Agenda 07/07/2015 Item #16B17/7/2015 16.6.1.
EXECUTIVE SUMMARY
Recommendation for the Community Redevelopment Agency (CRA) to approve a Commercial
Building Improvement Grant Agreement between the CRA and Antone C. Mendes in the amount
of $13,496 for property located at 2260 Tamiami Trail East and within the Bayshore Gateway
Triangle area.
OBJECTIVE: To approve and execute a Commercial Building Improvement Grant Agreement between
the Community Redevelopment Agency (CRA) and a Grant Applicant within the Bayshore Gateway
Triangle Community Redevelopment area.
CONSIDERATIONS: The purpose of the grant program is to provide an incentive to revitalize the area
by providing matching grant funds to encourage the private sector to upgrade /rehabilitate commercial
properties. The CRA provides a project cost -match of 50% from Tax Increment Funds. Remaining project
dollars are provided by the applicant. The CRA FY -2015 TIF Grant budget is funded at $25,000.00.
The Commercial Building Improvement Grant application (Exhibit A) submitted by Antone C. Mendes,
owner of the commercial property at 2260 Tamiami Trail East, Naples, Florida, 34112, is requesting 50%
reimbursement. The reimbursement is for improvements to the parking lot. There is no interior
reimbursement request. The application was recommended for approval with a 5 -0 vote, passing
unanimously by the Bayshore /Gateway Triangle CRA Local Advisory Board on June 2, 2015.
LEGAL CONSIDERATIONS: This item has been approved for form and legality and requires a
majority vote for approval. -JAB
FISCAL IMPACT: Sufficient budget exists within Fund (187) FY15 budget to satisfy this
application. This project totals $26,992.00 and the request is for up to $13,496.00 for exterior
improvement projects (with a 50% grantee match). A total of $25,000.00 is budgeted for all grant
programs.
GROWTH MANAGEMENT IMPACT: None.
RECOMMENDATION: That the CRA Board approves and authorizes the Chairman to execute the
Commercial Building Improvement Grant Agreement
and Antone C. Mendes, for the commercial property
$13,496.00.
Prepared by: Ekna Hue, Operations Coordinator
Agency
Attachments
between the Community Redevelopment Agency
at 2260 Tamiami Trail East in the amount of
Bayshore Gateway Triangle Community Redevelopment Agency
Agreement, Exhibit A (Application)
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7/7/2015 16.B.1.
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.16.13.16.13.1.
Item Summary: Recommendation for the Community Redevelopment Agency (CRA) to
approve a Commercial Building Improvement Grant Agreement between the CRA and Antone
C. Mendes for property located at 2260 Tamiami Trail East and within the Bayshore Gateway
Triangle area.
Meeting Date: 7/7/2015
Prepared By
Name: HueEkna
Title: Operations Coordinator, County Redevelopment Agency
6/5/2015 11:35:46 AM
Submitted by
Title: Operations Coordinator, County Redevelopment Agency
Name: HueEkna
6/5/2015 11:35:47 AM
Approved By
Name: JourdanJean
Title: CRA Operations Manager, County Redevelopment Agency
Date: 6/11/2015 10:54:53 AM
Name: DurhamTim
Title: Executive Manager of Corp Business Ops,
Date: 6/24/2015 7:57:45 AM
Name: BelpedioJennifer
Title: Assistant County Attorney, CAO General Services
Date: 6/24/2015 8:38:46 AM
Name: KlatzkowJeff
Title: County Attorney,
Date: 6/24/2015 8:49:51 AM
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Name: FinnEd
Title: Management/Budget Analyst, Senior, Office of Management & Budget
Date: 6/25/2015 1:42:34 PM
Name: CasalanguidaNick
Title: Deputy County Manager, County Managers Office
Date: 6/25/2015 2:19:07 PM
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7/7/2015 16. B.1.
GRANT AGREEMENT BETWEEN CRA AND GRANTEE FOR
COMMERCIAL BUILDING IMPROVEMENTS FOR BAYSHORE
GATEWAY TRIANGLE COMMUNITY REDEVELOPMENT AREA
THIS AGREEMENT is entered into this day of 2015 by and
between the Collier County Community Redevelopment Agency (hereinafter referred to as
"CRA ") and Antone C. Mendes (hereinafter referred to as "Grantee ").
