HomeMy WebLinkAboutRESOLUTIONS - 01012002 - 2002-015 r s'
C.17
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY,CALIFORNIA
Adopted this Resolution on January 15, 2002 by the following vote:
AYES: Supervisors Uilkema, Gerber, DeSaulnier, Glover and. Gioia
NOES: None
ABSENT: Norte
ABSTAIN: None
RESOLUTION NO.2002/15
SUBJECT: Approve Subdivision Agreement (Right of Way Landscaping) for Bollinger
Canyon Road RA 1102 (cross reference Subdivision 7976) being developed by
Windemere BLC Land Company,LLC,Dougherty Valley area. (District III)
The following document was presented for Board approval this date for, Bollinger
Canyon Road, RA 1102, (cross-reference Subdivision 7976), being developed by Windemere
BLC Land Company, LLC located in the Dougherty Valley area.
A Subdivision Agreement (Right of Way Landscaping) with Windemere BLC Land
Company, LLC, developer, whereby said developer agrees to complete all improvements as
required in said Subdivision Agreement (Right of Way Landscaping) within one year from the
date of said agreement. Improvements generally consist of landscaping.
Said document was accompanied by the following:
Security to guarantee the completion of right of way landscaping as required by Title 8
and 9 of the County Ordinance Code, as follows:
1. Cash Bond
Deposit Amount: $55,100.00
Deposit made by: Windemere BLC Land Company, LLC
Auditor's Deposit Permit No. and Date: 379205,December 24, 2001
G:\GrpData\EngSvc\BO\2001\TmV\RA 1102 Bo-16.doc I hereby certify that this is a true and correct copy of an
WL-
lad
Originator: Public Works(ES) action taken and entered on the minutes of the Board of
Contact: Teri Pje(313-2363) Supervisors on the date shown.
cc: Pubic Works- R.Bruno,Construction
Current Planning,Community Development
T--11-1s-02(P1) ATTESTED: January 15, 2002
Windemere BLC,LLC
3130 Crow Canyon PI.,#310 JOHN SWEETEN, Clerk of the Board of Supervisors and
San Ramon,CA 94583 County Administrator
The American Insurance Company
5 Peters Canyon
Irvine,CA 92606
By ,Deputy
RESOLUTION NO.2002/15
SUBJECT: Approve Subdivision Agreement (Right of Way Landscaping) for Bollinger
Canyon Road RA 1102 (cross reference Subdivision 7976) being developed by
Windemere BLC Land Company, LLC,Dougherty Valley area. (District III)
DATE: January 15,2002
PAGE 2
H. Surety Bond
Bond Company: The American Insurance Company
Bond Number and Date: 11127507082,December 19, 2001
Performance Amount: 5,455,800.00
Labor&Materials Amount: 2,755,500.00
Principal: Windemere BLC Land Company,LLC
NOW THEREFORE BE IT RESOLVED that said Subdivision Agreement(Right of Way
Landscaping)is APPROVED.
All deposit permits are on file with the Public Works Department.
RESOLUTION NO. 2002/15
Subdivisiou; RA 1102 X--Ref Sub 7976
Bond Na.: 111 2750 7082
Premium: $19,095.00
IMMOVEMENT SECURITY BOND
FoR Puuuc RIS'OF WAY LAnscAPR AcREEMTNT
(Pe fomance, Guarantee;and Payment)
(California Gov=iment Code Sections 66462 and 66463)
1. �C2E SVaptvtstQ_X ACREEMEWY. The Principal has executed an agreement wird the County to
install and pay fox public right of way landscaping,and othor related improvements in Subdivision ,
7976 as specified in the Subdivision Agceeruent{Right ofW ay Landscaping,and
to ca fete said work within the time:Wxifod for cozopledon in the Subdivi s oa Agreetniv(€2%&of Way
T!Xnd*capizW. all w accoudauce with Stft and local laws and rulizw d=etuuW m order to satisfy
conditions fm,fling of the Final Map or Parcel Map for said Subdivision.
