Blackburn Creek Community Development District
12051 Corporate Boulevard, Orlando, FL 32817
Phone 407-723-5900; Fax 407-723-5901
www.blackburncreekcdd.com

The meeting of the Board of Supervisors for the Blackburn Creek Community Development District will be held Wednesday, October 9, 2019 at 12:15 p.m. at the 5800 Lakewood Ranch Blvd, Sarasota, FL 34240. The following is the agenda for this meeting.

Call in number: 1-844-621-3956 (New) Passcode: 790 562 990 # (New)
BOARD OF SUPERVISORS’ MEETING AGENDA

Organizational Matters
Call to Order
Roll Call
Public Comment Period [for any members of the public desiring to speak on any proposition before the Board]

Consideration of Replacement for John Puscian Seat 2 Term Expires November 2022
Administer Oath of Office to Newly Appointed Board of Supervisors for Seat 2

General Business Matters

Consideration of Resolution 2020-01, Election of Officers
Consideration of the Minutes of the September 11, 2019 Board of Supervisors’ Meeting
Ratification of ADA Auditing Services Agreement
Ratification of Payment Authorizations 91 -- 93
Ratification of Requisitions 2018-109 – 2018-112
Ratification of Requisitions 2019-24 & 2019-29 -- 2019-35
Review of District Financial Statements

Other Business
Staff Reports
District Counsel
District Engineer
District Manager
Audience Comments
Supervisors Requests

Adjournment 

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of Replacement for John Puscian Seat 2 Term Expires November 2022

Venessa Ripoll	October 2, 2019
Assistant District Manager, LCAM PFM Group Consulting, LLC 12051 Corporate Blvd.
Orlando, FL 32817

RE: Blackburn Creek CDD-General Election Open Seats Dear Ms. Ripoll:
The following is in response to your October 2, 2019 email, requesting a summary of my background and experience, for your review.
Education:
1971-1975 Purdue University-West Lafayette, Indiana
A.A.S. Degree: Architecture and Civil Engineering
B.S Degree: Construction Technology
Professional Experience:
5 years as the Building Commissioner for the Village of Itasca in Illinois. I over saw and ran the day to day operation of the Itasca building Department, issued building permits, performed building inspections and code review. Additionally, I served for 15 years as the Chairman of the Village of Itasca Planning and Zoning Commission, reviewed and approved all code variances and Zoning Codes approvals. This was an appointed position by the Mayor of the Village of Itasca.
7 years as a licensed Illinois Real Estate Broker, licensed under Keller Williams Real Estate
Company.
30 years as Senior Construction Manager for Itasca Construction and Associates, Inc., a Design
Build General Contractor in Illinois. ICA was a site developer for industrial warehouses, commercial office building and retail shopping centers, developing projects in the scope of 1 to 12 million dollars, with a yearly volume between 60-70 million dollars.
4 years at INRYCO a design/build general contractor for the Inland Ryerson Building prefab metal building systems in Illinois.
4 years as an Estimator and Site Engineer with Morrison Construction Company in Indiana. Morrison was a mechanical contractor with projects ranging from petroleum refineries, fossil fuel power plants and nuclear power plants.

Summary:
My wife and I have been full time residents of Grand Palm since December 2017. I am
interested in the position on the Blackburn Creek CDD board in order to actively serve my community and work with the board to preserve the natural beauty and landscape areas of Grand Palm.
I feel with my professional background in Civil, Mechanical, and Commercial Construction; Site Development experience and many years of budgeting, and planning and zoning experience I could positively contribute to the Blackburn Creek CDD Board.

Thank you for considering me for this position. Jerald Dell

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Administer Oath of Office to Newly Appointed Board of Supervisors for Seat 2

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT BOARD OF SUPERVISORS
OATH OF OFFICE

I, 	, A CITIZEN OF THE STATE OF FLORIDA AND OF THE UNITED STATES OF AMERICA, AND BEING EMPLOYED BY  OR  AN  OFFICER OF  BLACKBURN  CREEK  COMMUNITY  DEVELOPMENT  DISTRICT AND A RECIPIENT OF PUBLIC FUNDS AS SUCH EMPLOYEE OR OFFICER, DO HEREBY SOLEMNLY SWEAR OR AFFIRM THAT I WILL SUPPORT THE CONSTITUTION OF THE UNITED STATES AND OF THE STATE OF FLORIDA.

Board Supervisor
ACKNOWLEDGMENT OF OATH BEING TAKEN STATE OF FLORIDA
COUNTY OF SARASOTA

The foregoing oath was administered before me this     day of 	, 2019, by 	, who personally appeared  before me, and
is   personally   known   to   me   or has  produced 	as
identification, and is the person described in and who took the aforementioned oath as  a Member of the Board of Supervisors of Blackburn Creek Community Development District and acknowledged to and before me that he/she took said oath for the purposes therein expressed.

(NOTARY SEAL)

Notary Public, State of Florida

Print Name:  	

Commission No.: 	Expires:  	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of Resolution 2020-01, Election of Officers

RESOLUTION 2020-01

A RESOLUTION OF THE BOARD OF SUPERVISORS OF THE BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT ELECTING THE OFFICERS OF THE DISTRICT, AND PROVIDING FOR AN EFFECTIVE DATE

WHEREAS,	the	BLACKBURN	CREEK	COMMUNITY DEVELOPMENT
DISTRICT (hereinafter the “District”) is a local unit of special-purpose government created and existing pursuant to Chapter 190, Florida Statutes; and

WHEREAS, pursuant to Section 190.006(6), Florida Statutes, as soon as practicable after each election or appointment to the Board of Supervisors (the “Board”), the Board shall organize by electing one of its members as chair and by electing a secretary, and such other officers as the Board may deem necessary.

NOW,	THEREFORE,	BE	IT	RESOLVED	BY	THE	BOARD	OF	
SUPERVISORS	OF	THE		BLACKBURN	CREEK	COMMUNITY	
DEVELOPMENT DISTRICT:					
Section 1.	 	is elected Chairman. Section 2.	 		is elected Vice Chairman. Section 3.	 		is elected Secretary.
 	 is elected Assistant Secretary.
 	 is elected Assistant Secretary.
 	 is elected Assistant Secretary.
 	 is elected Assistant Secretary.

Section 4.	 	is elected Treasurer.

Section 5.	 	is elected as Assistant Treasurer.

Section 6.	All resolutions or parts of Resolutions in conflict herewith are hereby repealed to the extent of such conflict.

Section 7.	This Resolution shall become effective immediately upon its adoption.

PASSED AND ADOPTED THIS 	th DAY of 	_, 2019

BLACKBURN CREEK COMMUNITY DEVELOPMENT
ATTEST:	DISTRICT

Secretary/Assistant Secretary	Chairman/Vice-Chairman

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of the Minutes of the September 11, 2019 Board of Supervisors’ Meeting

MINUTES OF MEETING

BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT BOARD OF SUPERVISORS MEETING MINUTES
Wednesday, September 11, 2019 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240
12:15 P.M.

Board Members Present:

Pete Williams	Chairperson		
Kevin Johnson	Assistant Secretary		
John Blakley	Assistant Secretary		
Dale Weidemiller	Vice Chairperson	(via phone)	
Also present:			
Venessa Ripoll	Assistant DM- PFM Group Consulting, LLC	
Jennifer Walden	PFM Group Consulting, LLC	(via phone)	
Bill Conerly	District Engineer- Kimley-Horn		
Jim Schier	Neal Communities		
Pam Curran	Neal Communities		

FIRST ORDER OF BUSINESS	Business Matters

Call to Order and Roll Call

Ms. Ripoll called to order at 12:17 p.m. the meeting of the Board of Supervisors of the Blackburn Creek Community Development District and proceeded with roll call. The persons in attendance are as outlined above.

Public Comment Period

There were no comments from the public present at this time.

Consideration for Replacement for John Puscian Seat 2 Term Expires November 2022- Tabled

This items was tabled until the next Board Meeting.

Consideration of the Minutes of the August 14, 2019 Board of Supervisors Meeting

The Board reviewed the Minutes of the August 14, 2019 Board of Supervisors Meeting.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board approved the August 14, 2019 Board of Supervisors Meeting.

Ratification	of	Payment Authorizations 88-90

The Board reviewed Payment Authorizations 88-90. Ms. Ripoll stated that the payment authorizations are contractual obligations for the District. The Board is being asked to ratify the action taken by the Chair.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board Ratified Payment Authorizations 88-90.

Ratification of Requisitions 2018- 095 – 2018-108

The Board reviewed Requisitions 2018-095 – 2018-108.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board Ratified Requisitions 2018-095 – 2018-108.

Ratification of Requisitions 2019- 15 – 2019-23 & 2019-25 – 2019-28

The Board reviewed Requisitions 2019-15 – 2019-23 & 2019-25 – 2019-28.

