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HomeMy Public PortalAboutPrequalification NEW BIDDER Application for Construction 2020 updated 2-1-2021Page 1 of 39 2/1/2021 THE METROPOLITAN ST. LOUIS SEWER DISTRICT 2350 Market Street St. Louis, MO 63103 Attn: Purchasing Department Elizabeth Goetz (314) 768-6269 and Stacey Hunter (314) 436-8738 CONSTRUCTION PRE-QUALIFICATION APPLICATION For the Period of 7/1/2020 thru 6/30/2021 (USED IN PRE-QUALIFYING ALL NEW BIDDERS ON CAPITAL CONSTRUCTION WORK) ___________________________________________________________ SUBMITTED BY (COMPANY) ___________________________________________________________ ADDRESS ___________________________________________________________ CITY, STATE, ZIP CODE ___________________________________________________________ DATE ___________________________________________________________ CONTACT NAME (FOR QUESTIONS) - TELEPHONE & FAX TAX ID NUMBER _____________________________________________________________ E-MAIL ADDRESS FOR BID NOTICES Page 2 of 39 2/1/2021 PREQUALIFICATION CHECK LIST Below is a checklist of required documentation  Signed Conflict of Interest Statement (Page 5).  Boxes checked indicating type of work requested (Page 8).  Bonding capacity indicated (Page 9).  Equipment Sheet is complete (Page 28).  Affidavit is complete with Notary Seal for whichever type of business is applicable (35-39).  Attach Certificate from the Secretary of State (Certificate of Good Standing) showing company is authorized to transact business in the State of Missouri.  Attach ACCORD Certificate of Insurance with MSD as certificate holder (pages 29-34).  Attach drain layers license for City of St. Louis and/or St. Louis County (required for Sewer Construction and Deep Sewer Construction categories).  Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require license.  Supplier form (can be found here: https://msdprojectclear.org/doing-business/suppliers/ (Download “New Supplier Data Form”). Please submit this with your package if you are a new bidder or if you are an existing bidder and you have any changes to your contact information or company.  W-9 Page 3 of 39 2/1/2021 RULES AND REGULATIONS FOR PREQUALIFICATION OF CONTRACTORS ON WORK LET BY CONTRACT WITH THE METROPOLITAN ST. LOUIS SEWER DISTRICT 1. An applicant for pre-qualification must furnish, under oath, detailed information with respect to its equipment, past record, personnel, and experience, together with other information as is called for in this Prequalification Application. 2. A contractor must be prequalified prior to bid opening of a project. 3. Any combination of qualified or unqualified contractors bidding jointly becomes a new contracting firm and it must be pre-qualified in accordance with these rules. All applications shall be in writing and signed by the principal parties in the joint venture. 4. Pre-qualification Application forms must be filed by July 1st of each year. This form must be completed in detail. The District may require any additional information deemed necessary for pre-qualification. Companies pre-qualified within 3 months prior to this date will not need to submit a renewal application until the following year. 5. No bidder will be pre-qualified unless its Pre-qualification Application indicates that it has the experience, organization, and equipment, sufficient in the judgment of the District, that it can satisfactorily execute its contracts and meet its obligations therein incurred. 6. The Financial Statement of the controlling individual or corporate owner of the business may be requested by MSD as part of the prequalification review. If requested by MSD the Financial Statement shall be submitted or the review cannot be completed. 7. If any significant change occurs in the information included on the contractors’ pre-qualification form, notice shall be given to the District immediately. 8. All corporations must furnish a certificate from the Secretary of State showing that it is authorized to transact business in the State of Missouri 9. A copy of your firm's Certificate of Insurance meeting the Districts coverages is required. 10. A copy of the applicable drain layers license from the City and/or County of St. Louis is required for Sewer Construction or Deep Sewer Construction. 11. Demolition work for MSD within the City of St. Louis – attach certification for specific classification. o Class I – no building size restrictions. o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require no demolition license. o St. Louis County does not require a license. NOTE: It is important that the work experience pages in Section V be completed and that it contains projects of the type for which pre-qualification is being requested. Pre-qualification will not be granted for types of work that you subcontract to others. Page 4 of 39 2/1/2021 IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS 1. CONTRACT DOCUMENTS Contract documents include, but may not be limited to; the advertisement, Instructions to Bidders, Proposal, General Specifications, Detailed Specifications, Agreement, Bond Form, and Plans. The documents are available on and after the day advertisement is published and will be available via MSD’s website at https://msdprojectclear.org/doing-business/capital-improvement-replacement-program/capital-construction/. Look for a link to “ELECTRONIC PLANROOM”. Plans and specifications are also available for viewing or purchase at Cross Rhodes Reprographics located at 2731 South Jefferson, St Louis, Missouri 63118. 