RECITALS:
WHEREAS, Collier County Ordinance No. 2002 -38, as amended, authorizes the CRA to
award and administer CRA grants such as the Commercial Building Improvement program; and
WHEREAS, Grantee has applied for a Commercial Building Improvement Grant in the
amount of $13,496.00 dollars; and
WHEREAS, the CRA has determined that Grantee meets the eligibility requirements and
approved a grant award in the amount of $13,496.00 dollars ( "CRA Approval ").
NOW, THEREFORE, in consideration of the mutual covenants contained herein and
other valuable consideration, the parties agree as follows:
,. 1. Grantee acknowledges that Grantee has received a copy of the Collier County
Community Redevelopment Agency Commercial Building Improvement Grant Program
Information and Application (hereinafter referred to as "Grant Program "), that Grantee has read
the Grant Program, and that Grantee has had ample opportunity to discuss the Grant Program
with Grantee's counsel or advisor. Grantee further acknowledges that Grantee understands and
agrees to abide by all of the terms and conditions of the Grant Program.
2. Grantee is the record owner of property described as 2260 Tamiami Trail East,
Naples, Florida, 34112.
3. Grantee has agreed to make certain improvements to the property pursuant to the
grant application submitted to the CRA attached hereto as Exhibit A and incorporated herein by
reference.
4. Grantee agrees to complete the construction of the commercial building
improvements by September 1, 2015. Grantee also agrees to fund at least 50% of the costs of the
commercial building improvements. Grantee is prohibited from paying contractors and/or
vendors with cash. All payments for approved projects must be in the form of a check or credit
card drawing on funds from Grantee's accounts. All receipts and invoices must reconcile against
payments.
5. The CRA has approved a grant to Grantee in the amount of $13,496.00 to be
administered pursuant to the terms of this Agreement based on an estimated cost of $26,992.00.
Commercial Building Improvement Grant Agreement FY 2014
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7/7/2015 16.B.1.
If the actual costs are less than $26,992.00 to construct the improvements, the grant amount shall
be reduced dollar for dollar in CRA funds using a 50150 ratio of matching private funds required.
6. Unless prior disclosure is included in the grant application, no Grantee, or any
immediate relative of Grantee, shall serve as a contractor or subcontractor for the construction of
the improvements and no Grantee, or any immediate relative of Grantee, shall receive
compensation for labor for the construction of the improvements. An immediate relative of
Grantee shall include mother, father, brother, sister, son, daughter, aunt, uncle and cousin or
family member by marriage to include mother -in -law, father -in -law, brother -in -law and sister -in-
law. Grantee has verified that all contractors who have provided bids for the approved work are
actively licensed by Collier County or the State of Florida. Grantee acknowledges that the total
grant award shall not exceed the sum of lowest bids /price quotes for all projects. Grant funds for
work performed by contractors shall only be disbursed upon verification that said contractors are
actively licensed by Collier County or the State of Florida.
7. Grantee agrees to obtain all necessary permits and submit any required plans to
the County's Growth Management Division. Upon completion of the work, Grantee shall
submit to the CRA staff a Project Summary Report, two 8 inch by 10 inch photos showing the
improvements, a list of materials and construction techniques used, a list of architects and/or
contractors, and any other information specific to the project or requested by the CRA staff.
The CRA, through its staff, shall confirm that the Commercial Building Improvements were
constructed pursuant to the terms of the application approved by the CRA.
8. Within forty -five (45) days after confirmation that the improvements were
constructed pursuant to the terms of the approved application, the Grantee shall be issued a check
in the amount of the grant. However, if the Grantee fails to make the improvements pursuant to
the terms of the approved application, or if the improvements are not completed by September 1,
2015, the grant shall be deemed revoked and Grantee shall not be entitled to funding.
9. This Agreement shall be governed and construed pursuant to the laws of the State
of Florida.
10. This Agreement contains the entire agreement of the parties and their
representatives and agents, and incorporates all prior understandings, whether oral or written.
No change, modification or amendment, or any representation, promise or condition, or any
waiver, to this Agreement shall be binding unless in writing and signed by a duly authorized
officer of the party to be charged.
11. This Agreement is personal to Grantee, and may not be assigned or transferred by
Grantee or to Grantee's respective heirs, personal representatives, successors or assigns without
the prior written consent of the CPA.