On MOTION by Mr. Blakely, seconded by Mr. Williams, with all in favor, the Board Ratified Requisitions 2019-15 – 2019-23 & 2019-25 – 2019-28.

Review	of	District	Financial Statements

The Board reviewed the District Financial Statements through August 31, 2019.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board accepted the District Financial Statements.

SECOND ORDER OF BUSINESS	Other Business Staff Reports
District Counsel – Not present

District Engineer – Mr. Conerly informed the Board that he is in the process of submitting the Grand Palm Phase 1B Final Plat. The Chairman and Secretary have signed the Plat. He is waiting on the Developer to execute their portion and then it will be submitted.

He stated that invoices are being processed that will be provided at the next meeting. He provided hard copies of the requisitions with the backup that was just presented.

District Manager – Ms. Ripoll was asked to look into discussion for newspaper publication. The District has been using different newspaper publications and have reached out to three different newspaper publications in the Sarasota County area. She received response from only two newspaper publications companies with the cost for advertisement. The companies were as follows:
The Business Observer and the Herald-Tribune.
She had both price out the exact same publication for today and the Business Observer was $50.31 and the Herald-Tribune was $145.75. The Herald-Tribune runs Tuesday through Saturday and the Business Observer only runs on Fridays.

Mr. Williams noted that the Law is specific that they want it advertised in the paper that is circulated 5 days per week unless there is no paper that is circulated 5 days per week. Mr. Williams discussed publications process.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board approved using the Herald-Tribune moving forward for all publications pertaining to the District.

THIRD ORDER OF BUSINESS	Audience	Comments	and Supervisors Requests

Mr. Weidemiller asked about Tab 1 on the agenda regarding the vacant seat. Another Board member responded that there is no interest from the public at this time. The next step is to put a request on the HOA website for a volunteer to come forward and serve on the District Board of Supervisors. The Board needs to review applications.

Mr. Johnson asked for a list or map of what the District owns and maintains vs. HOA. Mr. Williams asked Mr. Conerly to work on a list and send it to Ms. Ripoll. She will then circulate the list to the Board of Supervisors. A discussion took place. Mr. Conerly will provide the Board with copies of the Bond Issuance information.

FOURTH ORDER OF BUSINESS	Adjournment

There was no additional business to discuss. Ms. Ripoll requested a motion to adjourn.

On MOTION by Mr. Williams, seconded by Mr. Johnson with all in favor, the September 11, 2019 Meeting of the Board of Supervisors of the Blackburn Creek Community Development District was adjourned at 12:32 P.M.

Secretary/Assistant Secretary	Chair/Vice-Chair

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of ADA Auditing Services Agreement

AGREEMENT BETWEEN THE BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT AND NEWAGETUTORS LLC, D/B/A VGLOBALTECH, FOR WEBSITE AUDITING, REMEDIATION, AND MAINTENANCE SERVICES

THIS AGREEMENT (this "Agreement") is entered into as of this 	day of 	, 2019, by and between:
BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT, a local unit of
special-purpose government, established and existing pursuant to Chapter 190, Florida Statutes, with a mailing address of 12051 Corporate Boulevard, Orlando, Florida 32817 (the "District"), and
NEWAGETUTORS LLC, D/B/A VGLOBALTECH, a Florida limited liability company, with a mailing address of 636 Fanning Drive, Winter Springs, Florida 32708 ("Contractor").

RECITALS
WHEREAS, the District is a local unit of special-purpose government, created and existing pursuant to Chapter 190, Florida Statutes; and
WHEREAS, pursuant to section 189.069, Florida Statutes, the District must maintain an official website containing, at minimum, the statutorily required information (“Website”); and
WHEREAS, the District has a need to obtain a qualified independent contractor to perform audits of the Website to ensure compliance with the accessibility requirements of Title II of the Americans with Disabilities Act (“ADA”) based on federally recommended ADA best practices for state and local governments as promulgated by federal law and rulemaking, including but not limited to Web Content Accessibility Guidelines 2.0 and 2.1 Level AA, as the same may be amended and updated from time to time (as amended and updated from time to time, “WCAG”), and to remediate or otherwise convert the Website and to routinely audit the same to ensure continued compliance with the WCAG, and to perform ongoing maintenance of the website, all as more particularly described herein and in the proposal attached hereto as Exhibit A and made a part herein (together, the “Services”); and
WHEREAS, Contractor represents and warrants to the District that it is qualified, willing and capable of providing the Services; and
WHEREAS, the District and Contractor desire to enter into this Agreement for the purposes stated herein and the District and Contractor warrant and agree that they have all right, power and authority to enter into and be bound by this Agreement.
NOW, THEREFORE, in consideration of the recitals, agreements and mutual covenants contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged by the parties, the parties agree as follows:
SECTION 1. RECITALS. The recitals stated above are true and correct and by this reference are incorporated herein and form a material part of this Agreement.

SECTION 2. SCOPE OF WORK. Contractor shall provide Services in accordance with the terms provided in this Agreement and in Exhibit A. Specifically, Services include the following:

MAINTENANCE. Contractor shall provide an ongoing maintenance of the Website to ensure continued compliance with WCAG. Specifically, Contractor shall:
perform quarterly technological and human audits (four times per year) per the Florida Insurance Alliance guidelines, which may be amended or updated from time to time, and provide full audit reports of compliance status, including recommended actions to remedy the findings, if any. Performance of audits shall be conducted by Contractor and its subcontractor, as may be necessary;
remediate any insufficiencies found as a result of technological and human audits, including but not limited to performing full compliance checks, automated testing, screen magnifier and reader testing;
provide Contractor’s ADA compliance shield(s), such as the Digital Asset Technical Compliance Seal and the Human Audit Seal, which shall renew on a quarterly basis, for display and use on the Website;
ensure that the Website and any new content uploaded to the Website is compliant with WCAG and other federally recommended guidelines; and
provide all Services described in Exhibit A and any and all other effort reasonably necessary to allow the District to receive the maximum benefit of the Services contemplated by this Agreement and Exhibit A.

The District and Contractor understand and acknowledge that the Services are in addition to Contractor’s previously provided remediation services, which included the conversion of the Website into an ADA compliant format in accordance with WCAG and other federally recommended guidelines, as may be amended from time to time, and continued provision of website accessibility policy demonstrating commitment to accessibility for persons with disabilities. Furthermore, the District and Contractor understand and agree that maintenance services provided in this Section are in addition to any other maintenance service obligations Contractor may have, either directly with the District or with PFM Group Consulting LLC, including but not limited to providing assistive support via regularly corresponding with the District staff regarding remediation of existing or new documents, providing updates to the Website, remediating new documents identified by the District to accessible formats for assistive technologies, including but not limited to new agenda materials, and providing recommendations of remedial actions, as needed.

ADDITIONAL SERVICES. In the event the District desires additional work or services provided in this subsection or otherwise, Contractor agrees to negotiate in good faith to undertake such additional work or services. Upon successful negotiation regarding the terms of the additional work, including scope and compensation, the parties shall agree in writing to a work order, addendum, addenda, or change order to this Agreement prior to commencement of any such additional work. The following is a non-exhaustive list of possible additional services that the District may request of Contractor:

performing additional technical and human audit(s) of the Website;
providing a point of contact to respond to public’s requests for Website accommodation;
converting documents for public records requests received by the District;
providing any other ADA recommended compliance services requested by the District that Contractor is capable of performing.

Contractor shall be solely responsible for the means, manner and methods by which its duties, obligations and responsibilities are met to the satisfaction of the District and in accordance with this Agreement. Contractor shall use industry best practices and procedures when carrying out the Services.

SECTION 3. COMPENSATION. As compensation for the Services, the District agrees to pay Contractor in accordance with the following terms:

MAINTENANCE. For Contractor’s performance of the Services, the District shall pay One Thousand Two Hundred Dollars ($1,200.00) per year, payable in quarterly installments of Three Hundred Dollars ($300.00) after each quarterly audit event has been completed.
INVOICES; PAYMENT. Contractor shall maintain records conforming to usual accounting practices. Further, Contractor shall render each invoice to the District in writing, which shall be delivered promptly upon completion of each Service. Each invoice shall contain, at a minimum, the District’s name, Contractor’s name, the invoice date, an invoice number, an itemized listing of all costs billed on each invoice with a sufficient description of each allowing the District to approve each cost, the time frame within which the Services were provided, and the address or bank information to which payment is to be remitted. Consistent with Florida’s Prompt Payment Act, section 218.70, et al., Florida Statutes, the invoices shall be due and payable within forty-five (45) days of receipt by the District.
SECTION 4.	TERM AND TERMINATION.