2. PREQUALIFICATION A contractor must be pre-qualified prior to bids being opened. 3. SPECIAL PROVISIONS Any special provisions or requirements concerning the work on any particular contract will be noted in the contract documents or on the Plans. 4. MINIMUM WAGE AND EMPLOYMENT DISCRIMINATION The minimum wage to be paid to all labor will be shown in the contract documents where applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor, and there shall be no discrimination in the selection or employment of labor on account of race, creed, or color. 5. BID SECURITY The bid shall be accompanied by a certified check or cashier's check drawn on a bank or trust company located in either St. Louis City or County or by a bid bond issued by a surety company satisfactory to the District and which is authorized to transact business in Missouri. 6. RIGHT TO REJECT The Metropolitan St. Louis Sewer District reserves the right to reject any and all bids and to waive technicalities. Page 5 of 39 2/1/2021 VENDOR’S CONFLICT OF INTEREST STATEMENT 1. Name the individual or company requesting to do business with The Metropolitan St. Louis Sewer District (MSD). 2. In the past two (2) years has the individual or company name in 1. above (or any principal of such company, i.e. partner, officer, director, etc.) contributed cash or gifts in excess of $200.00 in value in the aggregate in any calendar year to any of the individuals or organizations listed on Attachment A hereto? Yes No If yes, describe in detail (date/amount/description). 3. In the past two (2) years, has the individual or company named in 1. above done business with any person listed in Attachment and/or their respective companies. Yes No If yes, describe in detail (date/amount/description). 4. The undersigned certifies that the above information is true and correct to the best of his or her knowledge and belief. Dated this day of _________________. 20 _ Printed Name: _____ Title: _____ Company Name: _____ Signature: _____ Page 6 of 39 2/1/2021 ATTACHMENT A NOTE: Attachment A contains a list of the MSD Trustees and their respective employer, MSD officers and Directors, and the organizations which each are individually associated with, as applicable. Updated September 21, 2020 MSD BOARD OF TRUSTEES & DIRECTORS Trustee/Director Name of Firm, Organization or Company Affiliation Bret A. Berthold American Water Works Association (AWWA) Member Director Engineers Club of St. Louis Member Missouri Water Environment Association Member National Association of Clean Water Agencies (NACWA) Member Water Environment Federation Member Tracey Coleman Association for Talent Development Member Director St. Elizabeth Mother of John the Baptist Member Society for Human Resource Management Member Michael Evans AFL-CIO Lawyers Coordinating Committee Member Trustee Bar Association of Metropolitan St. Louis Member Hartnett Reyes-Jones, LLC Partner International Foundation of Employee Benefit Plans Member Kentucky Bar Association Member Missouri Bar Association Member St. Louis City Labor Legislative Club Member Amy L. Fehr Algonquin Golf Club Member Trustee American Bar Association Member Bar Association of Metropolitan St. Louis Member Capes, Sokol, Goodman and Sarachan, PC Shareholder & Director Federal Bar Association, St. Louis Chapter Member Missouri Bar Association Member Marion M. Gee American Water Works Association (AWWA) Member Director Church on The Rock Member Government Finance Officers Association (GFOA) Executive Board Missouri Government Finance Officers Association Member Brian Hoelscher Engineers Club of St. Louis Member Executive Director Missouri Water Environment Association Member National Association of Cleanwater Agencies (NACWA) Executive Board Project MOSAIC Ambassador/Connector Washington University in St. Louis - W Club Executive Council Water Environment Federation Member Susan M. Myers Association of Corporate Counsel Member Director Association of Missouri Cleanwater Agencies (AMCA) Board Member Bar Association of Metropolitan St. Louis Member Missouri Bar Association Member National Association of Cleanwater Agencies (NACWA) Member Betsy Schubert Institute for Supply Management Member Manager Page 7 of 39 2/1/2021 Updated September 21, 2020 MSD BOARD OF TRUSTEES & DIRECTORS Trustee/Director Name of Firm, Organization or Company Affiliation James I. Singer AFL-CIO Lawyers Coordinating Committee Member Trustee American Bar Association Member American College of Employee Benefit Counsel Member Bar Association of Metropolitan St. Louis Member Electricians Historical Society Board member Illinois Bar Association Member Missouri Bar Association Member Missouri Botanical Gardens Member Missouri Historical Society Member Schuchat, Cook and Werner Partner Shaare Emeth Congregation Member St. Louis University Law School Adjunct Faculty St. Louis Zoo Member Timothy R. Snoke Director Contractor Loan Fund Board Member, Executive Committee Government Finance Officers Association Member Institute of Management Accountants Member Jonathon Sprague St. John's Lutheran Church Member Director Member Missouri Water Environment Member National Association of Clean Water Agencies (NACWA) Member Water Environment Federation Member Rich L. Unverferth Engineers Club of St. Louis Member Director Knights of Columbus - Council 2119 Webster Groves Member National Association of Clean Water Agencies (NACWA) Member St. Michael the Archangel Catholic Parish Member Ret. Col. Richard R. Wilson American Institute of Parliamentarians Member Trustee Anniversary Club Member Oaks Social Club Treasurer Pathfinders Golf