid documents, or within such time period as may be
agreed to by the Owner and Contractor, and the Contractor either (1) enters into a contract with the Owner
in accordance with the terms of such bid, and gives such bond or bonds as may be specified in the bidding or
Contract Documents, with a surety admitted in the jurisdiction of the Project and otherwise acceptable to the
Owner, for the faithful performance of such Contract and for the prompt payment of labor and material
furnished in the prosecution thereof; or (2) pays to the Owner the difference, not to exceed the amount of this
Bond, between the amount specified in said bid and such larger amount for which the Owner may in good
faith contract with another party to perform the work covered by said bid, then this obligation shall be null
and void, otherwise to remain in full force and effect. The Surety hereby waives any notice of an agreement
between the Owner and Contractor to extend the time in which the Owner may accept the bid. Waiver of
notice by the Surety shall not apply to any extension exceeding sixty (60) days in the aggregate beyond the time
for acceptance of bids specified in the bid documents, and the Owner and Contractor shall obtain the Surety's
consent for an extension beyond sixty (60) days.
If this Bond is issued in connection with a subcontractor's bid to a Contractor, the term Contractor in this
Bond shall be deemed to be Subcontractor and the term Owner shall be deemed to be Contractor.
By arrangement with the American Institute of Architects, the National Association of Surety Bond
Producers (NASBP) (www.nasbn.org) makes this form document available to its members, affiliates, and
associates in Microsoft Word format for use in the regular course of surety business. NASBP vouches that
the original text of this document conforms exactly to the text in AIA Document A310-2010, Bid Bond.
Subsequent modifications may be made to the original text of this document by users, so careful review of its
wording and consultation with an attorney are encouraged before its completion, execution or acceptance.
1
When this Bond has been furnished to comply with a statutory or other legal requirement in the location of the
Project, any provision in this Bond conflicting with said statutory or legal requirement shall be deemed deleted
herefrom and provisions conforming to such statutory or other legal requirement shall be deemed incorporated
herein. When so furnished, the intent is that this Bond shall be construed as a statutory bond and not as a
common law bond.
Signed and sealed this 2nd day of ,Aril. 2018.
gA,
(Witness)
Rita Jo genson (Witness
Jeff Wilson dba Wilson Custom Tree
(Principal)
Platte River Insurance Company
(Snreo)
(Seal)
(Seal)
Jack Anderson, Attonrey-in-Fact
By arrangement with the American Institute of Architects, the National Association of Surety Bond
Producers (NASBP) (www.nasbp.org) makes this form document available to its members, affiliates, and
associates in Microsoft Word format for use in the regular course of surety business. NASBP vouches that
the original text of this document conforms exactly to the text in AIA Document A310-2010, Bid Bond.
Subsequent modifications may be made to the original text of this document by users, so careful review of its
wording and consultation with an attorney are encouraged before its completion, execution or acceptance.
2
ACKNOWLEDGMENT OF PRINCIPAL (Individual)
State of 1 -B -W
County of (-Jv-wGA_.d
On this day of , in the year ,gtD 1 'b , before me
personally comes
t )116
to me known and known to me to be the person who is described in and executed the foregoing instrument, and
acknowledges to me that he/she executed the same.
State of
SAL
ow
.0111,
April D. Buis
Commission Number 783138
MY COMM, EXP E4111429_
ACKNOWLEDGMENT OF PRINC
County of
}
1 16140
Notary Public
AL (Partnership)
On this day of � , in the year , before me
personally come(s)
a member of the co -partnership of
to me known and known to me to be the per n who is described in and executed the foregoing instrument, and
acknowledges to me that he/she execute a same as the act and deed of the said co -partnership.
Notary Public
ACKNOWLEDGMENT OF PRINCIPAL"(Corporation/LLC)
State of
County of
On this day of , in e year , before me personally come(s)
, to ' e known, who being duly sworn, deposes and says that
he/she resides in the City of that he/she is the of the
, the corporation described in and
which executed the foregoing instrument, a d that he/she signed his/her name thereto by like order.
Notary Public
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�.4PLATTE RWER INSURANCE C hPANY 413 94 l�
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POWER OF Al ll ORNEY !:
\�.-'-:__ KNOW ALL MEN BY THESE PRESENTS, That the PLATTE RIVER INSURANCE COMPANY, a corporation of the State of Nebraska, having,'
kr.- - ,7-0
��rail ry it its principal offices in the City of Middleton, Wisconsin, does make, constitute and appoint
4 ---------------------------------------- JACK ANDERSON; RONALD KAIHOI - .