TERM. This Agreement shall become effective upon the date and year first written above and shall be in effect until terminated by either party in accordance with the terms of this Agreement.
TERMINATION. The District agrees that Contractor may terminate this Agreement for cause by providing sixty (60) days’ written notice of termination to the District; provided, however, that the District shall be provided a reasonable opportunity to cure any failure under this Agreement. Contractor agrees that the District may terminate this Agreement immediately for cause by providing written notice of termination to Contractor. Contractor agrees that the District may terminate this Agreement without cause; provided that the District shall provide thirty (30) days’ written notice of termination without cause. Upon any termination of this Agreement, Contractor shall be entitled to payment for all Services rendered up until the effective termination of this Agreement, subject to whatever claims or offsets the District may have against Contractor as the sole means of recovery for termination.

SECTION 5.	REPRESENTATIONS,	WARRANTIES	AND	COVENANTS.	Contractor
represents, warrants, and covenants that (a) the Services will conform to the requirements provided in Section 2 herein and Exhibit A; (b) the Services shall be performed by qualified personnel in a professional, prompt, diligent, good, safe and workmanlike manner in accordance with all laws, industry standards, and all applicable ADA and other website accessibility compliance standards, including but not limited to WCAG and other federally recommended guidelines, as may be amended from time to time; and (c) neither the Services nor any product provided by Contractor shall infringe, misappropriate, or otherwise violate the intellectual property rights of any third- party. To the extent that any defects are found and reported to the Contractor, the Contractor shall correct such defects within thirty (30) days.
SECTION 6.	INTELLECTUAL PROPERTY.
CONTRACTOR MATERIALS. Except as provided herein, Contractor shall retain all right, title, and interest in and to (i) all patents, trademarks, service marks, copyrights, and other intellectual property or proprietary rights of Contractor used in or otherwise associated with the Services, and other materials provided to the District hereunder; and (ii) all trade secrets, technical specifications and data to the extent they are intellectual property, and inventions which are authored, conceived, devised, developed, reduced to practice, or otherwise performed by Contractor which arise out of Contractor’s performance of the Services, none of which shall be deemed a "work made for hire" under the Copyright Act of 1976 (collectively, "Contractor Materials"), and nothing contained herein shall be construed to restrict, impair, transfer, license, convey, or otherwise alter or deprive Contractor of any of its intellectual property and proprietary interests associated therewith. Subject to the foregoing, Contractor grants to the District a non- exclusive, non-transferable worldwide perpetual limited right and license to access and use the Contractor Materials in connection with the ordinary and intended use by the District as contemplated in this Agreement, including viewing, downloading and printing the Contractor Materials for the District’s use, and without in any case removing Contractor’s copyright, trademark or other intellectual property ownership notices.
THE DISTRICT MATERIALS; PUBLICITY AND TRADEMARKS. The District shall own the Website, domain name, all e-mail addresses, and all website and e-mail content, under all circumstances. In the event of a termination of this Agreement for any reason, Contractor shall take all necessary steps to transfer, or otherwise allow the District to retain, such website, domain name, e-mail addresses and content of the same. Additionally, to the extent applicable, Contractor shall take commercially reasonable precautions consistent with industry standards to protect confidential information, including, e.g., credit card information and other sensitive information protected under Florida’s Public Records Laws. Contractor shall immediately notify the District of any breach or loss of data, and take such steps as are reasonably necessary to address any such issue. Except as provided herein, the District shall retain all right, title, and interest in and to all intellectual property of the District provided or made available to the Contractor in connection with Contractor’s Services (collectively, "District Materials") and nothing contained herein shall be construed to restrict, impair, transfer, license, convey, or otherwise alter or deprive the District of any of its intellectual property or other proprietary interests associated therewith, if any. Subject to the foregoing, the District grants to Contractor a non-exclusive, non-transferable worldwide limited right and license to access and use such District Materials in connection with the provision of the Services as contemplated by this Agreement. Further, the District permits Contractor to

identify the District as a customer of Contractor in Contractor’s marketing materials (including using the District’s name and logo for such limited purposes).

The District further acknowledges and agrees that for Contractor to perform the Services, it must, in some cases, give Contractor remote access to areas behind log-ins that are to be audited hereunder, including, without limitation to content management systems and/or servers (collectively, “System”), and agrees that it will furnish to Contractor all necessary information and/or user names and passwords required to do so. Contractor agrees to follow commercially reasonable security policies for accessing the District’s System including any specific security procedures as may be communicated to Contractor by the District prior to Contractor accessing the System. Contractor shall on its own or through coordination with the District’s Website provider, create a back-up copy of all data that may be affected by Contractor’s access to the System.

RIGHT TO DISPLAY CONTRACTOR’S COMPLIANCE SHIELD / ACCESSIBILITY POLICY. Pursuant to this Agreement, the Contractor shall provide the District with applicable Compliance Shield(s) and customized accessibility policy, which the District shall display on its Websites and web applications. The District is expressly prohibited from using the compliance shield(s) for any purpose not specifically authorized by this Agreement, and in no event may use such compliance shields for or on behalf of any other party or in connection with any domain name and/or organization name other than those being scanned or serviced in connection with the Services.

SECTION 7.  PUBLIC RECORDS.  Contractor understands and agrees that all documents   or on-line content of any kind provided to the District in connection with this Agreement may be public records, and, accordingly, Contractor agrees to comply with all applicable provisions of Florida law in handling such records, including but not limited to section 119.0701, Florida Statutes. Contractor acknowledges that the designated public records custodian for the District is Victoria Martinez (“Public Records Custodian”). Among other requirements and to the extent applicable by law, Contractor shall 1) keep and maintain public records required by the District to perform the Work; 2) upon request by the Public Records Custodian, provide the District with the requested public records or allow the records to be inspected or copied within a reasonable time period at a cost that does not exceed the cost provided in Chapter 119, Florida Statutes; 3) ensure that public records which are exempt or confidential, and exempt from public records disclosure requirements, are not disclosed except as authorized by law for the duration of the contract term and following the contract term if Contractor does not transfer the records to the Public Records Custodian of the District; and 4) upon completion of the contract, transfer to the District, at no cost, all public records in Contractor’s possession or, alternatively, keep, maintain and meet all applicable requirements for retaining public records pursuant to Florida laws. When such public records are transferred by Contractor, Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to the District in a format that is compatible with Microsoft Word or Adobe PDF formats.

IF	CONTRACTOR	HAS	QUESTIONS	REGARDING	THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO

CONTRACTOR’S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT (407) 723-5900, MARTINEZV@PFM.COM, OR AT 12051 CORPORATE BOULEVARD, ORLANDO, FLORIDA, 32817.
SECTION 8. INDEMNITY.
Contractor agrees to defend, indemnify, and hold harmless the District and its officers, agents, staff, employees, successors, assigns, members, affiliates, or representatives from any and all liability, claims, actions, suits, liens, demands, costs, interest, expenses, damages, penalties, fines, or judgments against the District, or loss or damage, whether monetary or otherwise, arising out of, wholly or in part by, or in connection with the Services to be performed by Contractor, its subcontractors, its employees and agents (including, but not limited to Lighthouse Central Florida, Inc., or any other company or individual performing human audits as required by Section 2 of this Agreement) in connection with this Agreement, including litigation, mediation, arbitration, appellate, or settlement proceedings with respect thereto. This specifically includes a lawsuit based on lack of ADA compliance or other website compliance insufficiencies. Additionally, nothing in this Agreement requires Contractor to indemnify the District for the District’s percentage of fault if the District is adjudged to be more than 50% at fault for any claims against the District and Contractor as jointly liable parties; however, Contractor shall indemnify the District for any and all percentage of fault attributable to Contractor for claims against the District, regardless of whether the District is adjudged to be more or less than 50% at fault. Contractor further agrees that nothing herein shall constitute or be construed as a waiver of the District's limitations on liability contained in section 768.28, Florida Statutes, or other statute.
Obligations under this Section shall include the payment of all settlements, judgments, damages, liquidated damages, penalties, fines, forfeitures, back pay awards, court costs, arbitration and/or mediation costs, litigation expenses, reasonable attorneys’ fees, paralegal fees (incurred in court, out of court, on appeal, or in bankruptcy proceedings), and any interest accrued against the District, all as actually incurred.
In the event that Contractor assigns its obligations under this Agreement to a third party, Contractor acknowledges and agrees that Contractor shall require such third party to provide indemnification to the District consistent with the requirements of this Section 8.
SECTION 9.   SCRUTINIZED COMPANIES STATEMENT.   Contractor certifies that it is not in violation of section 287.135, Florida Statutes, and is not prohibited from doing business with the District under Florida law, including but not limited to Scrutinized Companies with Activities in Sudan List or Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. If Contractor is found to have submitted a false statement, has been placed on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or has been engaged in business operations in Cuba or Syria, or is now or in the future on the Scrutinized Companies that Boycott Israel List, or engaged in a boycott of Israel, the District may immediately terminate the Contract.

SECTION 10. GENERAL PROVISIONS.