Club Treasurer Pin High Golf Club Member Reserve Officers Association Member Royal Vagabonds Foundation, Inc. Board Member Royal Vagabonds, Inc. Member Michael E. Yates North County Labor Legislative Club Executive Board Member Trustee St. Louis Labor Council Delegate Page 8 of 39 2/1/2021 APPLICATION FOR CERTIFICATE OF QUALIFICATION TO BID The undersigned hereby applies to the Metropolitan St. Louis Sewer District for a Certificate of Qualification to bid the following types of work: (Check each type of work for which qualification is requested) ________ Sewer Construction Section V. A., Page 12. Drain layers license required for City or County. ________ Deep Sewer Construction Section V. B., Page 14. Drain layers license required for City or County. To qualify in this category a contractor must demonstrate experience on multiple projects that are deemed complex by the District. Typically a project would be considered complex when the installation of the pipe required excavation at depths greater than 20 feet for an extended length along with one or more of the following addition construction challenges: significant involvement with trench bracing for urban type features; significant amounts of Class “A” or Class “B” excavation; significant amount of poor soil conditions; significant length of large diameter pipe installation (36-inch or larger); or installation in locations having extremely limited working room. The District shall be the sole judge as to whether a project is considered complex. ________ Building Construction Section V. C., Page 16 ________ Natural Channel Stabilization Section V. D., Page 17 ________ Green Infrastructure and Bio-Retention Section V. E., Page 18 ________ Pipe and Manhole Rehabilitation Section V. F., Page 19 Cured-In-Place Pipe (CIPP) Section V. G, Page 20 - 21 Cured-In-Place Lateral Liner (CIPL) Section V. H, Page 22 & 23 ________ Concrete Channels, Walls and Structures Section V. I., Page 24 ________ Mechanical/Electrical/Plumbing Section V. J., Page 25 ________ Tunneling / Trenchless Section V. K., Page 26 ________ Demolition Section V. L., Page 27; and for explanation of Class I & II ________ St. Louis County Demolition ________ St. Louis City – Class I and II ________ St. Louis City – Class II only Page 9 of 39 2/1/2021 TYPE OF ORGANIZATION (Check Applicable Category) _____ Corporation ______ Partnership ______ Joint Venture ______ Individual _________LLC Firm Name: ________________________________Firm Address: ________________________ By ___________________________________ Title _________________________ _________________________________ (Signature) THE SIGNATORY OF THIS APPLICATION GUARANTEES THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF ALL ANSWERS TO INTERROGATORIES HEREINAFTER MADE Please list any previous experience or projects your company has completed for each category you are requesting approval for, and any references you can provide. Attach additional sheets if necessary. Name of Contractor _____________________________________________________ Principal Address _______________________________________________________ ( ) A corporation ( ) A partnership ( ) A joint venture ( ) An individual ( ) A limited liability corporation ( ) MWBE (Minority or Woman Business Enterprise) If MWBE, what is the name of the agency/organization that issued the certification document? _______________________________________________________________ Please attach a copy of your certification document to this application. Incorporated or organized: Date _______________________ State ______________________________________ Radius of operations: ______________________________________________________ Type of work done: ______________________________________________________ Work usually sublet: Name of Bonding Company _______________________________________________ Total Bonding Capacity of Firm $__________________________________________ I. How many years have you operated under the above name: (a) As general contractor _____________________________________________ (b) As subcontractor ______________________________________________ Page 10 of 39 2/1/2021 II. List other names under which you have operated: Name of company _____________________________________________ Type of work done ______________________________________________ Operated during period ______________________________________________ Name of company ______________________________________________ Type of work done ______________________________________________ Operated during period _____________________________________________ III. List of all partners or officers: (Note: if partnership limited, explain and please list full 100% ownership) Name and title_________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned______________________ Name and title____________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ Name and title ___________________________________________________ Address, City and State____________________________________________ Fractional interest in firm or number of shares owned ______________________ IV. What is the construction experience of the principal individuals of your organization? (This includes the job superintendent). An individual’s name Present position or office Years of construction experience Magnitude and type of work An individual’s name Present position or office Years of construction experience Magnitude and type of work Page 11 of 39 2/1/2021 An individual’s name Present position or office Years of construction experience Magnitude and type of work