HomeMy WebLinkAboutContract 61002-FP4Page 1 of 2
City Secretary
Contract No.__________________
Date Received ______________
NOTICE OF PROJECT COMPLETION
(Developer Projects)
The Transportation and Public Works Department upon the recommendation of the Project
Manager has accepted the following project as complete:
Project Name: The Grove 2
City Project No.: 104228
Improvement Type(s): Water Sewer
Original Contract Price: $229,668.23
Amount of Approved Change Order(s): $47,642.61
Revised Contract Amount:$277,310.84
Total Cost of Work Complete:$277,310.84
Contractor Date
Title
Circle H Contractors
Company Name
Project Inspector Date
Project Manager Date
CFA Manager Date
_______________________________________ __________________________________
TPW Director Date
Asst. City Manager Date
Page 2 of 2
Notice of Project Completion
Project Name: The Grove 2
City Project No.: 104228
City’s Attachments
Final Pay Estimate
Change Order(s): Yes N/A
Pipe Report:Yes N/A
Contractor’s Attachments
Affidavit of Bills Paid
Consent of Surety
Statement of Contract Time
Contract Time: 270 WD
Work Start Date: 8/19/2024
Days Charged: 93 WD
Work Complete Date: 1/29/2025
Completed number of Soil Lab Test: 92
Completed number of Water Test: 0
CITY OF FORT WORTH
Contract Name THE VILLAGE GROVE 2
Contract Limits
Project Type WATER & SEWER
DOE Number 4228
Estimate Number 1 Payment Number 1 For Period Ending 1/29/2025
FINAL PAYMENT REQUEST
City Secretary Contract Number
93
WD
Contract Date
CIRCLE H CONTRACTORS, LP
NA
P O BOX 939
MIDLOTHIAN TX 76065
G.DEYON K. JACKSON
270WDContract Time
Days Charged to Date
CompleteContract is 100.00
Contractor
,
/Inspectors
Project Manager
City Project Numbers 104228
Tuesday, February 18, 2025 Page 1 of 5
Contract Name THE VILLAGE GROVE 2
Contract Limits
Project Type WATER & SEWER
DOE Number 4228
Estimate Number 1
Payment Number 1
For Period Ending 1/29/2025
Project Funding
City Project Numbers 104228
UNIT I: WATER IMPROVEMENTS
Item
No.Description of Items Estimated
Quanity Unit Unit Cost Estimated
Total
Completed
Quanity
Completed
Total
1 TRENCH SAFETY 466 LF $0.25 $116.50 466 $116.50
2 8" PVC WATER PIPE 466 LF $113.90 $53,077.40 466 $53,077.40
3 8" DUCTILE IRON PIPE FOR WATER
LOWERING AT STORM DRAIN CROSSING PER
DETA
34 LF $96.20 $3,270.80 34 $3,270.80
4 FIRE HYDRANT 1 EA $7,195.00 $7,195.00 1 $7,195.00
5 CONNECTION 4"-12" WATER MAIN 4 EA $5,618.00 $22,472.00 4 $22,472.00
6 1" WATER SERVICE (CO 4)33 EA $1,135.00 $37,455.00 33 $37,455.00
7 8" GATE VALVE 4 EA $2,454.00 $9,816.00 4 $9,816.00
8 DUCTILE IRON WATER FITTINGS w/RESTRAINT 1 TN $3,652.00 $3,652.00 1 $3,652.00
$137,054.70 $137,054.70Sub-Total of Previous Unit
UNIT II: SANITARY SEWER
Item
No.Description of Items Estimated
Quanity Unit Unit Cost Estimated
Total
Completed
Quanity
Completed
Total
1 8" SEWER PIPE 383 LF $98.41 $37,691.03 383 $37,691.03
2 4" SEWER SERVICE 32 EA $855.00 $27,360.00 32 $27,360.00
3 4' MANHOLE 1 EA $8,980.00 $8,980.00 1 $8,980.00
4 4' EXTRA DEPTH MANHOLE 7 VF $630.00 $4,410.00 7 $4,410.00
5 POST CCTV MANHOLE 1 LF $1,291.50 $1,291.50 1 $1,291.50