CONFLICTS. The terms of this Agreement and Exhibit A are intended to complement each other, and to the  extent  they  conflict,  the  terms  of  Exhibit  A  shall  control only to the extent that such provisions  provide clarifications  on Services  and materials to be provided by Contractor pursuant to Exhibit A; in all other respects, the provisions of this Agreement shall control.
AUTHORIZATION. The execution of this Agreement has been duly authorized by the appropriate body or official of the District and Contractor, both the District and Contractor have complied with all the requirements of law, and both the District and Contractor have full power and authority to comply with the terms and provisions of this Agreement.
INDEPENDENT CONTRACTOR. It is understood and agreed that at all times the relationship of Contractor and its employees, agents, successors, assigns or anyone directly or indirectly employed by Contractor to the District is the relationship of an independent contractor and not that of an employee, agent, joint-venturer, or partner of the District. Nothing in this Agreement shall be interpreted or construed as creating or establishing the relationship of employer and employee between the District and Contractor or any of its employees, agents, successors, assigns or anyone directly or indirectly employed by Contractor. The parties acknowledge that Contractor is not an employee for state or federal tax purposes. Contractor shall hire and pay all of Contractor’s or its employees, agents, successors, assigns or anyone directly or indirectly employed by Contractor, all of whom shall be employees of Contractor and not employees of the District and at all times entirely under Contractor’s supervision, direction, and control.

In particular, the District will not: i) withhold FICA (Social Security) from Contractor’s payments; ii) make state or federal unemployment insurance contributions on Contractor’s behalf;
iii) withhold state or federal income tax from payment to Contractor; iv) make disability insurance contributions on behalf of Contractor; or v) obtain workers’ compensation insurance on behalf of Contractor.

DISPUTE RESOLUTION. Before initiating any legal claim or action (except with respect to equitable relief), the parties agree to attempt in good faith to settle any dispute, controversy, or claim arising out of or related to this Agreement or the Services (collectively, "Dispute") through discussions which shall be initiated upon written notice of a Dispute by either party to the other. If the parties cannot resolve the Dispute within ten (10) business days, then the parties shall attempt to settle the Dispute by mediation. If mediation is unsuccessful, the parties may then proceed to filing a claim in the appropriate jurisdictional court in accordance with this Agreement. In the event that either party is required to enforce this Agreement by court proceedings or otherwise, then the parties agree that the substantially prevailing party shall be entitled to recover from the other all fees and costs incurred, including reasonable attorneys’ fees, paralegal fees, expert witness fees, and costs for trial, alternative dispute resolution, or appellate proceedings.
APPLICABLE LAW AND VENUE. This Agreement shall be governed by and construed in accordance with the laws of the State of Florida without reference to the principles of conflict of laws. Except for actions seeking injunctive relief (which may be brought in any appropriate jurisdiction), suits under this agreement shall only be brought in a court of competent jurisdiction in the county of Nassau, Florida. This choice of venue is intended by the parties to be

mandatory and not permissive in nature, and to preclude the possibility of litigation between the parties with respect to, or arising out of, this Agreement in any jurisdiction other than that specified in this Section. The District and Contractor waive any right they may have to assert the doctrine of forum non conveniens or similar doctrine, or to object to venue with respect to any proceeding brought in accordance with this Section.
LIMITATIONS ON GOVERNMENTAL LIABILITY. Nothing in this Agreement shall be deemed as a waiver of immunity or limits of liability of the District beyond any statutory limited waiver of immunity or limits of liability which may have been adopted by the Florida Legislature in section 768.28, Florida Statutes, or other statute, and nothing in this Agreement shall inure to the benefit of any third party for the purpose of allowing any claim which would otherwise be barred under the Doctrine of Sovereign Immunity or by operation of law.
THIRD-PARTY BENEFICIARIES. This Agreement is solely for the benefit of the District and Contractor and no right or cause of action shall accrue upon or by reason to or for the benefit of any third party not a formal party to this Agreement. Nothing in this Agreement expressed or implied is intended or shall be construed to confer upon any person or corporation other than the District and Contractor any right, remedy, or claim under or by reason of this Agreement or any of the provisions or conditions of this Agreement; and all of the provisions, representations, covenants, and conditions contained in this Agreement shall inure to the sole benefit of and shall be binding upon the District and Contractor and their respective representatives, successors, and assigns.
DEFAULT AND PROTECTION AGAINST THIRD-PARTY INTERFERENCE. A default by either party under this Agreement shall entitle the other to all remedies available at law or in equity, which may include, but not be limited to, the right of actual damages and/or specific performance. The District shall be solely responsible for enforcing its rights under this Agreement against any interfering third party. Nothing contained in this Agreement shall limit or impair the District’s right to protect its rights from interference by a third-party to this Agreement.
NOTICES. All notices, requests, consents, and other communications under this Agreement (“Notice” or “Notices”) shall be in writing and shall be delivered, mailed by Overnight Delivery or First Class Mail, postage prepaid, to the parties, as follows:
If to Contractor:	NewAgeTutors LLC
d/b/a VGlobalTech 636 Fanning Drive
Winter Springs, Florida 32708 Attn: Vaibhav V. Joshi

If to District:	Blackburn Creek Community Development
District 12051 Corporate Boulevard Orlando, Florida 32817
Attn:  District Manager
With a copy to:	Vogler Ashton, PPLC
705 10th Avenue West, Unit 103
Palmetto, Florida 34221

Attn:  District Counsel
Except as otherwise provided in this Agreement, any Notice shall be deemed received only upon actual delivery at the address set forth above. Notices delivered after 5:00 p.m. (at the place of delivery) or on a non-business day, shall be deemed received on the next business day. If any time for giving Notice contained in this Agreement would otherwise expire on a non-business day, the Notice period shall be extended to the next succeeding business day. Saturdays, Sundays, and legal holidays recognized by the United States government shall not be regarded as business days. Counsel for the District and counsel for Contractor may deliver Notice on behalf of the District and Contractor. Any party or other person to whom Notices are to be sent or copied may notify the other parties and addressees of any change in name or address to which Notices shall be sent by providing the same on five (5) days’ written notice to the parties and addressees set forth herein.
ENTIRE AGREEMENT. This Agreement, together with Exhibit A, sets forth the entire agreement of the parties, and supersedes any prior agreements or statements with respect to the subject matter hereof. No provision of this Agreement may be amended, waived or modified unless the same is set forth in writing and signed by each of the Parties to this Agreement, or their respective successors or assigns.
SEVERABILITY. The invalidity or unenforceability of any one or more provisions of this Agreement shall not affect the validity or enforceability of the remaining portions of this Agreement, or any part of this Agreement not held to be invalid or unenforceable.
ASSIGNMENT. Neither the District nor Contractor may assign this Agreement without the prior written consent of the other. Any purported assignment without such consent shall be null and void.
AMENDMENTS. This Agreement may be amended or modified only by a written instrument duly executed by both parties.
FORCE MAJEURE. If either party is prevented from performing any of its obligations under this Agreement due to any cause beyond the party's reasonable control, including, without limitations, an “act of God,” fire, flood, war, strike, government regulation, civil or military authority, acts or omissions of transmitters, utilities, providers or hackers, the time for that party's performance will be extended for the period of the delay or inability to perform due to such occurrence.
SURVIVAL. In addition to such other provisions hereof which, by their terms, survive any termination or expiration of this Agreement, Section 5 (Representations, Warranties and Covenants), Section 6 (Intellectual Property), Section 7 (Public Records), Section 8 (Indemnity), and Section 10 (General Provisions) shall survive any termination or expiration of this Agreement.
WAIVER. No breach of any term of this Agreement shall be deemed waived unless expressly waived in writing by the party who might assert such breach. Any failure or delay by either party to exercise any right, power, or privilege under this Agreement shall not be deemed a waiver of any such right, power, or privilege under this Agreement on that or any subsequent occasion. Any waiver by either party, whether express or implied, of any provision of this Agreement, any waiver of default, or any course of dealing hereunder, shall not affect such party’s

right to thereafter enforce such provision or to exercise any right or remedy in the event of any other default or breach, whether or not similar.
COUNTERPARTS. This instrument may be executed in any number of counterparts, each of which, when executed and delivered, shall constitute an original, and such counterparts together shall constitute one and the same instrument. Signature and acknowledgement pages, if any, may be detached from the counterparts and attached to a single copy of this document to physically form one document.
ARM’S LENGTH TRANSACTION. This Agreement has been negotiated fully between the parties as an arm’s length transaction. Both parties participated fully in the preparation of this Agreement and received the advice of counsel. In case of a Dispute concerning the interpretation of any provision of this Agreement, both parties are deemed to have drafted, chosen, and selected the language, and the doubtful language will not be interpreted or construed against either party.
DESCRIPTIVE HEADINGS. The descriptive headings in this Agreement are for convenience only and shall not control nor affect the meaning or construction of any of the provisions of this Agreement.