Page 12 of 39 2/1/2021 V. Only list projects completed or in progress within the last five years in the categories for which you want to qualify. Attach additional sheets if necessary. SECTION A. - Sewer Construction (See definition on page 8) (Includes storm sewer, sanitary sewers, and small pump stations) 1. Contract Amount __________________ When Completed or Percent Complete__________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount _________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: ____________________________________________ Pipe size and length laid______________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner__________________________________________ 3. Contract Amount __________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid______________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 13 of 39 2/1/2021 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size and length laid_______________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 14 of 39 2/1/2021 SECTION B. - Deep Sewer Construction (See definition Page 8) (Includes sanitary sewer, storm sewer, and small pump stations) 1. Contract Amount ____________________________________________________________ When Completed or Percent Complete____________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid___________________________________________ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ___________________________________________________________ When Completed or Percent Complete _______________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 15 of 39 2/1/2021 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 5. Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Pipe size, average depth and length laid ______ What was complex about this project? ___________________________________________ __________________________________________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 16 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION C - Building Construction (Includes large pump stations, treatment plants, and operational facilities) 1. Contract Amount ___________________________________________________________ When Completed or Percent Complete___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project __________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone Number of Owner _______________________________________ 2. Contract Amount __________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: ____________________________________________ Location of Project__________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount __________________ When Completed or Percent Complete __________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner____________________________________________ 4. Contract Amount ___________________________________________________________ When Completed or Percent Complete __________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project___________________________________________________________ Name, Address & Phone # of Owner_____________________________________________ Page 17 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION D. Natural Channel Stabilization: 1. Contract Amount _____________ When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner _____________________________________________ 2. Contract Amount _____________When Completed or Percent Complete _______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ___________________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of __________________________________________________ 3. Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ______________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4. Contract Amount ______________When Completed or Percent Complete ______________ Project Description/Scope of Work: _____________________________________________ Specify channel stabilization methods installed: ____________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 18 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION E. Green Infrastructure and Bio-Retention 1. Contract Amount ____________When Completed or Percent Complete Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project ________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner ____________________________________________ 2. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount _______________ When Completed or Percent Complete _____________ Project Description/Scope of Work: _____________________________________________ Specify green infrastructure methods installed______________________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner ________ __________ 4. Contract Amount _______________When Completed or Percent Complete _____________ Project Description/Scope of Work: ____________________________________________ Specify green infrastructure methods installed______________________________ Location of Project___________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 19 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION F. - Pipe and Manhole Rehabilitation (Give pipe sizes) (Includes point repair, pipe bursting, slip lining, etc.) 1. Project name, scope and description:___________________________________________ Contract Amount __________________________________________________________ When Completed or Percent Complete ________________________ Location of Project___________________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Project name, scope and description:___________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Project name, scope and description:____________________________________________ Contract Amount ___________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner 4. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Location of Project____________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 20 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION G. – Cured-in-Place Pipe (CIPP) Statement of Qualifications for Cured-in-Place Pipe 1. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) __________________________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Installed Pipe Length: _____ Pipe Sizes: _____ Pipe Type: Gravity ____ Pressure _______ Project Owner: ______________________________________________________________ Contact Name: ___________________________Contact No.:________________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus ___________________________ Tensile Strength _____________ (only applicable for pressure pipe) 2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Manufacturer of CIPP product ___________ Trade Name of CIPP product ______________ Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) ___________________________________________________________________________ Installation Method: Invert: _____ Pull-In: _____ Length of Pipe Installed: _______ Pipe Size: _____________ Pipe Type: Gravity _______ Pressure _______ Page 21 of 39 2/1/2021 Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________ Lowest 3rd Party D790 Testing Results on Project: Flexural Strength _____________ Flexural Modulus _________________ Tensile Strength _____________ (only applicable for pressure pipe) Page 22 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION H. – Cured in Place Lateral Lining (CIPL) Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral connection repairs). 1. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Manufacturer of CIPL product ___________ Trade Name of CIPL product _________________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: _____________________ Manufacturer of Water Tight Seal (waterstop): _____________________________________ Manufacturer of Lateral Connection Repair (LCR): _________________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ 2. Project name, scope and description_____________________________________________ Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Manufacturer of CIPL product ___________ Trade Name of CIPL product ________ Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl ester resin) _________________________________________________________ No. of Laterals Lined: ________ Total Length of Laterals Lined: __________ Page 23 of 39 2/1/2021 Manufacturer of Water Tight Seal (waterstop): ______________________________ Manufacturer of Lateral Connection Repair (LCR): __________________________ (Attach written documentation from manufacturer certifying that contractor is an approved installer of their product). No. of LCR’s Installed: __________ Project Owner: ______________________________________________________ Contact Name: ___________________________Contact No.:_________________ Relevant ASTM Specification: Lowest Value of 3rd Party D790 Testing Results on Project: Flexural Strength ____________ Flexural Modulus __________________ Page 24 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION I. - Concrete Channels, Walls & Structures 1. Contract Amount ____________________________________________________________ When Completed or Percent Complete ___________________________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: ____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 25 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION J. - Mechanical/Electrical/Plumbing 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 26 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION K. – Tunneling / Trenchless 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: ____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District Boundaries please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 27 of 39 2/1/2021 List all experience for the past five years in the categories for which you want to qualify. List projects that are completed or in progress, attach additional sheets if necessary. SECTION L. – Demolition Demolition work for MSD within the City of St. Louis – attach certification for specific classification. Class I–no building size restrictions. Class II -limited to buildings under 3 stories / 50 feet high / 50,000 square feet area / 200,000 cubic feet volume. Buildings under 1 ½ stories / 10,000 cubic feet volume, with no basement, require no demolition license. St. Louis County – does not require license. 1. Contract Amount ______________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project ________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 2. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 3. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ 4. Contract Amount ________________ When Completed or Percent Complete ________________________ Project Description/Scope of Work: _____________________________________________ Location of Project_________________________________________________ If project is in MSD District boundaries, please indicate P# or MSD Contract No.: ________ Name, Address & Phone # of Owner_____________________________________________ Page 28 of 39 2/1/2021 EQUIPMENT (What equipment do you own that is available for proposed work?) QUANTITY ITEM DESCRIPTION, SIZE, CAPACITY, ETC EQUIP HOURS CONDITION YEARS OF SERVICE PRESENT LOCATION * Condition shall be graded as follows: New under 12 months Over 12 months old Rebuilt N-1 0-1 (Good) R-1 0-2 (Average) R-2 0-3 (Fair) R-3 0-4 (Poor) R-4 (Poor) Page 29 of 39 2/1/2021 SAMPLE INSURANCE REQUIREMENTS REVISED 7/19/17: The following section supplements the provisions of Part 1, Section F, paragraph 8 of the Standard Construction Specifications (2009). a. Within fifteen (15) days after written notification by the District that the bid proposal has been accepted and receipt of the contract for signature, the Contractor must provide two (2) copies of executed Certificates of Insurance on the ISO ACORD 25 Form or current equivalent with the District, indicating that the bidder has obtained and will continue to carry commercial general liability, comprehensive business auto liability, workers compensation/employers’ liability, excess (umbrella), professional liability and pollution liability as required. The initial and renewal Certificates of Insurance must identify the MSD Project and Contract by name and reference number. A sample Certificate of Insurance Form in the format required is attached to these specifications. b. The Contractor shall carry and maintain adequate liability insurance as required by this Contract with a company or companies satisfactory to the District and which are:  Licensed to do business in the State of Missouri (Admitted) with a financial strength rating of “A-” or better and a financial size category of Class VI or higher per AM Best Company; or  Not licensed in the State of Missouri (Non-admitted) with a financial strength rating of “A” or better and a financial size category of Class IX or higher per AM Best Company; or  For workers compensation coverage only, organized pursuant to the Missouri Insurance Company Act (R.S.Mo §§ 287.900 to 287.920). The insurance policy/policies will be acceptable regardless of the above requirements if the insurance company furnishes a bond guarantee or policy containing a provision (commonly referred to as a “cut-through” endorsement) giving all claimants thereunder a direct right of recovery against the company’s reinsurer, provided the reinsurer meets one of the qualifications listed above. c. The amounts of coverage required herein shall not be construed to limit the liability of the Contractor under the indemnification provision of the contract. d. The District (including its Trustees, directors, officers, agents and employees), the Consultant ___________________________, and the following Sub-consultants _____________________________, shall be named as “Additional Insured(s)” for all required insurance coverage (with the exception of pollution liability, professional liability and workers compensation coverage) with respect to the __________________________________ (state project). The Contractor shall require that its sub-contractors name the District and the Contractor as “Additional Insured(s)”. The additional insured coverage must be sufficiently broad to afford the District coverage as required by the indemnification provision of the Contract and must include products and completed operations coverage included within the commercial general liability policy. e. In the event the Contractor is a joint venture, the following additional requirements shall apply: Page 30 of 39 2/1/2021 1. If the joint venture secures separate stand-alone coverage in the name of the joint venture for one or more of the required lines of coverage, each of the requirements set forth below shall apply to that coverage and the certificate of insurance shall so indicate. The District may request copies of the endorsements &/or policies of insurance to verify that coverage is in the name of the joint venture. 2. If separate stand-alone coverage in the name of the joint venture is not provided for one or more of the required lines of coverage, then for each such line of required coverage, the following requirements shall apply: (i) the coverages of each of the joint venture members must provide specific endorsements to each such line of required coverage; (ii) The joint venture shall be endorsed to each such line of coverage; (iii) The joint venture and each member of the joint venture must be “named insureds” for each such line of coverage; and (iv) The certificates of insurance for each such joint venture member shall be provided and shall reflect compliance with these requirements. It is anticipated that business auto and workers compensation/employers’ liability coverage will not be secured in the name of the joint venture, and will fall in this category. f. The coverage and minimum limits of liability shall be in accordance with the specifications below except as may be specifically modified elsewhere in the Contract Documents: COMMERCIAL GENERAL LIABILITY $1,000,000 Each Occurrence $1,000,000 Aggregate/Per Project* *The aggregate limits must be provided on a per project basis. Aggregate limits not provided on a per project basis must be noted on the Certificate of Insurance and the District must approve in advance. The Commercial General Liability (CGL) policy shall include the following: 1. Premises – Operations Liability 2. Blanket Contractual Liability 3. Products & Ongoing and Completed Operations Liability 4. Contractor’s Protective Liability (Independent Contractors) 5. Personal Injury Liability 6. Broad Form Property Damage Liability Endorsement 7. Coverage for explosion, collapse and underground hazards (XCU) 8. Blasting (provided that blasting coverage may be excluded if not to be performed in connection with