6 MANHOLE VACUUM TESTING 2 EA $350.00 $700.00 2 $700.00
7 TRENCH SAFETY (CO 1 & 2)687 LF $2.00 $1,374.00 687 $1,374.00
8 CONCRETE COLLAR 1 EA $850.00 $850.00 1 $850.00
9 CONCRETE ENCASEMENT FOR UTILITY PIPES 3 CY $400.00 $1,200.00 3 $1,200.00
10 4' DIA. CAST IN PLACE MANHOLE 1 EA $10,500.00 $10,500.00 1 $10,500.00
11 4" SEWER LINE UNDER PAVEMENT (CO 1)14 EA $1,782.00 $24,948.00 14 $24,948.00
12 POST CCTV INSPECTION UNDER PAVEMENT
(CO 1)
273.973 LF $6.57 $1,800.00 273.973 $1,800.00
13 TRAFFIC CONTROL (CO 1)1 MO $5,656.23 $5,656.23 1 $5,656.23
14 ADDITIONAL BOND (CO 2)1 LS $471.03 $471.03 1 $471.03
15 4" SEWER LINE UNDER PAVEMENT (ADDL
DUE TO PLACEMENT) (CO 2)
1 EA $3,712.00 $3,712.00 1 $3,712.00
Tuesday, February 18, 2025 Page 2 of 5
Contract Name THE VILLAGE GROVE 2
Contract Limits
Project Type WATER & SEWER
DOE Number 4228
Estimate Number 1
Payment Number 1
For Period Ending 1/29/2025
Project Funding
City Project Numbers 104228
16 POST CCTV INSPECTION UNDER PAVEMENT
(CO 2)
30 LF $60.00 $1,800.00 30 $1,800.00
17 TRAFFIC CONTROL (ADDL TRAFFIC CON.
MEASURES) (CO 2)
1 MO $3,278.00 $3,278.00 1 $3,278.00
18 CONCRETE/ASPH REMOVAL (CO 2)15 SY $282.29 $4,234.35 15 $4,234.35
$140,256.14 $140,256.14Sub-Total of Previous Unit
Tuesday, February 18, 2025 Page 3 of 5
Contract Name THE VILLAGE GROVE 2
Contract Limits
Project Type WATER & SEWER
DOE Number 4228
Estimate Number 1
Payment Number 1
For Period Ending 1/29/2025
Project Funding
City Project Numbers 104228
Contract Information Summary
Change Orders
$229,668.23Original Contract Amount
$277,310.84Total Contract Price
$277,310.84
Less
Total Cost of Work Completed
% Retained $0.00
Net Earned $277,310.84
Plus Material on Hand Less 15%$0.00
Balance Due This Payment $277,310.84
Less Liquidated Damages
Days @ / Day
$0.00
Less Penalty
LessPavement Deficiency $0.00
$0.00
$0.00Less Previous Payment
Earned This Period
Retainage This Period
$277,310.84
$0.00
1 $32,952.23Change Order Number
2 $13,555.38Change Order Number
4 $1,135.00Change Order Number
Tuesday, February 18, 2025 Page 4 of 5
Contract Name THE VILLAGE GROVE 2
Contract Limits
Project Type WATER & SEWER
DOE Number 4228
Estimate Number 1
Payment Number 1
For Period Ending 1/29/2025
Project Funding
City Project Numbers 104228
Line Fund Account Center
Amount
Funded Gross Retainage Net
CITY OF FORT WORTH
SUMMARY OF CHARGES
$277,310.84
Less
Total Cost of Work Completed
% Retained $0.00
Net Earned $277,310.84
Plus Material on Hand Less 15%$0.00
Balance Due This Payment $277,310.84
Less Liquidated Damages
0 Days @ $0.00 / Day $0.00
Less Penalty
LessPavement Deficiency $0.00
$0.00
$0.00Less Previous Payment
Earned This Period
Retainage This Period
$277,310.84
$0.00
City Secretary Contract Number
93
WD
Contract Date
CIRCLE H CONTRACTORS, LP
NA
P O BOX 939
MIDLOTHIAN TX 76065
G.DEYON K. JACKSON
270
WD
Contract Time
Days Charged to Date
CompleteContract is 100.000000
Contractor
,
/Inspectors
Project Manager
Tuesday, February 18, 2025 Page 5 of 5
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ea_.,�;=•ti., -
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� .� .
