HERALD INSURANCE BROKER, INC.
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- Ami Malone
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1 SUBDIVISION BOND REQUEST FORM DEVELOPER: SUBDIVISION NAME: DESCRIBE LOCATION: TYPE OF PRODUCT: TRACT NUMBER: NUMBER OF UNITS: SELLING PRICE OF UNITS: $ TO $ SQUARE FEET OF UNITS: TO ANTICIPATED START DATE: CONSTRUCTION LENDER: LOAN OFFICER: COMPLETION DATES(Off Sites) (Total Project). ADDRESS: PHONE: ( ) AMOUNT OF CONSTRUCTION LOAN: $ EQUITY: $ AMOUNT ALLOCATED OF OFFSITE IMPROVEMENTS: IS A SET ASIDE LETTER AVAILABLE YES NO TYPE OF DISBURSEMENT: CASHIER CHECK VOUCHER STAGE REIMBURSEMENT GENERAL CONTRACTOR IMPROVEMENTS COST NAME OF SUNCONTRACTOR BOND (IF APPLICABLE) SUBCONTRACTOR (Y) YES (N) NO EXCAV., GRADING, CLEARING $ ENGINEERING STREETS, CURBS, GUTTERS WATER SEWERS UTILITIES OTHER OBLIGEE (MUNICIPALITY REQUIRING BONDS): ADDRESS OF OBLIGEE: TYPE OF BOND PERFORMANCE LABOR & MATERIALS GRADING IMPROVEMENTS $ $ STREET IMPROVEMENTS WATER IMPROVEMENTS SEWER IMPROVEMENTS STROM DRAIN IMPROVEMENTS MONUMENT MAINT. GUARANTEE PROPERTY TAX OTHER
2 SUBDIVISION / GRADING BOND APPLICATION 1. NAME OF DEVELOPER: 2. TYPE OF ENTITY: CORPORATION PARTNERSHIP JOINT VENTURE SOLE PROPRIETORSHIP NUMBER OF YEARS IN BUSINESS: CONTRACTORS LICENCE# 3. BUSINESS ADDRESS: 4. PHONE: FAX: PRINCIPALS OF THE COMPANY POSITION OR TITLE WITH THIS FIRM: % OWNERSHIP: NAME: SOCIAL SECURITY#: RESIDENCE ADDRESS: CITY: STATE: ZIP: PHONE: BUSINESS #: SPOUSE S NAME: SPOUSE S SS# POSITION OR TITLE WITH THIS FIRM: % OWNERSHIP: NAME: SOCIAL SECURITY#: RESIDENCE ADDRESS: CITY: STATE: ZIP: PHONE: BUSINESS #: SPOUSE S NAME: SPOUSE S SS# POSITION OR TITLE WITH THIS FIRM: % OWNERSHIP: NAME: SOCIAL SECURITY#: RESIDENCE ADDRESS: CITY: STATE: ZIP: PHONE: BUSINESS #: SPOUSE S NAME: SPOUSE S SS#
3 ACCOUNTING NAME OF FIRM: PHONE: ADDRESS: WHOM TO CONTACT: YEARS WITH FIRM: WHAT IS YOUR FISCAL YEAR END IS: HOW OFTEN ARE STATEMENTS PREPARED AND ON WHAT BASIS : COMPILATION REVIEW AUDIT PERSONAL BANKING NAME OF BANK: PHONE: ADDRESS: YEARS WITH BANK: CONTACT: ACCOUNT NUMBERS: LINE OF CREDIT$: HOW MUCH AVAILIABLE: EXPIRATION DATE: (ATTACH COPIES OF PERSONAL BANK STATEMENTS TO VERIFY) BUSINESS BANKING NAME OF BANK: PHONE: ADDRESS: YEARS WITH BANK: CONTACT: ACCOUNT NUMBERS: LINE OF CREDIT$: HOW MUCH AVAILIABLE: (ATTACH COPIES OF BUSINESS BANK STATEMENTS TO VERIFY) BONDING & INSURANCE: NAME OF INSURANCE AGENCY: MAILING ADDRESS: PHONE #: YEARS WITH AGENCY: PRESENT/MOST CURRENT SURETY COMPANY: NAME OF UNDERWRITER: YEARS WITH THIS SURETY: PHONE #: LARGEST PROJECT BONDED WITH THIS COMPANY: $ WHEN / & TO WHOM:
4 EACH OF THE UNDERSIGNED AFFIRMS THAT THE FOREGOING STATEMENT AND ANSWERS ARE TRUE AND CORRECT AND ARE MADE TO INDUCE THE SURETY COMPANY TO EXECUTE OR PROCURE THE EXECUTION OF SURETY BOND OR ANY EXTENTION, MODIFIACTION, OR RENEWAL THEROF,ADDITION THERTO, OR SUBSTITUTION THEREFOR. EACH OF THE UNDERSIGNED FURTHER AFFIRMATION THAT HE /SHE UNDERSTANDS THAT SURETYSHIP IS CREDIT, AND AUTHORIZES SURETY, OR IT S AUTHORIZED AGENT, TO GATHER INFORMATION IT CONSIDERS NECESSARY FOR EVALUATING WHETHER OR NOT CREDIT SHOULD BE GRANTED. DATE: COMPANY NAME: BY: TITLE:
5 RESUME NAME: HOME ADDRESS: HOME PHONE ( ) (Street, City, State & Zip Code) PERSONAL DATA: Date of Birth: / / Social Security #: - - Drivers License #: Marital Status: Spouses Name: EDUCATION: Did you graduate high school? YES NO College: 19 to 19 Name of School: Courses studied: Special education relating to current business activity or employment: BUSINESS & PROFESSIONAL EXPERIENCE: (Indicate: Firm Name, Length of Time Employed, Occupation/Position, Reason for Leaving and, if construction related, largest project you were involved in) NO. OF YEARS WITH CURRENT EMPLOYER: NO. OF YEARS IN THIS INDUSTRY: Prior Employment: From: / To: / Company: Position: Responsibilities: From: / To: / Company: Position: Responsibilities: From: / To: / Company: Position: Responsibilities: From: / To: / Company: Position: Responsibilities: PROFESSIONAL REFERENCES: (Name, Address, Phone Number, Length of Time Aquatinted)
6 Janzer Court, Santa Clarita, CA Tel: (855) ~ FAX: (866) PERSONAL FINANCIAL STATEMENT AS OF, 20 NOTE: This form is to be used for PERSONAL FINANCIAL STATEMENTS only. NOT TO BE USED FOR BUSINESS STATEMENTS PERSONAL FINANCIAL STATEMENT OF: NAME STREET ADDRESS S.S. NO. D.O.B. CITY/STATE/ZIP NAME OF SPOUSE BUSINESS PHONE S.S. NO. HOME PHONE D.O.B. CURRENT ASSETS CURRENT LIABILITIES - Cash on hand (not in bank) Cash In following banks (names and addresses): Notes payable to (names and addresses): Sales contracts & chattel mtgs. (Sch 6) Stocks and bonds (Schedule 1) Accounts receivable (Schedule 2) Notes receivable Accounts payable Current portion of long term debt Other current liabilities (Schedule 6) Other current assets (Itemize): Current year's income taxes unpaid Prior year's income taxes unpaid TOTAL CURRENT ASSETS FIXED ASSETS Real estate (Schedule 4): Residence Other Cash value of life Insurance (Schedule 5): Other assets and Investments (Schedule 6): Real estate taxes unpaid TOTAL CURRENT LIABILITIES LONG TERM LIABILITIES Real estate debt (Schedule 4): Residence Other Borrowed on life insurance (schedule 5): Other long term debt (Schedule 6): TOTAL LONG TERM LIABILITIES TOTAL FIXED ASSETS TOTAL ASSETS CONTINGENT LlABILlTIES FOR ENDORSEMENTS OR GUARANTEES $ NET WORTH TOTAL LIABILITIES AND NET WORTH FOR OTHER PURPOSES $ GIVE DETAILS March 2002
7 SCHEDULE 1. STOCKS AND BONDS Name of security No. shares If any pledged, state to whom and for what purpose Dividends paid last two years Market value Book value SCHEDULE 2. ACCOUNTS RECEIVABLE TOTALS $ $ Name and address (street and city) from whom due For what is it due When sold When due Amount TOTALS $ SCHEDULE 3. NOTES RECEIVABLE Name and address (street and city) from whom due For what due How secured Date Maturity Amount SCHEDULE 4. REAL ESTATE TOTALS $ Description of property Title in name of Market value Cost DATE acquired Amount encumbrance Monthly payments Monthly income TOTALS $ $ $ $ $ Name of company Policy number SCHEDULE 5. LIFE INSURANCE - CASH VALUE Name of Insured Beneficiary Face value Cash value Amount borrowed SCHEDULE 6. DETAILS RELATIVE TO OTHER IMPORTANT ASSETS AND LIABILITIES Authority is hereby granted to any individual, firm or corporation, and any financial institution to furnish J.R. Olsen Bonds & Insurance Brokers, Inc. upon request with any information concerning the above statement or pertaining to the Undersigned's financial standing, credit or manner of meeting obligations. SIGNED AND SEALED THIS DAY OF 20 March 2002