[SIGNATURES ON NEXT PAGE]

IN WITNESS WHEREOF, the parties have, by their duly authorized representatives, executed this Agreement as of the date and year first set forth above.

ATTEST:	BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT

Secretary	Chairperson, Board of Supervisors

WITNESS:	NEWAGETUTORS LLC, D/B/A
VGLOBALTECH, a Florida limited liability company

Print Name:	By: Vaibhav V. Joshi, Owner

Exhibit A:	Proposal for Services

Exhibit A

tPER IENCE INNOVATION

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V

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IHI& Ratln1: A+

CIiek for Profll•

Technical & Human Audit Proposal for Public Facing Digital Assets (Software, Websites & Apps)
Goal: Ensure full compliance for people with disabilities as per:

Nondiscrimination requirements of Title II of
the American
Disabilities Act
(ADA)

WCAG(Web
Content Accessibility Guidelines)

Section sos

Stipulations

FIA)

Florida Insurance Alliance / eGIS Risk Advisors Guidelines

Read more about details of the above list on VGlobalTech's website. All ADA requirements and information on these topics has been compiled in one place for our clients.
URL: https://vglobaltech.com /website-compliance/

VGloboll ech .c om - Ex pe rience Innovation	Page 1 of 11
Your strategic partner for Web Design . Software. Marketing, and SEO solutions.
Call: 321-947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No part of this document sha R be produced, sent, copied to any parties ii is nol intended for. It Is
intended for the entities isled clearly on this proposal. Any distribution without written consent shalt be procecuted

Version Log:

Date	Version#	Comments	Author	
April 11, 2019	1.0	Technical and Human Audit	VB Joshi	
April 12, 2019	1.1	Added 3 Options	VB Joshi	
April 12, 2019	1.2	Added compliance process flow	VB Joshi	

Your website gets 2 Compliance Seals VGlobalTech's Technical Compliance Seal & Human Audit Compliance Seal

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.	·tllAN

llAfPL\

CERTIFIED ACCESSIBLE
By Analysts who are Blind & Visually Impaired

VGlobalTech is the ADA, WCAG Compliance Expert, with over 100 ADA & WCAG compliant  websites created  (....and counting) to-date I We	have partnered with a non-profit agency to conduct Human Audit and Certification Seal.

Working together with your company we wish to add social value to the community we live in!

COPYRIGHT ©: This proposal Is solely created by VGlobalTech team for Its customers and cannot be reproduced, copied, modified or distributed (including forwarding to other customers, competitors, web designers etc.) without the written consent of VGlobalTech. Any violations shall be prosecuted.

VGlobalTech.com - Experience rnnovat•on	Page 2 of 11
Your strategic partner for Web Design, Software, Mon.eting, and SEO solutions.
Call: 32l -947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No port of th document sha N be pr o d u ced. sent . c opied lo any parties it 1s not intended fOf. 11 is
intended for the entities listed clearly on this p rop osol. Any di strib u tion without written consenl shall be procecuted

Table of Contents
1.0	The Law	4
2.0	ADA & WCAG Compliance	4.
Quarterly Technical & Human Audit Testing	5
Digital Asset Technical Compliance Seal:	6
Human Audit Seal:	6
4.0	Compliance Process Flow:	7
5.0	Pricing Options	8
6.0	Proposal Acceptance:	10
7.0	References:	11

VGlobalTech.com -Experience Innovation	Page 3 of 11
Your strategic partner for Web Design, Software, Marketing . and SEO solutions.
Coll: 321-947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No part of this document shall be produced, sent. copied lo any parties it is not intended for . ti is intended for the entities listed clea y on this proposal. Any distribution without written consent shall be procecuted

1.0The Law

Please familiarize your team with the Florida Statute 189.069 Special districts; required reporting of informationj web-based public access. Source: http://www.leg.state.fl.us/statutes/index.cfm? App_mode= Display_Statute&URL =01 00- 0199/0189/Sections/0189.069.html

2.0 ADA & WCAG Compliance

Every individual must have equal access to information whether it is in person service or online. This is a general agreement and understanding of access.
The Internet has dramatically changed the way state and local governments do business. Today, government agencies routinely make much more information about their programs, activities, and services available to the public by posting it on their websites. As a result, many people can easily access this information seven day a week, 24 hours a day.
Many government services and activities are also provided on websites because the public is able to participate in them at any time of day and without the assistance of government personnel. Many government websites offer a low cost, quick, and convenient way of filing tax returns, paying bills, renewing licenses, signing up for programs, applying for permits or funding, submitting job applications, and performing a wide variety of other activities.
The Americans with Disabilities Act (ADA) and, if the government entities receive federal funding, the Rehabilitation Act of 1973 generally require that state and local governments provide qualified individuals with disabilities equal access to their programs, services, or activities unless doing so would fundamentally alter the nature of their programs, services, or activities or would impose an undue burden. One way to help meet these requirements is to ensure that government websites have accessible features for people with disabilities, using the simple steps described in this document. An agency with an inaccessible website may also meet its legal obligations by providing an alternative accessible way for citizens to use the programs or services, such as a staffed telephone information line. These alternatives, however, are unlikely to provide an equal degree of access in terms of hours of operation and the range of options and programs available.
The World Wide Web Consortium (W3C) sets the main international standards for the World Wide Web and its accessibility. W3C created the Web Content Accessibility Guidelines (WCAG 2.0 and 2.1) which are similar to Section 508, but on an international level. WCAG 2.0 and 2.1 requires specific techniques for compliance and is more current than Section 508.
Source: bttps:/ /www.w3,org/WAJ/  standards-&uidelines/ wca&L

VGlobalTech.com - Expenence lnnovalron	Page 4 of 11
Your strategic pottner tor Web Design, Software, Marketing, and SEO solufions.
Coll: 321-947-7777 I Email: confact@VGlobalTech.com
Private and Confidential Document. No part of this document shall be produced, sent, cop ied to any parties ii 1s not intended for. II is
1nlended tor the entities listed clea v on this proposal. Any distrib u tion wilhout written c onsen t shall be procecuted

Quarterly Technical & Human Audit Testing

This audit is as per the Florida Insurance Alliance, eGIS Insurance Advisors and other insurance guidelines. Please check with your insurance agency for specific requirements. Read more here: https:/ /vglobaltech.com/wp­ content/uploads/2019/03 /FIA_ADA_Guidelines-2019-2020.pdf
VGlobalTech team is trained and well aware of ADA and WCAG 2.x Compliance guidelines. VGlobalTech has partnered with a local agency for the visually impaired - LightHouse Works. LightHouse has developed a unique program for digital accessibility that is run by visually impaired personnel that are highly skilled in human auditing of websites and software as per the section 508 stipulations. Read more about our partnership here:
https://vglobaltech.com/website-compliance/

V.f1l	 IMmo•

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CENTRAL	FLORIDA
Charting a course for living , learn ing, & earning with vi sio n loss

Together we are now able to provide not one but two compliance seals for all our customers. Details of the compliance seals are below.

VGlobolTech.com - Experience tnno vo tioo	Page 5 of 11
Your strategic partner for Web Design, Software, Marketing, and SEO solutions.
Coll: 321-947-7777 I Email: contact@VGlobalTech.com
Privale and Confidential Document. No port of lhis documenl sha ll be produced . sent. copied to ony parties ti is not intended fO(. ll is intended for the enti ties i sled clearly on this proposal. Any distribufon without written consent shall be proceculed

Digital Asset Technical Compliance Seal:

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ADA coMPUAMCl:.
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VGlobalTech in-house technical team shall remediate / test the website / software for ADA, WCAG compliance. VGlobalTech's technical design & development team is fully aware of the Americans with Disability Act (ADA), Web Content Accessibility Guidelines (WCAG), Section 508 of the Rehabilitation Act of 1973 and overall the design principles of a professional, accessible, functional and responsive web design. The entire team has taken dedicated time and efforts to learn these design principles first hand. Our purpose is clear - Universal, Creative Web design that works for everyone, everywhere and every time!
Human Audit Seal:

CERTIFIED ACCESSIBLE
By Analysts who are Blind & Visually Impaired

0

LightHouse Works' visually impaired personnel shall actually test the website for compliance as per the section 508 and ADA requirements. The VGlobalTech technical team shall remediate any points discovered by LightHouse team and send the site for re-certification. Upon satisfactory completion LightHouse shall provide the Human Audit Seal that will be specific to the site and the VGlobalTech team shall put the seal on the site. This is an added layer of true Human Audit testing that provides full ADA compliance.