2. ONAG&TW Windemere BLC land conafiy, ,as PfiodA and
The American Insurance. Company,.. .� t�ttorg�'2iCd 1 C�t3=�qTS
W., ofthe:State of Nebraska and authorized to transact suray business in
Capt ds a i tjr,Vty;jointly-wd sw 1 -biud ourselvesivour hairs,-e�tors,�adminis :
successors,and assigns to the County of Ccntra-Costa;, Califcn-Aia to pay it
A. ra orizance and Gisitsutee:- .Five-.Million F2ur 11
andred F *
]3 5,455,800'.ocw )tor`itself cu any cdty Essig c u r above qty
Subdivision Agr6ewwn;Ph *Eight Hundred and no/100
F. Paywente Two Million Seven Hundred Fifty Five Thousand Five Hundred and no/100
DOIJUS(S 2,755,500.00 )to socvrc the t:lai= to wbich refarence is made is
Titic XV(comencing with Section 3082)of Part 4 of Division M of the:Civil Code of the Stare
of California.
3.
A. The Condition of this obligation as to Section 2.(A) above is such that if the above bounded
Principal,his or its hairs,executors,adnainistratars,moe:easons or assiM shall in all things stand
to and abide:by,and well and truly keep and pcform the coveny moons and provisions in the
said sgraemart and any alteration:dwaofmade as the:rcia provided,on is or ins part,to be kept and
performed at the time and in the mannor therein specified,and in all respects according to their"mmue
intent and musing, and shall indcmnify and save:}armless the County of Contra Cassa (or city
assi ),its officers.agemss and anploya s„as therein stipulated„thea flus obligationshall becotner
.nuU arA void;o9ww1se it sball be and remain is AM thrce and e.M=.
As part of the obligation secured hereby and in addition too the face amount speoWead therefom there
shall be uacluded casts and reaumablo expenses and fleas, including reasonable attiAneys fms,
incurred by County(or city assignae) in sucomfully enforcing such obligation, all to be taxed as
costs and included in any judgement r
B. The condition of this obligation as to Section. 2•(l1) above is such that said Principal and the
undersigned as corporate swety are held firmly bound unto the County of Contra Costa and all
contractors,subcouftutors,laborer,material meal and odrer persons employed in the pagmumce
of the aforesaid agreement and re f ured to in the aforesaid Civil Cade fir materials fmdslaetl or labor
thereon of any kind,or for amounts do under the tlnemploymertt Irixwm=Act with respect to such
work or labor, that said surety will pay the same in an amount not exceeding the amount herein
above set forth, and also in case suit is brought upon this bond„ will pay, in addition to the fact
amount the=t casts and reasonable expimses and lees, including reasonable attornsy's fees,
incurred by County(or city assignee)in=cessfully enforcing such obligation,to be awarded=4
feed by the court,and to be tweed as coats and to be incltuW in the judgemmA therein rendered.
It is hereby ezx rressiy stipulated and a that ibis bond shall inure to the benefit of any anis all
persons.companies;maid corlfaryatiiyns entitled to file claims=der Title 15 with section
3082)ofPact 4 of Division 3 of the Civil Code,so as to give a right of action to'tb=Ordu r assips
is any suit brought upon this bomd•
Should the condition ofthis bond be folly pertbrmt d them dais obligation shall bw4ime acrll and void,
otherwise it shalt be and resin in full faire,and dfec
C. No alteration of said subdivisi=agreement or any plan or specification of said work agreed to by
doe Principal smd the County shall relieve any Surety ftm liability on this bond; and consent is
heresy given to UWU suuch alteration without ff uthcr notice to or ccroby 15turW,and the Surety
h#Xcby Waivcs the prirvisinas of Ca Mcnia Civil Code Saxhorn 2819, and bolds itselfbound wi u-1
regard to and itWepcodently of any action against prin+dipal whenever talren.
VA
99M AM919 ort December 2001
WIN3EMERE BLC LAND COMPANY, LLC
By: Lennar Homes of California, Inc.
pMCIPAx.: its manager SUZY: THE AMERICAN INSURANCE COMPANY
Address: 3130 Crow Canyon Place, #310 A 5 Peters Canyon
City' San Ramon,/6 94583 Irvi ri4, CA, CA 92606
,..�.�, i� '-
PriatN Lawrence H. Th son Prim Nan": Patricia Brebner �
71c1U: Vice President Title. Attorney-in-Fact
asr
CALIFORNIA ALL-PURPOSE ACKNOWLEDGEMENT
State of California
County of Orange
On December 19, 2001 before me, S. McDonald, Notary Public, personally
appeared Lawrence H. Thompson, personally known to me to be the person whose
name is subscribed to the within instrument and acknowledged to me that
he executed the same in his authorized capacity, and that by his signature
on the instrument the person or the entity upon behalf of which the person
acted, executed the instrument.
Witness my hand and official seal. MC LONALc
` r Commiswsion#/2609831 .
Orange county
MY COMM.ExOres Apr I&X04
OPTIONAL.
Though the data below is not required by law, it may prove valuable to persons relying on the document
and could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNER SIGNER IS REPRESENTING:
Corporate Officer—Vice President Lennar Homes of California. Inc.
DESCRIPTON OF ATTACHED DOCUMENT
Type of Document: Bond No. 111 2750 7082
Number of Pages: Two (2,)
Date of Document: December 19, 2001
Signers (other than those named above): Patricia Brebner
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT No.5907
State of Califomia
County of Orange
On December 18, 2001 before me, Alexis H.Bryan,Notary Public
r
DATE NAME,TITLE OF OFFICER-E.G.,"JANE DOSE,NOTARY PUBLIC"
personally appeared Patricia Brebner
NAME(S)OF SIGNER(S)
® personally known to me-OR- ❑ proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon
behalf of which the person(s) acted, executed the instrument.
ALEXIS H.BRYAN WITNESS my hand and official seal.
t Commission#1306738
z
y* Notary Public-California 3AL6
Orange County C
SIGNATURE OF NOTAR
My Comm.Expires Jun 1,2005
t
OPTIONAL
Though the data below is not required by law, it may prove valuable to persons relying on the document and
could prevent fraudulent reattachment of this form.
CAPACITY CLAIMED BY SIGNER DESCRIPTION OF ATTACHED DOCUMENT
INDIVIDUAL
�] CORPORATE OFFICER
TITLE OR TYPE OF DOCUMENT
TITLE(S)
❑
PARTNER(S) LIMITED
GENERAL
ATTORNEY-IN-FACT
TRUSTEE(S)
❑ GUARDIAN/CONSERVATOR NUMBER OF PAGES
❑' OTHER:
SIGNER IS REPRESENTING. DATE OF DOCUMENT
NAME OF PERSON(S)OR ENTITY(IES)
SIGNER(S)OTHER THAN NAMED ABOVE
S-4087/GEEF 2198 0 1993 NATIONAL NOTARY ASSOCIATION.8236 Remmet Ave.,P.O.Box 7184-Canoga Park,CA 91302-7184
FIREMAN'S FUND INSURANCE COMPANY
NATIONAL SURETY CORPORATION ASSOCIATED INDEMNITY CORPORATION
WE AMERICAN INSURANCE COMPANY AMERICAN AZTI'OMOBZB INSURANCE COMPANY
GENERAL POWER OF ATTORNEY
KNOW ALL UMN BY T1WSE PRESENTS: That FIREMAN'S FUND INSURANCE COMPANY, a California corporation, NATIONAL
SURETY CORPORATION,an Illinois corporation,TETE AMERICAN INSURANCE COMPANY,a New Jersey corporation redornesticated In
Nebraska, ASSOCIATED INDEMNITY CORPORATION, a California corporation, and AMERICAN AUTOMOBILE INSURANCE
COMPANY,a I++fissouri corporation,(herein collectively called"the Companies")does each hereby appoint Patricia Brebner
6f Costa Mesar CA
their true and lawful Attorneys)-in-Fact, with full power of authority hereby conferred in their name, place and stead, to execute, seal,
acknowledge and deliver any and all bonds,undertakings,recognizances or other written obligations in the nature thereof------------
and to bind the Companies thereby as fully and to the same extent as if such bonds were signed by the President,sealed with the corporate seals of the
Companies and duly attested by the Companies'Secretary,hereby ratifying and confirming all that the said Attorney(s)-in-Fact.may do in the premises.
This power of attorney is granted under and by the authority of Article VII of the By-laws of each of the Companies which provisions are now
in full force and effect.
This power of attorney is signed and Staled under the authority of the following Resolutio adopted by the Bond of Directors of each of the
Companies at a meeting duly called and held,or by written consent,on the 19th day of 1995,and said Resolution has not been amended
or repealed=
"RF OLVED,that the signature of any Vice-President,Assistant Secretary,and Resident Assistant Secretary of the Companies,
and ties seal of the Companies may be affixed or printed on any power of attarncy,on any revocation of any power of attorney,
or on any certificate relating thereto,by facsimile,and any power of attorney,any revocation of any pourer of attorney,or
certificate bearing such facsimile signature or facsimile seal shall be valid and binding upon the Companies."
IN WITNESS,WHEREOI;-tbe Compainies have caused these presents to be sired by their Vic�Piuident,and their corporate seals to be hereunto.,
affixed this 30 day of January 290
s�SI'tLY,YtC �. i,y `*�*,.»•,,•<*<"'y rr,w,"r •*t'�,cwrx `Spy'
FRID4U"TOMS FUND
EINSURANCE COMANY
NATIONAL SURETY CORPORATION
THE AMERICAN
� 7Ut,N4E ryJ LNy
ASS INDEMNITYCORPy�ION
CE COMANY
'y��+ � **Ian*,•
STATE OF CALIFORNIA
COUNTY OF MARIN v�cc.t�restdeat
On this3 0 day of January 2 0 01,before me personally came, Donn R. Kolbeck
to me known,who,being by me duly sworn,did depose and say:that he is a Vice-President of each company,described in and which executed
the above instrument;that he brows the seals of the said Companies:that the seals affixed to the said instrument are such company seals;that
they were so affixed by order of the Board of Directors of said companies and that he signed his name thereto by like order.
IN WITMS VMERREOF,I have hereunto set my hand and affixed ray official seal,the day and year herein first above written.
,.
KRISTIN A.GAZZO.l D
COMM.01252236
• NC37 LWTNC iF�JItNtN
My M"M Apt 20,20M *1
STATE OF CALIFORNIASS, CRRTI:1rICATE .0or Nt3dj
COUNTY OF N UUN
I, tate undersigned, Resident Assistant Secretary of each company, DO HEREBY CERTIFY that the foregoing and attached POWER OF
ATTORNEY remains in full force and has not been revoked;and furthermore that Article VII of the By-laws of each company,and the Resolution
of the Board of Directors;set forth in the Power of Attorney,are now in force.
Signed and sealed at the County of Marin. Bated the 18th day of December 2001
CW
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SUBDIVISION AGREEMENT
(Right of Way Landscapirl ) '-J
(Government Code§66462 and66463)
Subdivision: RA 1102 (cross-reference SUB 7976 Effective Date: SSC (!t t
Subdivider: W indemere BLC Completion Period: 1 year
THESE SIGNATURES ATTEST TO THE PARTIES'AGREEMENT HERETO: SUBDIVIDER:(Name and Title)
WINDEMERE BLC LAND COMPANY LLC,
CONTRA COSTA COUNTY A California limited liability company
By:LEN-OBS Windemere,LLC,
Maurice Ms ShiuI Public Works-Dire _.
A Delaware limited liability company
_._ _. Managing Member
: i' is,Inc.,
B Ii
is ra on
.� .. an
By. Vu tslgn.a+rel
(prbtt name a
RECOMMENDED FOR APPROVAL: chard Peterson Vice President
I2)t� Lh
By: f tas�+• ai
Engineering Sery s ivi n
Don Larson Chief Financial Officer
FORM APPROVED: Victor J.Westman,County Counsel
(NOTE:AN signatures to be acknowledged. if Subdivider is incorporated,
signatures nnrst confomm with the designated representative groups
pursuant to Corporations Code§313.)
1. PARTI E Effective on the above date,the City of County of Contra Costa,California,hereinafter called" "and the
above-ment&rned Subdbdde ,mutually promise and agree as follows concerning this subdivision:
2. C ;(y�� Subdivider agrees th install c;ert�lin road improvement both public and private),drainage Improvements,
signs. streetg , rydrants, landscaping, and such other improvements {including appurtenant equipment) as required in the
I
mprovement plans for this sutxilviskrn as reviewed and on file with the Contra Costa County public Works Department and In conformance
with the Coma Costa County Ordinance Code{Including future amendments thereto).