TRANSPORTATION AND PUBLIC WORKS
PIPE REPORT FOR:
PROJECT NAME: The Grove 2
CITY PROJECT NUMBER: CPN 104228
WATER
PIP� LAID SIZE TYPE OF PIPE LF
C-900 8" PVC 466 LF
FIRE HYDRANTS: 1
PIPE ABANDONED
N/A
DENSITIES:
NEW SERVICES:
SIZE
f�
VALVES (16" OR LARG�R)
TYPE OF PIP�
UPLOADED TO ACCELA
COPPER
LF
N/A
33 EA
SEW�R
PIPE LAID SIZE TYP� OF PIPE LF
SDR-26 8" PVC 383 LF
PIPE ABANDONED
N/A
SIZE
TYPE OF PIPE
LF
DENSITI�S: UPLOADED TO ACCELA
N�W SERVICES: 4" PVC
TItANSPORTATION r1ND PUBLIC WORKS
The City of Fort \�lorth • 1000 Throcl�norton Street • Fort \�/ordi, T�i 76012-6311
32 EA
Rev. 8/20/19
TRANSPORTATION AND PUBLIC WORKS
February 13, 2025
Circle H Contractors
1550 W FM 875/ P.O. BOX 220
Midlothain TX 76065
RE: Acceptance Letter
Project Name: The Grove 2
Project Type: Water,Sewer,Drainage
City Project No.: 104228
To Whom It May Concern:
On February 13, 2025 a final inspection was made on the subject project. There were punch list items
identified at that time. The punch list items were completed on February 13, 2025. The final inspection
and the corrected punch list items indicate that the work meets the City of Fort Worth specifications and
is therefore accepted by the City. The warranty period will start on February 13, 2025, which is the date
of the punch list completion and will extend of two (2) years in accordance with the Contract
Documents.
If you have any questions concerning this letter of acceptance, please feel free to contact me at
Senior Professional Engineer, Office: 817-392-7830
Izeldeen.Ahmed@fortworthtexas.gov .
Sincerely,
Izeldeen Ahmed, Project Manager
Cc: Kevin Jackson, Inspector
Gary Deyon, Inspection Supervisor
Lorrie Pitts, Senior Inspector
Andrew Goodman, Program Manager
Clay Moore Engineering,, Consultant
Circle H Contractors, Contractor
Village Homes, Developer
File
E-Mail: TPW_Acceptance@fortworthtexas.gov
i • � i 2105 Greenwood Dr
� � �� � � . Southlake, TX 76092
� 817-416-8881 (voice)
817-416-8886 (fax)
Date: _�/�/ � ,�
mm dd yy
Anticipated Annual Purchases: $_
Tax Exeinpt? � Yes [] No, If yes, please include Tax Exemption Certificate (Certificate #
Are Purchase Orders used to place orders? [] Yes �[ No, If no, how are orders placed?
Is Electronic Invoicing Available/Required? [] Yes �No If yes, website
�
Any special requirements for invoicing (ie. signature � quired/approval stamp/coding/etc.)?
Business Information
Company Legal Name: c— �/C, ��J � �
Trade Name - d/b/a: �� � _
Ph #: ( � 72 ) ��-� Fax #: { -
Billing Address:
REQUIRED � n%�j�� . f� > ,� `� �
i%l 1 ��
Type of Ownership []"C" Corporation �artnership I�L-� L l� []"S" Corporation
[ ] Private [ } Publicly Held [ ] Non-Profit [ ] Sole Proprietor
�7 r /
Incorporation: State: Year: Tax Payer ID# 1`� ��' � 3 L� �
Contact Information
Field Contact: l2 a�1� 13�n.- �J
Phone: t � - `t `tG - � Z 7 _
Email Address:
Supervisor: rx� tc€ �aaes�
Phone: � _ - 3s''S-'7
Email Address: Wt �iC� � Gr•� es' �f��F�•�r ra�►s . t�
---------------------------------------------------------------------------------------
Purchasing: Phone:
Email Address:
Accounts Payable: �.,.� L.,, Phone:
�. _ � �Q Z
Email address: � ^! 1 � � ��'rs, �"�
�E n„" 01-339(Back)
sl'�" �;,, IRev.6-04/5)
TEXAS SALES AND USE TAX EXEMPTION CERTIFICATION
Name of purchaser, firm or agency
CIRCLE H CONTRACTORS, LP
Address (Street & number, P.O. Box or Route number)
PO BOX 220
City, State, ZIP code
MIDLOTHIAN, TX 76065
Phone (Area code and number)
972-723-0802
I, the purchaser named above, claim an exemptian from paymen# of sales and use taxes (for the purchase of taxable
items described below or on the attached order ar invoice) from:
Kimark
Seller:
Street address: 2105 Greenwood Drive
Description of items to be purchased or on the attached order or invoice:
Scada System for Lift Station
Purchaser claims this exemption for the following reasan:
PROJECT: EI Dorado
LOCATION: Granbury
City, State, ZIP code: Southlake,Tx 76092
UPON COMPLETION OF THIS PROJECT ALL fNFRASTRUCTURE WILL BE TURNED OVER TO THE CITY FOR
OWNERSHIP
I understand that I will be liable for payment of sales or use taxes which may become due for failure to comply with the provisions of the
Tax Code: Limited Sales, Excise, and Use Tax Act; Municipal Sales and Use Tax Act; Sales and Use Taxes for Special Purpose Taxing
Authorities; County Sales and Use Tax Act; Counry Health Services Sales and Use Tax; The Texas Health and Safety Code; Special
Provisions Relating to Hospital Districts, Emergency Services Districts, and Emergency Services Districts in counties with a population
of 125,000 or less.