VGlobolTech.com - Experience Innovation	Page 6 of 11
Your strategic partner for Web Design, Software, Marketing, and SEO solutions.
Call: 321 -947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No port of this document !>hall be produced, sent. copied to any parties it is not intended for . It is
intended for the entities risted clearly on this proposa l Any distribution without written consent shoQ be procecuted

4.0 Compliance Process Flow:

•	··	•

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CENTRAL FLORIDA
Chorffng a c.our.,. for llvlAQ . '-o "" lng . & aarnlng with Yl &k>n &o...a

•
•

A Partnership with a Social Cause to Ensure:

ADA COMPLIANCE WCAG COMPLIANCE
SECTION 508 STIPULATIONS
FIA/ eGIS / OTHER INSURANCE & RISK ADVISERS' COMPLIANCE

HUMAN AUDIT COMPLAINCE SEAL QUARTERLY AUDITS REMEDIATION
PEACE OF MIND

•

·---···o

TECHNICAL COMPLAIN CE SEAL

..
Full Compliance Checks

YGlobalTech.com - Exp erience Innovation	Page 7 of 11
Your strategic partner for Web Design, Software. Marketing, and SEO solutions .
Call: 321- 947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No port of this document moll be prod uc ed , sent . copied to any parties ii is not intended fo r. II is in1ended lor the entities listed cleo{ly on !his proposal. Any distribution without written co115en1 man be proceculed

This proposal includes following points, stipulations terms and conditions:

*(1) conference call or in person meetings per month with client to review metrics, results and monthly recaps *unless otherwise noted
* email and phone communication

*Anything out of the scope of work in the above proposal will be addressed and client will be immediately notified. After notification of additional work, a subsequent  quote will be provided to cover that work.
*Client is responsible to adhering to timelines as far as information required to complete the task is concerned. If timelines are not adhered to and exceed 15 business days past the current marketing months, last day, all work will end. A new month with new allocated costs will be presented forfuture work to commence. No refunds and owed work will be due unless otherwise agreed upon. An Invoice will be provided once signature approval of this project proposal. Payments will be made to VGLOBALTECH
*Client is responsible for verifying quality of work, providing feedback, verifying that compliance has been met as required. VGlobalTech team shall not be responsible for any legal ramifications arising from work not done as per external agencies/ organizations/ associations  needs if proper feedback is not provided by the customer. VGlobalTech's work will be in best faith but cannot guarantee all compliance/ legal needs since we are not the final authority in the ADA or WCAG compliance area. VGlobalTech shall not be liable for any legal ramifications arising from compliance issues and cannot be held responsible for any legal or other lawsuits.
Refund Policy: The client may halt work and request for  a refund within seven days of the date of signing this services agreement by mailing a signed letter to the main address listed on www.VGlobalTech.com website. If client requests a refund within seven days of the date of signing their agreement they shall be liable to pay for all work completed and will be refunded the remaining balance of the initial payment if billable work has not exceeded a charge that would be greater than client's initial payment. If client requests a refund after the seven days from the date of the signing of the agreement client is liable to pay for  all work completed plus an additional 25% of any remaining balance that may still be due. Once line item projects are complete no refunds will be issued. Confidentiality: All information between client and service provider  inclusive  of  technical and business information relating to proprietary ideas, patentable ideas and/or trade secrets, existing and/or contemplated products and services, research and development, production, costs, profit and margin information, finances and financial projections, customers, clients, marketing, and current or future business plans and models, regardless of whether such information is designated as "Confidential Information" at the time of its disclosure  and will be treated as such and with absolute confidentiality and will  not be shared or used, which will be maintained at all times. The client is not allowed to disclose their price with any third part ies. Doing so is in breach of this agreement . All information development  will be shared and proprietary  information  and property between client and service providers.

VGlobolTech.com - fxperieoce Innovat ion	Page 9 of 11
Your strategic partner for Web Design, Software, Marketing, and SEO solutions.
Call: 321-947-7777 I Email: contact@VGlobalTech.com
Private and Confidential Document. No pan of this document shall be produced. sent, copied lo any ponies ii is not intended !Of. 11,s
intended tor the entities isled cleor1y on !his proposal. Any distribution without written consent shall be procecuted

6.0 Proposal Accept ance:

To accept these project, associated costs and conditions as listed above please sign and date below.
The VG/oba/Tech proposed solution and terms have been accepted by the customer and the VG/oba/Tech team can proceed with the project. All payments shall be made according to this agreement.

Please Sign and Date, Return to contact@vglobaltech.com:

F orcustc!l		/Y"d

[1ut(117
Date

VB Joshi
For VGlobalTech	Date

VGlobal Tech .c om - Ex perience rnn o vo fion	Page 10 of 11
Your strategic partner for Web Design , Sof tware. Marketing , and SEO solutions.
Co ll: 321 -947-7777 I Email: c ontact@VGlobol Tech.com
Private and Confidential Document. No port of this document shall be produced . sent, copied to any parties ii is not intended for. ti is
intended for the entities listed clearly on this proposal. Any distribution without written consent shon be proceculed

7.0 References:

ADA Best Practices Tool Kit for State and Local Governments: https://www.ada.gov/pcatoolkit/chapStoolkit.htm

U.S. Department of Justice, Civil Rights Division, Disability Rights Section
https:ljwww.ada.gov/websites2.hJm

Web design Standards: https://www.w3schools.com/

Web Content Accessibility Guidelines (WCAG) https:llwww.w3.org/TR/WCAG21/

VGlobalTech Web Content Accessibility Implementation and Checkpoints: http://vglobaltech.com/website-compliance/

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EXPERIENCE INNOVATION

(!.

Contact Information: Website: https://vglobaltech.co_m Email: contact@VGlobalTech.com
Call: 321-947-7777

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click for Profile

VGlobolTech.com -Experiencelnnovotian	Page 11 of 11
Your strategic partner for Web Design , Software. Marketing, and SEO solutions .
Ca ll: 321-947-7777 I Email: contac t@VGlobal Tech.com
Privale ond Con fiden tial Document . No part of this d ocu ment sha ll be produced, sent. copied lo any parties ii is nol intended for. It is
intended lar the entities fisted cleally on this prop osa l. Any distribution without written consent shall be procecuted

19

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Payment Authorizations 91 -- 93

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorizations 91-93

No. 91	Business Observer	$50.31	
No. 92	Supervisor Fee $800.00 Vogler Ashton $237.00	$1,037.00	
No. 93	Egis Insurance $5,922.00 Fishkind $12.32	$5,934.32	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 91

9/6/2019

Item	

Payee	

Invoice	

General	
No.		No.	Fund	

1	
Business Observer
Legal Advertising on 08/30/2019	

19-02469S	

$	50.31	
				
		TOTAL	$	50.31	

Chairman I Vice Chairman

RECEIVED SEP 0 7 2019

INVOICE
Legal Advertising Invoice # 19-02469S

Business Observer
1970 Main Street
3rd Floor
Sarasota, FL 34236
941-906-9'386 x322

Date 08/30/2019

Attn: Blackburn Creek Community Development District PFM Group Consulting LLC
12051 CORPORATE BLVD.
ORLANDO FL 32817

Please make checks payable to: (Please note Invoice # on check) Business Observer
1970 Main Street 3rd Floor
Sarasota, FL 34236

Description	Amount

[

$50.31

I

Serial # 19-02469S
Notice of Meeting
RE: Notice of Meeting for Blackburn Creek Community Development District K>n September 11, 2019 at 12:15PM
Published: 8/30/2019

Total

PaidI

$50.31

-	0

I

Payment is expected within 30 days of the first publication date of your notice.

ImportarifMessage

RECEIVED SEP O 5 2019

NOTICE
The Business Observer makes every effort to ensure that its public notice advertising is accurate and in full compliance with all applicable statutes and ordinances and that its information is correct. Nevertheless, we ask that our advertisers scrutinize published ads carefully and alert us immediately to any errors so that we may correct them as soon as possible. We cannot accept responsibility for mistakes beyond bearing the cost of republishing advertisements that contain errors.

'-

./

Attention: If you are a government agency and you believe that you qualify for a 15% discount to the second insertion of your notice per F.S. revision 50.061, please inform Kristen Boothroyd directly at 941-906-9386 x323.

Serial Number 19-02469S

O..,sseinrevsesr

Published Weekly Sarasota, Sarasota County, Florida
COUNTY OF SARASOTA

STATE OF FLORIDA

Before the undersigned authority personally appeared Karen Ovadia who on oath says that he/she is Publisher's Representative of the Business Observer a weekly newspaper published at Sarasota, Sarasota County, Florida; that the attached copy of advertisement,

being a Notice of Meeting

in the matter of Notice of Meeting for Blackburn Creek Community Development District on September 11, 2019 at I 2: l 5PM

in the _ Court, was published in said newspaper in the issues of 8/30/2019
Affiant further says that the said Business Observer is a newspaper published at Sarasota, Sarasota County, Florida, and that said newspaper has heretofore been continuously published and has been entered as periodicals matter at the Post Office in Sarasota in said Sarasota County, Florida, for a period of one year next preceding the first publication of the attached copy of advertisement; and affiant further says that he/she has neither paid nor promised any person, firm or coiporation any discount, rebate, commission or refund for the putpose of securing this advertisement for publication in said newspaper.
*This Notice was placed on the newspaper's website and floridapublicnotices.com on the same day the notice appeared in the newspaper.