the work) If any exceptions or exclusions have been made to the standard CGL Policy, the exceptions and exclusions must be specifically listed and identified in the Description of Operations section of the Certificate of Insurance and must be submitted to the District for approval. If using a non-standard policy form (Form CG 00 01 04 13 or equivalent), then additional endorsements may be required. Page 31 of 39 2/1/2021 The commercial general liability policy must provide primary and non-contributory coverage that is equivalent to the terms of ISO Form CG 20 01 04 13, Primary and Noncontributory Other Insurance Conditions (or current equivalent). The commercial general liability coverage including products and completed operations shall be maintained for a minimum period of five (5) years following final payment. BUSINESS AUTOMOBILE LIABILITY $1,000,000 Combined Single Limit Insurance shall apply to all owned, non-owned and hired vehicles. A MCS-90 endorsement shall be included on the Policy when required by Missouri law. WORKERS COMPENSATION & EMPLOYERS’ LIABILITY INSURANCE Workers Compensation: Statutory Limits Workers Compensation Insurance shall comply with all applicable State and Federal laws, including but not limited to U.S. Longshore & Harbor Workers (USL&H) Act and Jones Act. Employers’ Liability: $500,000 Each Accident $500,000 Disease Each Employee $500,000 Disease Policy Limit EXCESS (UMBRELLA) COVERAGE – Applies to CGL, Business Auto & Employers Liability Excess coverage must be provided and with the following limits for each of the Commercial General Liability, Business Auto & Employers’ Liability coverages. These limits are in addition to the primary limits set forth above. Limits For Contracts $100,000 & Over: $5,000,000 Per Occurrence $5,000,000 Aggregate Limits For Contracts Less Than $100,000: $2,000,000 Per Occurrence $2,000,000 Aggregate Page 32 of 39 2/1/2021 POLLUTION LIABILITY For contracts in excess of $100,000, the Contractor shall maintain in force for the full period of the Contract, pollution liability insurance coverage in the minimum amount set forth below for losses caused by sudden and non-sudden pollution conditions that arise from the operations of the Contractor. Such insurance shall apply to bodily injury and property damage, including loss of use of the damaged property or property that has not been physically injured, and shall cover cleanup, transportation, disposal, remediation and defense costs, including all expenses incurred in the investigation, defense, payment or settlement of claims. $2,000,000 Per Claim or Occurrence $2,000,000 Aggregate If claims made, the insurance coverage shall be retroactive to the earlier of the date of this Contract or the commencement of the Contractor’s work on the Project, and Contractor shall cause the same to remain in effect for a period of at least five (5) years after final acceptance of the Project by the District or such other period as may be set forth in the Contract or in the Project Specifications. NOTE: For contracts less than $100,000, the District does not require the Contractor to provide pollution liability coverage for the District. The Contractor may wish to provide such coverage for its own protection. The District is not providing such coverage to the Contractor. PROFESSIONAL LIABILITY For contracts in excess of $5,000,000, Contractor shall maintain, or shall cause its subcontractor(s) providing professional design or advice to maintain, in force for the duration of this Contract errors and omissions/professional liability insurance. Coverage as required in this Article shall apply to liability for professional errors, acts or omissions arising out of the scope of the Contractor’s services as set forth in this Contract and the Project Specifications. $2,000,000 Per Claim or Occurrence $2,000,000 Aggregate If claims made, the insurance coverage shall be retroactive to the earlier of the date of this Contract or the commencement of the Contractor’s work on the Project, and Contractor shall cause the same to remain in effect for a period of at least five (5) years after final acceptance of the Project by the District or such other period as may be set forth in the Contract or in the Project Specifications. NOTE: If Contractor provides combined Pollution Liability and Professional Liability coverage, separate limits in the amounts required must be provided. If a policy aggregate applies, the certificate of insurance must so indicate and the amount must be approved by the District. DEDUCTIBLE/SELF-INSURED RETENTION: For any coverage, a deductible or retention that exceeds $100,000 shall be noted and approved by the District’s Risk Management Group. The District will reserve the right to review the funding for a deductible or retention program. Satisfaction of any such deductible or retention shall be the sole responsibility of the Contractor. If self-insured, the District reserves the right to request acceptable proof of financial responsibility before approval. Page 33 of 39 2/1/2021 CANCELLATION: Should any of the required insurance coverage be cancelled prior to the expiration date, the Contractor must provide at least sixty (60) days written notice to the District prior to the cancellation. For policy cancellation for non-payment of premium by the Contractor, the Contractor must notify the District at least ten (10) calendar days prior to the cancellation. Cancellation provisions within any coverage shall be in accordance with Missouri Cancellation and Non-Renewal provisions. It is the duty of the