I understand that it is a criminal offense to give an exemptian cerfificafe to fhe selfer for taxable items thaf 1 know, at the time of purchase,
will be used in a mannerother fhan that expressed in this cerfificafe and, depending on the amount of tax evaded, the offense may range
from a C/ass C misdemeanor to a felony of the second degree.
sign
here `
Purchaser
PROJECT MANAGER
2/17/2025
NOTE: This certificate cannot be issued far the purchase, lease, or rental of a motor vehicle.
THIS CERTlFlCATE DOES NOT REQUtRE A NUMBER TO BE VAtlD.
Sales and Use Tax "Exemption Numbers" or "Tax Exempt" Numbers do not exist.
This certificate should be furnished to the supplier. Do not send the completed certificate to the Comptroller of Public Accounts.
006219-1
Bond#S-342462 M�NTENANCEBOND
Page 1 of 3
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SECTION 00 62 l9
MAINTENANCE B�ND
THE STATE OF TEXAS §
§ KNOW ALL BY TAESE PRESENTS:
COUNTY OF TARRANT §
That we _ �jr���j_��act�rs._LP _, known as
"Principal" herein and NGM Insurance Company , a corporate surety
(sureties, if more than ane) duly authorized to do business in the State of Texas, known as
10 "Surety" herein (whether one or more), are held and firmly bound unto the Developer, Village
11 Homes, LP, authorized to do business in Texas ("Developer") and the City of Fort Worth, a
12 Texas municipal corporation ("City"), in the sum of Two Hundred Thirty Two Thousand One
13 hundred Sixty Eight Dollars and Twenty Three Cents ($232a168.231 lawful money of the United
14 States, to be paid in Fort Worth, Tarrant County, Texas, for payment of which sum well and truly
15 be made jointly unto the Developer and the City as dual obligees and their successors, we bind
16 ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally,
17 firmly by these presents.
18
19 WHEREAS, Developer and City have entered into an Agreement for the construction of
20 community facilities in the City of Fart Worth by and through a Community Facilities
21 Agreement, CFA Number CPN 104228; and
22 WHEREAS, the Principal has entered into a certain written contract with the Developer
23 awarded the day of _ , 20 , which Contract is
24 hereby referred to and a made part hereof for all purposes as if fully set forth herein, to furnish all
25 materials, equipment labor and other accessories as defined by law, in the prosecution of the
26 Work, including any Work resulting from a duly authorized Change Order (collectively herein,
27 the "Work") as provided for in said Contract and designated as The Grove 2; and
2$
29 WHEREAS, Principal binds itself to use such materials and to so construct the Work in
30 accordance with the plans, specifications and Contract Documents that the Work is and will
3 j remain free from defects in materials or workmanship for and during the period of two (2) years
32 after the date of Final Acceptance of the Work by the City ("Maintenance Period"); and
33
CCTI' OF FdRT VvOR1'H The Grove 2
STANDARU CITY CONDITIONS - DEVELOPER AWARDED PROJECTS CPN 104218
Revised January 31, 2012
006219-2
MAINTENANCE BOND
Page 2 of 3
1 WHEREAS, Principal binds itself to repair or reconstruct the Work in whole or in part
2 upon receiving notice from the Developer and/or City of the need thereof at any time within the
3 Maintenance Period.
4
5 NOW THEREFORE, the condition of this obligation is such that if Principal shall
6 remedy any defective Work, for which timely notice was provided by Developer or City, to a
7 completion satisfactory to the City, then this obligation shall become null and void; otherwise to
8 remain in full force and effect.
9
10 PROVIDED, HOWEVER, if Principal shall fail so to repair or reconstruct any timely
11 noticed defec;tive Work, it is agreed that the Developer or City may cause any and all such
12 defective Work to be repaired ancUor reconstructed with all associated costs thereof being borne
13 by the Principal and the Surety under this Maintenance Bond; and
14
15 PROVIDED FURTHER, that if any legal action be filed on this Bond, venue shall lie in
16 Tarrant County, Texas or the United States District Court for the Northern District of Texas, Fort
17 Worth Division; and
18
19 PROVIDED FURTHER, that this obligation shall be continuous in nature and
20 successive recoveries may be had hereon for successive breaches.
21
22
23
C1TY OF FORT WORTH The Gruve 2
STANDARD CrI'Y CONDiTIONS — DEVELOPER AWARDED PR07EC'CS CPN ]04228
Revised January 31, 2012
006219-3
MAINTENANCE BOND
Page 3 of 3
IN WITNESS WHEREOF, the Principal and the Surety have each SIGNED and SEALED this
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ar
�FF
instrument by duly authorized agents and officers on this the 25th day of _ March,
._—� 2a 24
PRINCIPAL:
Circle H Contractors, LP
ATTEST:
(Principal) Secretary
Witness as to Principal
ATTEST:
S ec
ss as Surety �
BY
Signature
Name and Title
Address: P(� R�x22Q —
Mi thian: TX 760b5--
SURETY:
NGM. ___ _nce Compan�
BY:
Signature
Sheri.RAllen, Att4rn��-i�F��t_
Name and Title
Address: 55 West Street
Keene, I�II��?3�3-1_ —
Telephane Number: _6II3_3��_5281
*Note: If signed by an officer of the Surety Company, there must be on file a certified extract
from the by-laws showing that this person has authority to sign such obligation. If
Surety's physical address is different from its mailing address, both must be provided.
The date of the bond shall not be prior to the date the Contract is awarded.
C1TY OF FORT WORTH
STANDARD CITY CONDITIONS - DEVELt)PER AWARDED PROJECTS
Revised January 31, 2012
The Grnve 2
CFN 104228
IMPORTANT NOTICE
To obtain information or make a complaint:
You may contact your surety underwriter at
1-904-380-7378
You may also write to Main Street America Group and NGM lnsurance Company at:
4601 Touchton Road East
Suite 330
Jacksonville, Fl 32246
Attn: Bond Underwriting
You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or
copnplaints at:
1-800-252-3439
You may write the Texas Departmea�t of Insurance:
P.O. Box 149104
Austin, TX 78714-9104
Fax: (512) 475-1771
E-mail: ConsumerProtection@tdi.state.tx.us
PREMIUM OR CLAIM DISPUTES
Should you have a dispute concerning your premium or about a claim you should contact the agent or the company
first. If the cEispute is not resolved, you may contact the Texas Department of Insurance.
This notice is for information onlv and does not become a part or condition of the attached document.
AVISO IMPORTANTE
Para obte�er informacion o para someter una queja:
Puede comunicarse con su surety underwriter al
1-904-380-7482
Usted tambien puede escribir a Main Street America Group a�d NGM insurance Company at:
46o1 Touchton Road East
Suite 330
Jacksonville, Fl 32246
Attn: Bond Ua►derwriting
Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de cornpanies,
coberturas, derechos o quejas al:
1-800-252-3439
Puede escribir al Departamento de Seguros de Texas:
P.O. Bax 149104
Austin, TX 78714-9104
Fax:(512)475-1771
E-mail: ConsumerProtection@tdi.state.tx.us
DISPUTAS SOBRE PRIMAS O RECLAMOS:
Si tiene una disputa concerniente a su prima o a un reclaano, debe cotnunicarse con el agente o la compania primero.
Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDl)
Este aviso es solo para �onosito de informacion v no se convierte en parte o condicion del documento adiunto.