12. Should the property be transferred, sold, or the Grantee otherwise divested of its
interest, or fail to maintain the improvements during the five -year period following receipt of
grant funds, the CRA must be reimbursed the grant funds.
Commercial Building Improvement Grant Agreement FY 2014
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e
7/7/2015 16.8.1.
13. This Agreement shall be recorded in the Public Records of Collier County, Florida.
IN WITNESS WHEREOF, the parties have executed this Agreement on the date and year
first written above.
(1)
Witness Signature
Printed/Typed Name
(2)
Witness Signature
Printed /Typed Name
ATTEST:
DWIGHT E. BROCK, Clerk
, Deputy Clerk
Approved as to form and
legality:
�
IX N
Jennifer A. Belpedio �7 \
Assistant County Attorney c�
GRANTEE:
C
Antone C. Mendes
COLLIER COUNTY COMMUNITY
REDEVELOPMENT AGENCY
By:
Donna Fiala, Chairman
Commercial Building Improvement Grant Agreement FY 2014
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EXHIBIT
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Applicant Information
Grantee Name
Grantee Address
256 T�vnjrrt✓tiTr.�
Site Address
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G�' t�wll�,dr�;Tr. E
tv les, Fl i l
N4�) es, FL- 3w/1
Daytime Phone
2,3q-v,5- � �S
Alternate
Phone
E -Mail Address
N a /„� -r A4 a �L , c GM
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Do you own or lease the property?
Occupational License No.
0WV%
if applicabi e
Project Information
Describe the existing conditions of the site attach additional sheets if necessa
pG,'kti7�r rt%� 1''.5 id av,� ct�lcNFi,_ �f Y.1 5Pv ed r fr <<YS
or- ►?Gff11FS vvet- 1E` yclrl APE'j tic+ J r4tn Gvrll
amd rcu (d %F c1c���e -r s -fir Fccplc. 4k "lk otA,
kalWc -\ of cvS.
Outline the proposed improvements in detail attach additional sheets if necessary).
Ta kr y CXO,' i5 at - cu. aild re clo evih- e4cr --
PaVeK5 Or 11C;qlv a fIla /`f . P(r y4r i f -, avd Pt I'-,-
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REQUIRED ATTi%Cllkll,"NTS FROM Al'I'LICANT:
dotabase lit
CRASTAFF:
Estimated cost of improvements: $
1) Attach two color photos of each project to be
performed.
Maziumm rant award:
d
grant _ • $
2) Attach Property Appraiser ID.
3) Attach proof ofp8yment of property taxes.
Signature: Date:
t
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7/7/2015 16.B.17
Applicant Commitment of Resources
I / we, G 1%' / /&i//t S , owner(s) / tenant(s) of the
commercial property located at Z-56 IC- IMiLnj 7)'. , have the funding and all
other capability necessary to begin the site improvements listed above and have the ability to
complete all improvements within one year of the approval of the improvement grant by the Collier
County Community Redevelopment Agency. I / we further affirm that payment for all work on
approved improvements will come from accounts in my / our name(s) or the name(s) of entities
registered in the State of Florida which I / we have incorporated or otherwise registered with the
state (verification is required). Payment for improvements by from persons or entities not a party to
this Grant Application is grounds for disqualification.
Signature of Tenant (if leased)
Signature of Tenant (if leased)
(if Jointly leased)
Owner
Signature of Owner
(if Jointly owned)
3
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Date
Date
Da e
Date
5701 E. Hillsbrough Ave. Suite 1122
Tampa, Florida 33610
Contact: Roberto Perera
Phone: (941) 894 -7760
Fax: (239) 267 -1336
Quote T • Antone Mendes- Property Management
2256 Tamiami Trail East
Naples, FL 34112
Phone: (239) 825 -2295
ATTN: Antone Mendes
Job Name: 2256 Tamiami Trail East Parking Lot
Date of Wow 5/28/15
Otiote #• RP15192
Revision Date:
ITEM
DESCRIPTION
QUANTITY
UNIT
UNIT PRICE
AMOUNT
PARKING LOT
10
MILL, PAVE. STRIPE, CAR STOPS -F & I
1.00
LS
29,350.00
29,350.00
GRAND TOTAL
$29,350.00
NOTES:
General Notes:
1. Unless "Lump Sum" or "LS" appears next to an item of work, it is understood and agreed that the quantities referred to
above are estimates only and that payment shall be made at the stated unit prices for actual quantities of work performed by
PREFERRED MATERIALS, INC. This proposal expires thirty (30) days from the effective date of this Proposal.