Contractor to notify the District of any cancellation or non-renewal and provide the District 60 days’ notice. REPLACEMENT POLICY: Should any of the required insurance coverage be cancelled, terminated or materially altered, the Contractor will send written notice to MSD at least sixty (60) days prior to the effective date of said cancellation, termination or alteration. Upon receipt of any notice of insurance cancellation, termination or alteration, the Contractor shall within thirty (30) days procure other policies of insurance identical in all respects to the policy or policies about to be canceled, terminated or altered and shall provide the District with evidence of coverage before the cancellation or termination date; and if the Contractor fails to provide, procure and deliver acceptable policies of insurance and satisfactory certificates or other evidence thereof, the District may obtain such insurance at the cost and expense of the Contractor without notice to the Contractor, and elect to pursue any other remedy permitted by law or the contract terms, including but not limited to termination of the Contract. Page 34 of 39 2/1/2021 Metropolitan St. Louis Sewer District 2350 Market Street St. Louis, Missouri 63103 RE: Insurance Requirements for Annual Pre-Qualification Metropolitan St Louis Sewer District (MSD) requires contractors to be prequalified prior to bidding on Capital Improvement Projects. In the prequalification process, contractors must demonstrate their ability to perform in the event they are awarded a contract, including meeting the District’s insurance requirements. MSD has certain contract requirements relating to contractor insurance coverage, including increasing the limits for certain coverage and requiring pollution liability coverage. The District recognizes that these additional coverage requirements impose additional costs upon contractors. In an effort to alleviate any short term burden on contractors, for pre-qualification and bid purposes only, MSD is willing to accept a letter signed by both the contractor and the contractor’s insurance broker stating that the contractor has been approved for the additional insurance coverage and that the contractor will obtain all required coverage and with the limits required in the event a contract is awarded to the contractor. Further, the letter must state affirmatively that the policy will be endorsed and coverage will be in place in the event a contract is awarded. Additionally, the letter must state that in the event a contract is awarded and insurance is not secured within the required timeframe, the contractor will forfeit its bid bond on the project and will be determined non- responsive. These affirmative representations must be repeated as part of any bid submitted by a contractor that does not have the required coverage in place at the time of the bid. Thank you for your cooperation in this matter. Sincerely, Betsy Schubert Purchasing Manager Page 35 of 39 2/1/2021 AFFIDAVIT FOR CORPORATION STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am the _________________(title) of _____________________________________; 2. I am authorized to sign this Affidavit on behalf of the corporation; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name and affixed the official seal of the corporation this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: Page 36 of 39 2/1/2021 AFFIDAVIT FOR PARTNERSHIP STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am a partner in the partnership known as ____________________________________________________________; 2. I am authorized to sign this Affidavit on behalf of the partnership; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name this __ day of ________________, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: Page 37 of 39 2/1/2021 AFFIDAVIT FOR JOINT VENTURE STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am a joint venture partner &/or am authorized to sign this Affidavit on behalf of the Joint Venture between _______________________ and _________________________; 2. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 3. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name this __ day of ________________, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: Page 38 of 39 2/1/2021 AFFIDAVIT FOR INDIVIDUAL STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, _____________________________________, depose and state under oath that the foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name and affixed my official seal this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20__. Notary Public My commission expires: Page 39 of 39 2/1/2021 AFFIDAVIT FOR LIMITED LIABILTY COMPANY STATE OF _____________ ) ) ss COUNTY/CITY OF ___________ ) AFFIDAVIT I, ____________________, depose and state as follows: 1. I am the _________________(title) of _____________________________________, a limited liability company; 2. I am authorized to sign this Affidavit on behalf of the limited liability company; 3. The foregoing information and responses to interrogatories set forth herein are true and correct to the best of my knowledge, information and belief; and 4. Any depository, vendor, agency or entity herein named is authorized to supply The Metropolitan St. Louis Sewer District with any information appropriate to verify the accuracy of any statement herein. In witness hereof I have hereunto subscribed my name on this day of ____, 20 . Affiant (Seal) Subscribed and sworn to before me, a Notary Public, this day of , 20___. Notary Public My commission expires: