Full text
Exhibit A – Documentation Pertaining to
Claim/Demand Under Bonds
First Stipulation of Facts
Between
Plan Administrator and
Hartford Fire Insurance Company
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received
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HARTFORD INS CO. OF THE MIDWEST
i HARTFORD PLZ
T^ll
HARTFORD, CT 06155-0001
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SEP 1 0 2025
BOND CLASM
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81259649500
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Bond Effective Date
Page 1 of 2
Estimated duties, fees, taxes and charges for entry number 80011094374 included under Periodic Monthly
Statement Number 2524P06001 due on 04/19/2024 were not paid until 06/24/2024, 66 days late.
Description of Bond
Importer or broker
Demand is hereby made for payment of $1.000.00 , representing O Penalties 0 Liquidated damages assessed
against you for violation of law or regulation, or breach of bond, as set forth below:
2. You may petition for relief as specified below if you believe further relief than that provided by option (1) is
warranted and can be substantiated. You can expect further relief only if you can demonstrate that the violation
did not occur or was solely the result of CBP error. If your petition fails to demonstrate the yiolation did not
occur or was the result.of CBP error, mitigation will only be afforded to an amount in excess of the option (1)
amount.
DEPARTMENT OF HOMELAND SECURITY
U.S. CUSTOMS AND BORDER PROTECTION
NOTICE OF PENALTY OR LIQUIDATED DAMAGES INCURRED
AND Demand for payment
19 use1618,19 use 1623
DEMAND ON SURETY
If you wish to file a petition for relief, you may submit it to GBP in paper at the address listed on this Form or
you may submit it electronically (and include any attachments) through the following url: https://epet.cbp.dhs.
gov/
LAWDR REGULATION VIOLATED
19 CFR 113:62(a)(l)(i), 19 CFR 113.62(n).(4), 19 USC 1505(a),
General Notice 73 FR 61891
Bond Type
8
BOND BREACHED
Bond Activity Type: 1
Bond #: 22C000T8M
Amount
$400000.00 06/08/2022
In Accordance with Part 172 of the Customs Regulations, You may:
1. Pay $1,000.00 within 60 days from the date of this notice. This payment constitutes a waiver of the right to
file a petition.
Case Number
2025411120720901
Port Code and Name
4111 INDIANAPOLIS,
REVENUE (FPF
ONLY)
TO:
HARTFORD INS CO. OF THE MIDWEST
1 HARTFORD PLZ
T-11
HARTFORD, CT 06155-0001
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81259649500
TO:
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60 days from
the date of
this notice
DEPARTMENT OF HOMELAND SECURITY
U.S. CUSTOMS AND BORDER PROTECTION
NOTICE OF PENALTY OR LIQUIDATED DAMAGES INCURRED
AND DEMAND FOR PAYMENT
19 use 1618,19 use 1623
DEMAND ON SURETY
Signature
BRIAN GIESE
Case Number
2025411120720901
Port Code and Name
4111 INDIANAPOLIS,
REVENUE (EPF
ONLY)
TIME LIMIT
FOR
PAYMENT
OR FILING
PETITION
FOR RELIEF
HARTFORD INS CO. OF THE MIDWEST
1 HARTFORD PLZ
T-11
HARTFORD, CT 06155-0001
Name and Address of Principal on Bond
VYAIRE MEDICAL INC.
26125 N Riverwoods Blvd
METTAWA, IL 60045^3401
Name and Address of Surety on Bond
HARTFORD INS CO. OF THE MIDWEST
1 HARTFORD PLZ
T-11
HARTFORD, CT 06155-0001
Unless the amount herein demanded is paid or a petition for relief is filed with the FP&F
officer within the indicated time limit, further action will be taken in cohnectioh with your
bond or the matter will be referred to the Justice Department. Payment may be inade
through pay.gov or by remitting to the address above. Any partial payments will not be
considered an accord and satisfaction of the claim.
If you feel there are extenuating circumstances, you have the right to object to the above action. Your
petition should explain why you should not be penalized for the cited violation. Write the petition as a
letter or in legal form; submit in duplicate, addressed to the Commissioner of Customs and Border
Protection, and forward to the FP&F officer at:
U.S. CBP / ATTN:FPFO, 1945 SOUTH BANNER AVE, INDIANAPOLIS, IN 46241,
FPFINDYUNIT@CBP.DHS.GOV.
Title
FP&F Officer (317) 381-5465
Surety Identification No
367
Date
09/03
/2025
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