Subdivider shall comFplett said work and Improvements{hereinafter called"work"}within the above completion period from date
hereof as required by the Califomis Subdivision Map act(Government Code§§66410 and following),In a good workmanlike manner,In
accordance with accepted construction practices and in a manner equal or superior to the requirements of the County Ordinance Code and
nAnnggs made thereunder, and where there is a conflict between the Improvement plans and the County Ordinance Code,the stricter
requirements shall govern.
3. IMPROVEMENT SECURITY. Upon e)wuWV this Agreement,the Subdivider shall,pursuant to Government Code§66499,and
the County Ordinance lode,provide as security to the County:
A. EIX eerformangg;in : $ cash, plus additional security, In the amount of$ which
together total one hundred percent(100%)of the estimated cost of the work. Such additional security Is presented n t e rm cf:
Cash,certified check or cashiers check.
_X Acceptable corporate surety bond.
Acceptable Irrevocable letter of credit.
With this security,the Subdivider guarantees performance under this Agreement and maintenance of the work for one year after its
completion and acceptance against any defective workmanship or materials or any unsatisfactory performance.
B. For Pavment Security in the amount of$2.765.500.00.which is fifty percent(50%)of the estimated cost of the work.
Such security Is presented in the form or
Cash,certified check,or cashier's check
�X Acceptable corporate surety bond.
Acceptable Irrevocable letter of credit.
With#his securlfiy,the Subdivider guarantees payment to the contractor,to his subcontractors,and to persons renting equipment or
furnishing labor or materials to therm or to the Subdivider.
C. Upon acceptance of the work as complete by the Board of Supervisors and upon request of the Subdivider,the amount
securities may be reduced in accordance with§94-4.406 and§94-4.408 of the Ordinance Code.
4 Subdivider guarantees that said work shall be free from defects In material or
workmanship ands all perform satisfactorily for a perlodot one-year from and after the Board of Supervisors acceptsithe work as complete
in accordance with Article 984.8,"Acceptance",of the Ordinance Code. Subdivider agrees to correct,repair,or replace,at his expense,
any defects kr said work.
The guarantee period does not apply to road Improvements for private roads which are not to be accepted into the County road
system.
5, PLANT ESTABLIS4MENT WORK. Subdivider agrees to perform establishment work for landscaping Installed under this
agreement Saidplant establishment work shall consist of adequately watering plants,replacing unsuitable plants,doing weed,rodent and
other pest control and other work determined by the Public Works Department to be necessary to Insure establishment of plants.Said plant
establishment work shall be performed for a period of one-year from and after the Board of Supervisors accepts the worts as complete. At
the discretion of the County,bids may be released after final acceptance of landscaping improvements by the County.
8. IMPBOVEMBN7l3B@!�lIY Subdivider warrants the improvement plans for the work are adequate to accomplish the
work as promised n on 2 a as required by the Conditions of Approval for the Subdivision. if, at any time before the Board of
Supervisors accepts the work as complete or during the one-year guarantee period,said Improvement plans prove to be Inadequate In any
respect,Subdivider shall make whatever changes are necessary to accomplish the work as promised
7. NO WAIVES BY_ OSJNIY. Inspection of the work and/or materials,or approval of work and/or materials or statement by any
officer, agent or em oyes o e unty Indicating the work or any part thereof complies with the requirements of this Agreement,or
acceptance of the whole or any part of said work and/or materials,or payments,therefor,or any combination or all of these acts,shall not
relieve the Subdivider of his obligation to fulfill this agreement as prescribed;nor shall the County be thereby be stopped from bringing any
action for damages arising from the failure to comply with any of the terms and conditions hereof.
8. IN12EMNlTY; Subdivider,shall hold harmless and indemnify the indemnitees from the liabilities as defined In this section:
A. The benefitted and protected by this promise are the County,and Its special district,elective and appointive
boards,commissions,o cors,agents,and employees.
B. The protected against are any liability or claim for damage of any kind allegedly suffered,Incurred or threatened
because of actions de n w and Including personal injury,death,property damage,inverse condemnation,or any combination of
these,and regardless of whether or not such liability,claim or damage was unforeseeable at any time before the County reviewed said
Improvement plans or accepted the work as complete,and including the defense of any sult(s),action(s),or other proceeding(s)concerning
said liabilities and claims.