<04-e--
0e its true and lawful Attomey(s) in fact, to make, execute, seal and deliver for and on its behalf, as surety, and as its act and deed any all bonds; undertakings- ,
W� { and contracts of suretyship, provided that no bond or undertaking or contract of suretyship, executed under this authority shall exceed in amount the sum of zp
* -ALL WRITTEN INSTRUMENTS IN AN AMOUNT NOT TO EXCEED: $20 000 000.00-.v\
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This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following Resolution adopted by the Board of
Directors of PLATTE RIVER INSURANCE COMPANY at a meeting duly called and held on the 8th day of January, 2002:,
"RESOLVED, that the President, Executive Vice President, Vice President, Secretary or Treasurer, acting individually or otherwise, be and they hereby
are granted the power and authorization to appoint by a Power of Attorney for the purposes only of executing and attesting bonds and undertakings, and
other writings obligatory in the nature thereof, one or more resident vice-presidents, assistant secretaries and attorneys) -in -fact, each appointee to have
the powers and duties usual to such offices to the business of this company; the signature of such officers and seal of the Company may be affixed to any
such power of attorney or to any certificate relating thereto by facsimile, and any such power of attorney or certificate bearing such facsimile signatures
or facsimile seal shall be valid and binding upon the Company, and any such power so executed and certified by facsimile signatures and facsimile seal
shall be valid and binding upon the Company in the future with respect to any bond or undertaking or other writing obligatory in the nature thereof to
which it is attached. Any such appointment may be revoked, for cause, or without cause, by any of said officers, at any time."
In connection with obligations in favor of the Florida Department of Transportation only, it is agreed that the power and authority hereby given to the
Attorney -in -Fact includes any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts
required by the State of Florida Department of Transportation. It is fully understood that consenting to the State of Florida Department of Transportation
making payment of the final estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its bond.
In connection with obligations in favor of the Kentucky Department of Highways only, it is agreed that the power and authority hereby given to the
Attorney -in -Fact cannot be modified or revoked unless prior written personal notice of such intent has been given to the Commissioner — Department of
Highways of the Commonwealth of Kentucky at least thirty (30) days prior to the modification or revocation.
IN WITNESS WHEREOF; the PLATTE RIVER INSURANCE COMPANY has caused these presents to be signed by its officer undersigned and its
corporate seal to be hereto affixed duly attested, this 3rd day of May, 2017.
Attest:
Jdlin E. Rzepinski
Vice President, Treasurer & CFO
Suzanne M. Broadbent
Assistant Secretary �o
STATE OF WISCONSIN Nimuinntitl� �\\\
COUNTY OF DANE f S.S.: i
On the 3rd day of May, 2017 before me personally came Stephen J. Sills, to me known, who being by me duly sworn, did depose and say: that he resides
in the County of New York, State of New York; that he is President of PLATTE RIVER INSURANCE COMPANY, the corporation described in and
which executed the above instrument; that he knows the seal of the 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 signed his name thereto by like order.
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(1-4' TAitj,Fa
i
STATE OF WISCONSIN 5 ��°F %+l nawoea`
COUNTY OF DANE }
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OMTF co
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SEAL =
PLATTE RIVER INSURANCE COMPANY
At',04 'd4
Stephen J. Sills
CEO & President
David J. Regele
Notary Public, Dane Co., WI
My Commission Is Permanent
I, the undersigned, duly elected to the office stated below, now the incumbent in PLATTE RIVER INSURANCE COMPANY, a Nebraska
Corporation, authorized to make this certificate, DO HEREBY CERTIFY that the foregoing attached Power of Attorney remains in full force and has
not been revoked; and furthermore, that the Resolution of the Board of Directors, set forth in the Power of Attorney is now in force.
Signed and sealed at the City of Middleton, State of Wisconsin this 2nd day of April , 20 1 8
0,tft..0
Antonio Celii ,
General Counsel, Vice President & Seccretary
THIS DOCUMENT IS NOT VALID UNLESS PRINTED ON GREEN SHADED BACKGROUND WITH A RED SERIAL NUMBER iN THE UPPER RIGHT HAND
CORNER. IF YOU HAVE ANY QUESTIONS CONCERNING THE AUTHENTICITY OF THIS DOCUMENT CALL 800-475-4450. PR-POA(Rev. 10-2017)
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ACKNOWLEDGEMENT OF SURETY
STATE OF MINNESOTA
COUNTY OF CHIPPEWA
On this 2nd day of April , 2018 , before me, a Notary Public within and for said
County, personally appeared Jack Anderson to me personally known, who being by me duly
sworn he/she did say that he/she is the attorney-in-fact of Platte River Insurance Company ,
the corporation named in the foregoing instrument, and the seal affixed to said instrument is the
corporation seal of said corporation, and sealed on behalf of said corporation by authority of its
Board of Directors and said Jack Anderson acknowledged said instrument to be the free act
and deed of said corporation.
1�
,4111M4/1—e--
NOTARY PUBLIC
My Commission Expires
/3/A2 &3
LEANNE C. DUIS
Notary Public -Minnesota
My Commission Expires J