NOTICEOFPUIIUCMEETING BIACKBURN CREEK COMJ\IIJNITY DEYEI.OPMF.NT DISTRICT
A meeting of the Board of SupenisoN of the Blackbum Crt>ek Community De,·elopmcnt District v.ill be held, Sep­ tt"mbt'r 11, 2019, at 12:15 p.m. at 5800 Lakewood Ranch Blvd.. Sarasota. FL 3·1·21-0. The meeting is oi,en to the pub­ lic ;md will he conducted in acr.urdanre with the pertinent provisions of Florida l,.'lw for Community Development Dis­ trit.'tS. Th meeting may be L-ontiuued t•J a date, time, and place to be specified on the record at the meeting.  A copy of the agenda for the meeting m.1y be obtained from PF'.'.\-1 Group Consulting, I.LC, 12051 C'.orpordlP "'81\l'l.. Orlando, 1'1orida 32817.
There may be occasions when one
or  mort> Supervisors  will  participate by
telephone.  At the abow location there
\\ill present a speakrr t IP.phone  o that any intere ted person can attend the meeting nt the above location and be fully intCmnnl of tht> disrus.c;,inni,; ttkin,1-!; place either in person or by tele­ phone communication.
Any person requiring special acNJm­ modations at this meeting because of a disability or phy.',:ical impairment should contact the llist.ri1..1: Otfo.-e at ( t-07) 723-5900 at least 3 c.1lendar days prior to the met>ting.
Each person who decides to appeal any decision made by the Board \\-ith re!lpect to an -  matter  cuasidered  ,tt the meeting is advised that person \\-ill need a record of the proceedings and that accordingly, the person may nee-ti to ensure that a 1,-crbatim record of the pn.k--et>dings is made. including tlw te:;­ timony il.Ild e\idcncc upon which such appcnl is to he b t.:d.
Vivi:m Cflrvalhu
Distn ct M,mager
August 30, 201H	19-02469S

Sworn to and subscribed before me this 30th day of August, 2019 AD.

Karen Ovadia

by Karen Ovadia who is personally known to me.

Notary Public, State of Florida
(SEAL)	Ll 8Z£ '1:1 'opuupo
"PA18 d}l?JOdIO;J l!;0Zl
P llS Q lUd lll d Op AdQ   l\l UnUIWO;J ){ddl;J UJUq){JR18 :uny
;J'TI i5u91nsuo;J dn01O W::Id

FILE COPY
ORIGINAL DELIVERED TO COURTHOUSE

BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 92
9/16/2019

Item	Payee	Invoice	General	
No.		No.	Fund	

Supervisor Fees -09/11/2019 Meeting
Dale Weidemiller	-	$	200.00
Pete Williams	-	$	200.00
John Blakley	-	$	200.00
Kevin Johnson	-	$	200.00
Vogler Ashton
General Counsel Through 08/31/2019	4833	$	237.00

TOTAL	$	1,037.00

riuu

Chairman I Vice Chairman

Blackburn Creek COMMUNITY DEVELOPMENT DISTRICT

Date of Meeting: September 11, 2019

($200.00 per Supervisor per Meeting)

Board  Members:		Present	Absent			Fee Dale Weidemiller	 					Jaot).OO Pete Williams	 		/		J9rooiJ 
John Blakley	I	JJaoo.oo 
Kevin Johnson	I	JJ,aoo.oiJ
Vacant	 	

Total: Jsoo.aD

Approved For Payment:
 	v		a.w .
Chairman/ Secre--t-a:-.ryI -

September 11, 2019
Date

Vogler Ashton, PLLC
705 10th Avenue West, Unit 103
Palmetto, Florida  34221
Phone:  941-304-3400

Blackburn Creek Community Development District c/o Neal Communities of Southwest
Florida, LLC
Sarasota FL 34240
us

Page : 1 09/10/2019
Account No:	1-33006
Statement No:	4833

Attn: District Manager
BlackbL1rn Creek COD District Counsel	RECEIVED SEP 1 0 2019

For Legal Services Rendered August 1, 2019, through August 31, 2019

Previous Balance	$1,271.50

Fee§

08/12/2019
KA	Review Agenda
For Current Services Rendered

Hours

0 60
0.60

237.00
237.00

Timekeeper Kimberly Ashto n

Recapitulat ion

Hours 0.60

Rate
$395.00

Total
$237.00

Total Current Work	237.00

E9.Y.!!ln..!._l?

09/09/2019	Payment	-1,271.50

Balance Due	$237.00

Payments Due Upon Receipt Please

BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 93
9/20/2019

Item	Payee	Invoice	General	
No.		No.	Fund	
1	
Egis Insurance & Risk Advisors			
	FY 2020 Insurance	9643	$	5,922.00	
2	Fishkind & Associates			
	Conference Calls	24597	$	12.32
-	
		TOTAL	$	5,934.32	

 	oP	
/ Assistant Secretary

�	- 
Chairman I Vice Chairman

RECEIVED SEP 2 3 2019

g	IinsSurance & R,sk Advisors

INVOICE

Customer

Acct#	Blackburn Creek Community Development District
174	
Date	09/13/2019	
Customer
S.rvlce	
Charisse Bitner	
Page	1 of 1	

		
Invoice	Summary	$	5,922.00	
Payment Amount		
Payment for:	lnvoice#9643	
100119121	

Blackburn Creek Community Development District c/o PFM Group Consulting, LLC
12051 Corporate Blvd
Orlando, FL 32817
X	Please detach and return with payment
Customer: Blackbum Creek Community Development District

Thank You

Invoice	Effective	Transaction	Description	Amount	

9643	

10/01/2019	

Renew policy	Policy #100119121 10/01/2019-10/01/2020
Florida Insurance Alliance POL,EPLl,EBL,Herb & Pest- Renew policy Due Date: 9/13/2019

RECEIVED SEP t 6 2019	

5,922.00	
	Total	
	$	5,922.00	
	Thank You	
FOR PAYMENTS SENT OVERNIGHT:
Egis Insurance Advisors LLC, Fifth Third Wholesale Lockbox, Lockbox #234021, 4900 W 95th St Oak/awn, IL 60453		

Remit Payment To: Egis Insurance Advisors, LLC
Lockbox 234021 PO Box 84021
Chicago, IL 60689-4002

(321)233-9939

sclimer@egisadvisors.com

Date
09/13/2019

IIE !

Florida
Insurance

\1 '1 Alliance

PREMIUM SUMMARY

Blackburn Creek Community Development District
c/o Fishkind & Associates, Inc.
12051Corporate Blvd
Orlando, Fl 32817

Term: October 1, 2019 to October 1, 2020

Quote Number: 100119121

PREMIUM  BREAKDOWN

Property (Including Scheduled Inland Marine) Crime
Automobile Liability Hired Non-Owned Auto Auto Physical Damage General Liability
Public Officials and Employment Practices Liability TOTAL PREMIUM DUE

Not Included Not Included Not Included
Included Not Included
$3,499

$2,423

$5,922

IMPORTANT NOTE
Defense Cost - Outside of Limit, Does Not Erode the Limit for General Liability, Public Officials liability, and Employment related Practices Liability.

Deductible does not apply to defense cost. Self-Insured Retention does apply to defense cost.

Additional Notes:
Quote Subject To:

Blackburn Creek Community Development District making their website ADA Compliant. If not completed, an ADA Exclusion will be added to the policy.
Page I 7

..	Ill
Fishkind & Associates, Inc.
12051 Corporate Blvd.
Orlando, FL 32817

i FISHKIND
·& ASSOCIATES

Blackburn Creek COD 12051 Corporate Blvd.
Orlando, FL 32817

RECEIVED SEP 1 6 2019

Invoice

Invoice #:  I24597
9/13/2019

File: BlackburnCreekDM

Blackburn Creek COD

Services:	Amount
Conference Calls	12.32

Please include the invoice number on your remittance and submit to:
Fishkind & Associates, Inc.
12051 Corporate Blvd.
Orlando, FL 32817
Ph: 407-382-3256
Fax: 407-382-3254
www.fishkind.com

Balance Due	$12.32

Conference Detail
MODEMTOR	40323156 - Vivian Carvalho

LOCATION

1• nvo1• ce
INVOICE NUMBER INVOICE DATE ACCOUNT NO. DU£ DATE
TAXIO
AMOUNT OU£

PAGE)
28299102
08/26/2019
85735742
09/25/2019
58-2421656
US0$577.17

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BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2018-109 – 2018-112