C. The actiong,plualps liablliiv are any act or omission(negligent or non-negligent)in connection with the matters covered by
this Agreement and attributable to the Subdivider,contractor,subcontractor,or any officer,agent,or employee of one or more of them;
D. n:. The promise and agreement In this section are not conditioned or dependent on whether or not any
Indemnitee has prepared,supp ed,ora proved any plan(s)or specification(s)in connection with this work or subdivision,or has insurance
or other Indemnification covering any of these matters,or that the alleged damage resulted partly form any negligent or willful misconduct of
any Indemnity.
9. ; Subdivider shall pay when due,all the costs of the work,Including Inspections thereof and relocating existing utilities
required
10. . Subdivider shall set and establish survey monuments in accordance with the filed map and to the sa n of the
County Ro " mmissioner-Surveyor before acceptance of any work as complete by the Board of Supervisors,
11. ; If Subdivider falls to complete the work within the time specified In this Agreement,and
subsequent:extensions, or s to maintain e work, the County may proto complete and/or maintain the work contract or
otherwise,and Subdivider agrees to pay all costs and charges incurred by the County(including,but not limited to: engineering,Inspection,
surveys,contract,overhead,etc.)Immediately upon demand.
Subdivider hereby consents to entry on the subdivision property by the County and its forces,Including contractors,In the event the
County proceeds to complete and/or maintain the work.
Once action Is taken by County to complete or maintain the work,Subdivider agrees to pay all costs Incurred by the County,even If
Subdivider subsequently completes the work.
Should County sue to compel performance under this Agreement or to recover costs Incurred in completing or maintaining the
work,Subdivider agrees to pay all attorney's fees,and all other expenses of litigation Incurred by County in connection therewith,even If
Subdivider subsequently proceeds to complete the work.
12. IN�ORPOI ATIS2NIA if,before the Board of Supervisors accepts the work as complete,the subdivisk�r Is Included in
tenitoey incorporated as city or Is anne, an existing city,the County's rights under this agreement and/or any deposit,bond,or letter
of credit securing said rights shall be transferred to the new or annexing city. Such city shall have all the rights of a third party beneficiary
against Subdivider,who shall fulfill all the terms of this agreement as though Subdivider had contracted with the city originally.
13. RgCO2MMAP. In consideration hereof,County shall allow Subdivider to file and record the Final Map or Parcel Map for said
Subdivisiom
wrw
1102 AG 7oA dw
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of t t`n i
County of
On __ � PYI @l r'1 xz 1 before me,
Dat Name and Title of Officer(e.g.,"Jane Doe,Notary Public")
personally appeared
Name(a)of Signer(a) '
+personally known to me–OR–❑proved to me on the basis of satisfactory evidence to be the person(s)
whose name(s)49/are subscribed to the within instrument
and acknowledged to me that /they executed the
same in his/hw/their authorized capacity(ies),and that by
"B` A. I Whw/their signature(s)on the instrument theperson(s),
DEBRA A.SHERWt70D
U COMM.#1313582 or the entity upon behalf of which the person(s) acted,
NOTARY PUBLIC-CAUFORNIA
CONTRA COSTA COUNTY 0 executed the instrument.
COMM.EXP.JULY 16,2005''
WITNESS hand and official seal.
V
Signature of Notary Public
OPTIONAL
Though the information below is not required by law,it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date: Number of Pages:
Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑ Individual ❑ Individual
❑ Corporate Officer ❑ Corporate Officer
Title(s): Title(s):
❑ Partner—❑ Limited ❑ General ❑ Partner--❑ Limited ❑ General
❑ Attomey-in-Fact ❑ Attorney-in-Fact
• Trustee ❑ Trustee
❑ Guardian or Conservator ti ❑ Guardian or Conservator
❑ Other: Top of thumb here ❑ Other: Top of thumb here
Signer is Representing: Signer is Representing:
1995 National Notary Asaoclation•8238 Remmet Ave.,P.O.t3ax 7194•Canoga Park,CA 91309-7184 Prod.No.5947 ReoMer.Cell Toll Free 1-800-87827