8 HERALD INSURANCE BROKERS, INC. NOTE: This sample letter must be supplied to your banker. This outline must be followed and all current balances and average balances must be indicated in actual dollar amounts. Should your banker have any questions, please have him/her contact our home office at (818) DATE: HERALD INSURANCE BROKER, INC Janzer Ct. Santa Clarita, CA SAMPLE BANK LETTER BANK LETTERHEAD RE: BANK RELATIONS/MR. JOHN DOE AND ABC CONSTRUCTION COMPANY Mr. John Doe originally opened his accounts with this institution on DATE and maintains the following accounts: BUSINESS CHECKING ACCOUNT: Acct # ; CURRENT BALANCE= $10,245.00; 6 mo. avg. Balance= $18, BUSINESS CHECKING ACCOUNT: Acct # ; CURRENT BALANCE= $30,876.00; 6 mo. avg. Balance= $32, PERSONAL CHECKING ACCOUNT: Acct # ; CURRENT BALANCE= $9,624.00; 6 mo. avg. Balance= $3, PERSONAL SAVINGS ACCOUNT: Acct # ; CURRENT BALANCE= $12,900.00; 6 mo. avg. Balance= $10, Certificate of Deposit in the name of John Doe or Jane Doe: No ; Amount= $50,000.00; Term= 1 year; Opened - 11/30/90; matures - 11/30/90; AUTOMATICALLY RENEWABLE Mr. Doe also maintains a Revolving line of Credit in the name of ABC Construction Company for working capital. AMOUNT = OPENED - 6/12/91; EXPIRATION - 6/12/96; SECURITY - Trust Deed on 123 Elm St., Anytown, USA and personal guarantee of Mr. & Mrs. Doe;TERMS - 2% over banks prime rate but not less than 9%; CURRENT AMOUNT OUTSTANDING = $22, Mr. Doe has conducted all of his relationships in a very satisfactory manner and is on of our most valued customers. Very Truly Yours, By: (Bank Officer) Typed name and title
9 BROKER FEE AGREEMENT Principal: The undersigned hereby understands that Herald Insurance Broker, Inc. shall make every effort to secure, negotiate and procure the placement of Bond(s)/Insurance and to assist the undersigned in the preparation of any and all applications and other documentation for procurement of the Bond(s)/Insurance the undersigned has requested. As consideration for the above stated services, the Herald Insurance Broker, Inc. may charge a fee and the undersigned agrees to pay the Licensee of the bond amount, for the services that are involved in the preparation of any and all Bond(s)/Insurance services requested. Fees and premiums may earn interest. This undeclared income is non-refundable and fully. In addition to performing the aforementioned services, the Licensee may also be acting on behalf of the insurer issuing the subject Bond(s)/Insurance and will be receiving a commission. This agreement shall serve as the writing required pursuant to the rules set forth by the California Department of Insurance (Broker/Agents shall comply with their applicable state regulations regarding fees). Please sign and return Agreement Accepted Herald Insurance Broker, Inc. By: Janzer Ct. Title: Santa Clarita, CA 91350
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