2. PREFERRED MATERIALS, INC. will mobilize the asphalt paving crew on the project one (1) time. PREFERRED
MATERIALS, INC. shall have no obligation to perform in increments, quantities, or portions of the work that PREFERRED
MATERIALS, INC. plans to perform in a single operation; nor shall PREFERRED MATERIALS, INC. have any obligation to
perform work in a different sequence than planned by PREFERRED MATERIALS, INC. Any additional asphalt paving crew
mobilizations shall require additional compensation of $1000.00 per mobilization.
3. Asphalt pricing is based on F.D.O.T. specifications for asphalt materials and includes the use of recycled asphalt products.
This quotation is predicated on PREFERRED MATERIALS, INC. receiving all F.D.O.T. Fuel and Asphalt Liquid Index
Adjustments (If Applicable).
4. Payment and performance bonds are not included (Please add 1/2 %, if required).
5. Pricing excludes any permits, fees, testing, as- builts, surveying, staking, utility location and adjustment or relocation,
asphalt patching, asphalt leveling, asphalt saw - cutting, asphalt milling, asphalt removal, temporary/permanent striping, and light
towers.
6. Pricing does not include any maintenance of traffic. Prime contractor to provide maintenance of traffic devices (i.e.
flagmen, temporary signs, barricades, arrow boards, variable message boards, off -duty law enforcement officers, WAS System"
etc.) that may be required. Maintenance of Traffic deficiencies on this project that cause delays to PREFERRED MATERIALS,
INC.'s work shall result in back charges for "stand -by" time.
7. Pricing does not include any additional work to adhere to the F.D.O.T. Index 600 drop -off criteria.
8. This quote is contingent upon PREFERRED MATERIALS, INC.'s satisfaction with credit conditions.
9. PREFERRED MATERIALS, INC, cannot be held responsible for any damage caused to any concrete surfaces while
performing our portion of the proposed work. PREFERRED MATERIALS, INC. cannot be held responsible for any cleaning of
any concrete surfaces while performing our portion of the proposed work.
10. Pricing based on performing work during daytime operational hours and in accordance with PREFERRED MATERIALS,
INC.'s normal operational schedule.
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11. Asphalt yield is estimated at 1 i0lbsisy for each inch of asphalt. Any asphalt overruns due to irregular base conditions,
improper curb height, etc. to be invoiced at an additional $ 115.00 per ton of asphalt. Any asphalt leveling can be performed at a
unit price of S 125.00 per ton of asphalt. Any asphalt patching can be performed at a unit price of S 250.00 per ton of asphalt.
12. Pricing excludes any tack cleanup on existing concrete, asphalt, etc. Prime contractor to provide any sanding if required to
Protect these areas.
13. Pricing does not include placement of "asphalt wedges" at asphalt transitions or the removal of these "asphalt wedges" prior
to asphalt paving.
TERMS AND CONDITIONS
Payment in full for all work performed during any month shall be made no later than the tenth (10th) day of the month next
Following. Final and complete payment for all work performed hereunder shall be made no later than fifteen (15) days after the
completion of such work. Interest at the highest rate allowable under the laws of the state in which the work is performed, or
one and one half percent (I % %) per month, whichever is less, shall be charged and paid on all unpaid balances from the due
date to the date we receive payment. You agree to pay in full all costs and expenses incurred by PREFERRED MATERIALS,
INC. in collecting the amounts owed by you under the Agreement, including any and all court costs and attorney's fees.
Payments received will be applied against open items on unpaid invoices in an order and sequence determined by PREFERRED
MATERIALS, INC. in its sole discretion. Any monies paid to you for our work shall be held in trust for our benefit.
We shall not become obligated to perform the work called for under this Proposal and Contract until we check and approve your
credit. This Proposal and Contract shall be null and void if your credit is not approved. If credit conditions become
unsatisfactory at any time prior to our completion of the work hereunder, you will furnish adequate security upon our request.
To the extent you fail to provide adequate security, we may stop work.
