Form SF 28 SF 28 Affidavit of Individual Surety

AFFIDAVIT OF INDIVIDUAL SURETY
(See instructions on reverse)

OMB Control Number: 9000-0001
Expiration Date: 2/28/2021

Public reporting burden for this collection of information is estimated to average 0.3 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the Regulatory Secretariat (M1V1CB), Office of Acquisition Policy, GSA, Washington, DC 20405.
STATE OF

COUNTY OF

I, the undersigned, being duly sworn, depose and say that I am: (1) the surety to the attached bond(s); (2) a citizen of the United States; and of full age and legally
competent. Where the sureties are acting as co-sureties, we, the Sureties, bind ourselves in such sum "jointly and severally" as well as "severally" only for the
purpose of allowing a joint action or actions against any or all of us. For all other purposes, each Surety binds itself, jointly and severally with the Principal. I
recognize that statements contained herein concern a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious or fraudulent
statement may render the maker subject to prosecution under Title 18, United States Code Sections 1001 and 494. This affidavit is made to induce the United States
of America to accept me as surety on the attached bond.
1. NAME (First, Middle, Last) (Type or Print)

2. HOME ADDRESS (Number, Street, City, State, ZIP Code, email address) AND
TELEPHONE NO.

3. TYPE AND DURATION OF OCCUPATION

4. NAME AND ADDRESS OF EMPLOYER (Number, Street, City, State, ZIP Code, Email
address)(If Self-employed, so State)

5A. NAME AND ADDRESS OF INDIVIDUAL SURETY BROKER USED
(Number, Street, City, State, ZIP Code, email address)

5B. TELEPHONE NUMBER AND EMAIL ADDRESS

6A. NAME AND ADDRESS OF FINANCIAL INSTITUTION SUBMITTING THE PLEDGE
OF SECURITIES ON BEHALF OF INDIVIDUAL SURETY (Number, Street, City, State,
ZIP Code, email address) AND ROUTING TRANSIT NUMBER (RTN)

HOME –
BUSINESS 6B. CONTACT PERSON NAME, TELEPHONE NUMBER, AND EMAIL

7. THE FOLLOWING IS A TRUE REPRESENTATION OF THE ASSETS I HAVE PLEDGED TO THE UNITED STATES IN SUPPORT OF THE ATTACHED BOND. (LIST THE
COMMITTEE ON UNIFORM SECURITIES IDENTIFICATION PROCEDURES (CUSIP) NUMBER AND PAR (FACE) AMOUNT OF EACH SECURITY):

8. IDENTIFY ALL LIENS, JUDGEMENTS, OR ANY OTHER ENCUMBRANCES INVOLVING SUBJECT ASSETS

9. IDENTIFY ALL BONDS, INCLUDING BID GUARANTEES, FOR WHICH THE SUBJECT ASSETS HAVE BEEN PLEDGED WITHIN THREE YEARS PRIOR TO THE
DATE OF EXECUTION OF THIS AFFIDAVIT.

DOCUMENTATION OF THE PLEDGED ASSET MUST BE ATTACHED.
10. SIGNATURE

11. BOND AND CONTRACT TO WHICH THIS AFFIDAVIT RELATES (Where Appropriate)

12. SUBSCRIBED AND SWORN TO BEFORE ME AS FOLLOWS:
b. CITY AND STATE (Or other jurisdiction)
a. DATE OATH ADMINISTERED
MONTH

DAY

YEAR

c. NAME AND TITLE OF OFFICIAL ADMINISTERING OATH
(Type or print)

AUTHORIZED FOR LOCAL REPRODUCTION
Previous edition is not usable

d. SIGNATURE

e. MY COMMISSION
EXPIRES

Official
Seal

STANDARD FORM 28(REV. 9/2018)
Prescribed by GSA-FAR (48 CFR) 53.228(e)

INSTRUCTIONS

1. Individual sureties on bonds executed in connection with Government contracts must complete and submit
this form with the bond. (See 48 CFR 28.203, 53.228(e).) The surety must have the completed form notarized.
2. No corporation, partnership, or other unincorporated association or firm, as such, is acceptable as an
individual surety (i.e., must be a natural person). Likewise, members of a partnership are not acceptable as
sureties on bonds that a partnership or an association, or any co-partner or member thereof, is the principal
obligor. An individual surety will not include any financial interest in assets connected with the principal on
the bond that this affidavit supports.
3. United States citizenship is a requirement for individual sureties for contracts and bonds when the contract is
awarded in the United States. However, when the Contracting Officer is located in an outlying area or a foreign
country, the individual surety is only required to be a permanent resident of the area or country in which the
contracting officer is located.
4. All signatures of the affidavit submitted must be originals. Affidavits bearing reproduced signatures are not
acceptable. An authorized person must sign the bond. Any person signing in a representative capacity (e.g.,
an attorney-in-fact) must furnish evidence of authority if that representative is not a member of a firm,
partnership, or joint venture, or an officer of the corporation involved.

STANDARD FORM 28 (REV. 9/2018) BACK