68-TX-N001
�� �
=� AMERICA u,' �'
� �N��E � PowER oF aT�� 12 5 9 9 3
KNOW }�LL MEN BY THESE PRESENTS: That NGM Insurance Company, a Florida corporation having its principa[
office in the City of Jacksonville, State of Florida, pursuant to Article IV, Section 2 of the By-Laws of said Company, to wit:
"Article IV, Sec#ion 2. The board af directors, the president, any vice president, secretary, ar the txeasurer
shall hav� the power and autharity to appoint attorneys-in-�act and to authorize them to execute on behalf
of the company and affix the seal of the company thereto, bonds, recognizances, contracts of indemnity or
writings obligatory in the nature of a bond, recognizance or conditional undertaking and to remove any
such attorneys-it�-faet at any time and revoke tha pawer and aui%ority given tQ ihem. "
daes herehy rnake, constilute and appoint Bret Tamlinson, Sl�eri R Allen, David Q�fard, Steven Lott, �herrel Breazeale,
PeggyHogan -----------------------------------------------------------------------------------------------------------------------------------
its true and lawful Attorneys�in-fact, ta make, execute, seal and deliv�r for and on its behalf, and as its act and deed, bonds,
undertakings, rec�gnizanc�s, contracts of indemniiy, or ather writings abligatory in nature of a bond subject ta the following
limitation:
1. No one bond to exceed Five Million Dollars ($5,000,000)
and to bind NGM Insuranc� �ompany ther�by as fully ar�d to the same extent as ifsuch instruments were signed by the dnly
authorize� afficers of NGM Insurance Cornpany; the acts af said Attorney are hereby ratifred and confirmed.
This power of attorney is signed and sealed by facsimile under and by the authority of the follawing resolution adopted by
the Direciors of NGM InsuranG� Co�pany at a�tteeting duly called and held on the 2nd day c�f Llecember 1977.
Voted: That the signafure of any offcer authorized by the By-Laws and the company seal may be affixed by facsimile to
any power of attorney or special power of attorney or certification of either given for the execution of any bond,
undertaking, recognizance ar other written obligation in the nature thereof; such signature and seal, when so used being
hereby a€iopted by the company as the arigina� signature of such ofiice anri the origina{ seal of the company, to be valid
and binding upon the camparzy with the same force and effect as thaugh manuallq affixed.
IN WITNESS WHEREOF, NGM Insurance Company has caused these presents to be signed by its Assistant Secretary and
its corporate seal to be hereto affixed this 24th day of August, 2023.
NGM [NSURANCE C�MPANY By: �� `��
O� � �1."� _ �
z 19xi �
Lauren K. Powell s
Vice President, Corparate Secretary� ��
State of Wisconsin,
County of Dane.
On this 24th day of August, 2023, before the subscriber a Notary Public of State of Wisconsin in and for the County of Dane duly
comntzssioned and qualifterl, came Lauren K. Aowell nf NGM Insurance Eompany, to me persortalty known to be the officer described
herein, and who execu#ed the prece�ti�g insirument, and skte a�cknawiedged the execution of same, and being by me fully sworn, deposed
and said that she is an o�cer of said Company, aforesaid: that the seai affrxed to the preceding instrument is the corporate seai of said
Company, and the said corporate seal and her signature as officer were duly affixed and subscribed to the said instrument by the authority
and direction of the said Company; that Article IV, Section 2 of the By-Laws of said Company is now in force.
IN 1MTNESS WHEREOF, I have h�reunto s�t my hand and affixed rt�y official seal at Madison, Wiseonsin this 24th day Qf Augu�,
2023. � �
� ���r6et �
My C mmissi4n Expires May 21, �Q27 `g,�""�'''��
�"—� --
I, Andrew Rose, Vice President of NGM Insurance Cnmpany, do hereby certtty tnat tne above and fnregomg is a true and correct copy
of a Power of Attorney executed by said Company which is still in full force and effect.
IN_WIT�FS�S WHE , I h e hereu o s t hand and af�xed the seal of said Company at Madison, Wisconsin this
� y of
' ,� �c�.
Andrew Rose, Vice President ��
WARt+IING. Any unauthonzed reproduct�on or aktezatian of tliis document is prohib�ted.
TO CONFIRM VALIDI3'Y of the attached bond please call 1-603-354-5281
TO SUBM[T A CLAIM. 5end all correspondence to 55 West Street, Keene, NH 03431 °"°f �v�
Attn: Bond Claim Dept or call our Bond Claim Dept. at 1-603-358-1437 6
. ��_
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