This document is the full agreement between us, regardless of any prior proposals or communications. Any deviations from the
specifications or modification of the terms of this contract and any extra or incidental work, or reductions in work, shall be set
forth in writing and signed by both parties prior to the making of such change. We will be compensated for any increase in our
costs caused by such change, on the basis of the increase plus ten percent (10°/") profit.
If a time is set for the performance of work, and if, in our judgment, such change or other circumstances beyond our reasonable
control will increase the time necessary for our performance, we will be granted a reasonable time extension.
We will provide and pay for Workers' Compensation covering our employees, as well as General Liability and Property
Damage Insurance. You agree to carry General Liability amid Property Damage Insurance sufficient to protect yourself against
any and all claims and liabilities arising from the performance of the work, including but not limited to claims arising under
your agreement to indemnify and hold us harmless under this contract.
We shall be provided with suitable access to the work area. If our work is dependent upon or must be undertaken in conjunction
with the work of others, such work shall be so performed and completed as to permit us to perform our work hereunder in a
normal uninterrupted single shift operation.
Unless a time for the performance of our work is specified, we shall undertake in the course of our normal operating schedule.
We shall not be liable for any failure to undertake or complete the work for causes beyond our control, and we may suspend the
work for causes beyond our control, including but not limited to fire, flood or other natural disaster, war, government restriction,
the inability to obtain necessary materials or transportation, or other casualty; the presence on or beneath the work site of
utilities, facilities, substances, or objects, including but not limited to any substance that in our opinion is hazardous or toxic or
the reporting, remediation, or clean -up of which is required by any law or regulation (together "subsurface conditions "); labor
disputes or other disagreement; and accidents or other mishaps, whether affecting this work or other operations in which we are
involved, indirectly or indirectly. We shall be entitled to an increase in compensation commensurate with any increased cost of
performance resulting from delays arising from causes beyond our reasonable control.
If for causes beyond our control our work is not completed within twelve (12) months after the date of your acceptance of the
Proposal, We may cancel this agreement at any time thereafter on ten (10) days' notice. In such event (i) mve shall be relieved of
any further obligation with respect to the balance ofthe work; and (ii) we shall be entitled to receive final and complete payment
for all work performed by us to the date of cancellation within fifteen (15) days thereafter.
We shall not be responsible for, and you agree to indemnify and hold us harmless from any suit, claim, liability, cost or expense
arising from or in any way related to: sidewalks, driveways, or other improvements located within our work area or designated
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areas of access, and to adjacent property and improvements: subsurface conditions; and any and all other alleged damages to
persons or property, including but not limited to personal injury and death, arising from the performance of the work, unless
such alleged damages arise from our sole negligence. You further agree to indemnify and protect us and save us harmless from
any and all loss, damage, costs, expenses and attorney's fees suffered or incurred on account of your breach of any obligations
and covenants of this contract. It is further understood that we shall not be responsible for any damage to or deterioration of any
of our work, whether completed or in process, resulting from any cause or causes beyond our reasonable control, including but
not limited to design, failure of subgrade or other subsurface conditions, or failure or inadequacy of any labor or materials not
furnished and installed by us, whether or not such failure or inadequacy was or could have been known at the time our work was
undertaken or work performed under adverse weather conditions. You agree that proper jurisdiction and venue for adjudication
concerning this contract in Collier County, Florida, and you waive any right to jurisdiction and venue in any other place.
If you agree to these terms, prices and conditions, please acknowledge acceptance by signing in the space provided on the third
page and returning the original to us, retaining a copy for your files. The person signing for PREFERRED MATERIALS, INC.
represents that Ire or she is fully authorized to eater into this Agreement.
ACCEPTED:
Contractor Name:
By:
Date:
PREFERRED MATERIALS, INC. - South Florida Region
By;
Date:
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Ajax Paving Industries of Florida, LLC.
510 0000 Green Road, NAomi FI 34276
Pl atie: 941. 486-3600
Fox, 941-486-3500
www.s%xpeltifty.com
To: Anton C. Mendes Property Mgt.
Address: 2256 Tamlami Trail E
Naples, FL 34112 USA
7/7/2015 163.1.
The f ddiv is Riding on Ajax-
Contact: Anton Mendes
Phone: (239) 825 -2295
Fax:
Project Name: 2260 Tamiami Trail East Bid Number: LSIS -153
Project Location: 2260 Tamiaml Trail East, Naples, FL Bid Date: 5/29/2015
Item # Item Description Estimated Quantity unit Unit Price Total Price
01 Mill, Grade And Pave Parking Lot 1100 LS $26,992.82 $26,992.82
Total Bid Price: $26,992,82
Notes:
' This Proposal Includes ONLY those Items and services specifically described above.
• This Proposal Is based on _1_.., Mobilizations. Additional Mobilizations will require negotiation of price.
Asphalt overruns due to pre - existing conditions, including soft base, subgrade or base tolerance will be an additional charge of $100.00 per ton.
• Prices on this quotation are based on construction prior to June 30, 2015. Any construction after this date will be subject to increased prices of
labor, materials and supplies.
Acceptance of this proposal confirms agreement with and Incorporation of the standard terms of contract of Ajax Paving Industries of Florida, LLC.
This proposal Is binding on customer when signed and transmitted to Ajax by mail, PDF, or fascimlle.
The prices on this quotation are firm for 30 days from the date of this quote.
• Mobilization /MOT 1 EA
25'X20' Excavate and install 8" of asphalt millings
Saw Cut and Remove 10' concrete slab, Remove and haul off existing car stops
MITI to Baserock and cleanup and dispose of millings as necessary
Grade as Necessary to achieve proper drainage
1,156.00 SY
Wirtgen 150 Milling Machine (5' Cutting Head) w/
Operator & 1 Ground Laborer
Import & Install Type S -III asphalt to finished
compacted thickness of 1.5"
Tack as necessary
Striping and Carstops (16 STALLS, 16 CARSTOPS)
• 300 /6 Deposit required to execute this contract
• Pricing only valid If granted full access to the entire lob site.
ACCEPTED:
The above prices, specifications and conditions are satisfactory and
are hereby accepted.
Buyer:
Signature:
Date of Acceptance:
5/29/2015 8:55:03 AM
CONFIRMED:
Ajax Paving Industries Of Florida, LLC
Authorized Signature:
Estimator: Lee Strauss
941- 238 -8833 istrauss @ajaxpaving.com
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Grantee Project Summary & Evaluation (attach additional sheets as necessary)
Project Summary
Describe the improvements made.
List all vendors / contractors providing materials or services for this project with contact information.
Vendor Service Provider
Phone Number or Address or Website
Grantee Signature Date
Grantee Signature Date
CRA Staff, Color dimf completed t frAm site visit ,nicest be attached to this
1
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B
Payment Request
On , the Collier County Community Redevelopment
Agency approved funding in the amount of $ to cover a portion of the costs listed
below through the Commercial Building Improvement Grant program:
Improvement Cost
Total
I hereby confirm that all items listed above have been completed as outlined in the Commercial Building
Improvement Grant application submitted to the CRA and authorized by the CRA. Therefore, I am
requesting the approved funding in the total amount of $ as approved by the CRA.
Grantee Signature Date
The foregoing Payment Request Form was executed before me this day of
,200_ by
owner of the property located at , who:
is personally known by me
OR
who has produced as proof of identity.
Affix notarial seal
Notary Public (Signature)
Print Name of Notary Public
Commission No:
My Commission expires:
IMPORTANT NOTgt NO REIMBURSEMENT WILL $E i'ROVIDED WITIOUI Ax TACHIIYG T1iE
FOLLOf WING {(1) VENDOR /CONTRACTgRINVOICE7 /RECEIpTA D;(2)`COPYOFsCANGELT.N;D
CIiECK OR.`GREPIT CARD VALIDATION TO GRANTEE'S ACCOUNT FOR E�ERV �
tEIMBTJRSABLE4XPENSE. x
2
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Lessor / Owner Authorization for Improvements
owner of the property located at
understand that , who has a valid
lease for the above listed property, authorize said tenant to complete the improvements listed under
Section 2 of the completed Commercial Building Improvement Grant application and to request
reimbursement funds from the Collier County Community Redevelopment Agency.
Signature of Owner
Signature of Owner
(if jointly owned)
STATE OF:
COUNTY OF:
Date
Date
The foregoing Lessor / Owner Authorization Form was executed before me this day
of , 200_ by , owner of the property located at
who:
is personally known by me
OR
who has produced as proof of identity.
Affix notarial seal
Notary Public (Signature)
Print Name of Notary Public
Commission No:
My Commission expires: _
2
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