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2018-109—2018-112

2018-109	Neal Communities	$29,500.00	
2018-110	Forsberg Construction, Inc.	$262,418.07	
2018-111	Forsberg Construction, Inc.	$3,420.00	
2018-112	Kimley-Horn and Assoc.	$11,502.33	

Blackburn Creek Community Development District
FORM OF REQIDSITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, For Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March 1, 2018 (the Master Indenture as amended and supplemented is hereinafter refetTed to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2018-109

Neal Communities of Southwest Florida 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240

$29,500.03

Purpose for which paid or incutTed (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs of Issuance, if applicable):

Reimbursement of developer-funded Utility Construction Permit Fee and payment of Contractor and Sub-Contractor invoices for Grand Palm, Phase 2B East

The undersigned hereby certifies that [obligations in the stated amount  set  forth  above have been incurred by the District, that each disbursement set forth above  is a  proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has  not  previously  been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or kpproving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By: �	
Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (0 the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

-	-
Consulting Enginee. 1

SARASOTA COUNTY GOVERNMENT
1001 Sarasota Center Blvd, Sarasota, Fl 34240 (941) 861-6678
4000 S.Tamiami Trail.Venice FL 34293	(941) 861-3029
1660 Ringling Blvd, Sarasota, FL 34232	(941) 861-5000

Receipt#   1514335	- June 11, 2019 NEAL COMMUNITIES OF SW FLORIDA LLC
5800 LAKEWOOD RANCH BLVD N LAKEWOOD RANCH FL 34240-8479
Phone: (941)328-1052

19 130389 00 UE

GRAND PALM 28 EAST		

Fee Description	
Payment Type	
Memo		Amount Paid	
Utility Acct Deposit	Check	1-00163908		$29,500.03	
			Total:	$29,500.03	

To request the installation of a water meter by Sarasota County Public Utilities after all applicable capacity/meter fees have been paid, please call (941) 861-6767 option 2.

Check review status,lnspection status and pay fees on the IVR (941) 861-6441 and on the Web at https://bullding.scgov.net. Available 24n

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March 1, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2018-110

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

Amount Payable:

$262,418.07

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Grand Palm, Phase 2B East Application No. 4 (See attached Invoice). This Application for Payment is approved based on a site and observation of work.

The undersigned hereby certifies that [obligations in the stated amount set fo1th  above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting  the  right to receive payment of, any of the moneys payable to the Payee set  forth  above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no  item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs oflssuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the  vendor of the prope1ty acq uired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:	·

Aut'ed Officer

CONSULTING ENGINEER' S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalize d interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

w
Consulting Engineer

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2B East (CDD Portion)

ENGINEER	Kimley-Horn and Associates, Inc. OWNER	Blackburn Creek CDD
5800 LakewoodRanch Boulevard
Sarasota, FL 34240	REQUESTNO

NTP DAT E
Contract Tim SUBSTANTIA FINAL

CONTRACTO	.

e L

R	4

March 1, 2019
330 Days
January 25, 2020
February 22, 2020

Forsberg Construction,Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FORWORK COMPLETED FROM	8/1/2019	TO	8/31/2019	

CONTRACT PAYMENT SUMMARY

O riginal Co ntract Amount (CHANGE ORDER #8)
Change Orders:	1,197,472.00	
Change Order Summary		
Number	Date Aooroved	Additive	Deductive		
		-			
		-			
		-			
		-			
Subtotals	-	-		
Net Change Order Subtotal (Additive less Deductive)	-	
Current Contract Amount (Original Amount+ CO's)	I,197,472.00	
	Previous Status	Current Status		
Value of Work in Place		719,724.00	90%	1,080,700.00		
Value of Material Purchased by Owner Total Earned(% & $)
Retainage (% & $)	
41%
5%	225,551.68
494,172.32
24,708.62	
64%
5%	310,298.12
770,401.88
38,520.09		
Net Earned (Total earned minus retainage)		469,463.71		731,881.78	731,881.78	
Total Previous Estimat es					469,463.71	
AMOUNT DUE THIS PERIOD					262,4 I8 .07	

CERTIFICATION OF CONTRACTOR
The undersigned Contractor hereby swears under penalty of perjury that (I) all previous progress payments received from the Owner on account of Work performed under the Contract referred to above have been applied by the undersigned to discharge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 3 inclusive; and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances; and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective as that term is defined in the Contract Documents.

                                 erg Construction, Inc.
Notary Public, State of Florida	645 Charlotte Street
My Commiss ion expires August	"('Y"Y"Y",,,...,.Y V' ......,.,...'V V Y"'-"'7' Punta Gorda, Florida 33950 Sworn and subscribed to  me this		Phone (941 ) 637-8500

5th day of September AD 2019	Fax (941) 639-1073 (STAMP / SEAL )
Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

SIGNATURE	DATE

Engineer Owner

Project: Owner: Engineer:

Grand Palm Phase 2B East (CDD Portion)
Blackburn Creek CDD
Kimley-Hom and Associates, Inc.

Forsberg 0,nstruction, Inc.
645 Charlotte Street
Punta Gorda, FL 33950

Pay Request No. For work from:
To:

I

I

PREVIOUS WORK

I

WORK THIS PERJOD

I

WORK TO DATE

4
8/1/2019
8/31/2019
I PERCENT

 	 	 	

1	910	24" RCP	221	LF  -! ---65.00	14,365.00	75.0	4,875.00	146.00	9,490.00	221.00	14,365.00	COMPLETE
%	
	11111--
100.00%	
2	910	30" RCP	348	LF i	84.00	29,232.00	320.0	26,880.00	28.00	2,352.00	348.00	29,232.00	100.00%	
3	9IO	36" RCP	1,211	LF	116.00	140,476.00	1211.0	140,476.00	0.00	-	1211.00	140,476.00	100.00%	
4	910	42" RCP	177	LF	151.00	26,727.00	177.0	26,727.00	0.00	-	177.00	26,727.00	100.00%	
5	910	34"x53" RCP	475	LF	226.00	107,350.00	475.0	107,350.00	0.00	-	475.00	107,350.00	100.00%
'	
6	910	Grated Swale Inlet	3	EA	3,400.00	10,200.00	3.0	10,200.00	0.00	-	3.00	10,200.00	100.00%	
7	910	Type "F" Inlet 36" x 48" (inside size)	2    EA	4,200.00	8,400.00	0.0	-	2.00	8,400.00	2.00	8,400.00	100.00%	
8	9IO	Type "F" Inlet 42" x 60" (inside size)	2    EA	6,900.00	13,800.00	2.0	13,800.00	0.00	-	2.00	13,800.00	100.00%	
9	910	Type "M" Inlet 36" x 48" (inside size)	2	EA	4,200.00	8,400.00	2.0	8,400.00	o.oo:	-	2.00	8,400.00	100.00%	
10	9IO	Type "M" Inlet 42" x 60" (inside size)	4    EA	6,900.00	27,600.00	4.0	27,600.00	0.00 1	-	4.00	27,600.00	100.00%	
II	9IO	30" Flared End Section	2    EA	4,500.00	9,000.00	2.0	9,000.00	o.oo:	-	2.00	9,000.00	100.00%	
12	910	36" Flared End Section	3    EA	5,800.00	17,400.00	3.0	17,400.00	0.001	-	3.ooi	17,400.00 '	100.00%	
13	9IO	42" Flared End Section	1	EA	6,600.00	6,600.00	1.0	6,600.00	0.00	-	1.00:	6,600.00 :	100.00%	
14	910	34"x53" Flared End Section	2    EA	6,600.00	13,200.00	2.0!	13,200.00	0.00	-	2.00:	13,200.00  i	100.00%	
15	9IO	Small Control Structure	3     EA	5,600.00	16,800.00	3.0	16,800.00	0.00	-	3.00[	16,800.00 i	100.00%	
16	9IO	Construct Swale	360	LF	12.00 !	4,320.00	0.0	-	360.00	4,320.00	360.00i	4,320.00	100.00%	
17	9IO	Rip-Rap for Bubbler Structures	23	SY	l00.00;	2,300.00	0.0	-	23.00	2,300.00	23.00i	2,300.00	100.00%	
18	910	16" Roadside underdrain	-	LF	16.00	-	0.0	-	0.00	-	0.00'	-	100.00%	
19	9IO	Underdrain cleanout	-	I         EA	450.00	-	0.0	-	0.00	-	0.00	-	100.00%	
20	910	I6" Underdrain plug	-	,  EA	50.00	-	0.0	-	0.00	-	0.00	-	100.00%	
21	9IO	!Modified Type "F" curb	3,230 '  LF	l0.80	34,884.00	0.0	-	0.00	-	0.00	-	0.00%	
22	910	Type "M" curb, includes all transitions	4,550 i LF	l0.80	49,140.00	0.0	-	0.00	-	0.00	-	0.00%	
23	910   JCurb ramp	1 ! EA	780.00	780.00	0.0	-	0.00	-	0.00	-	0.00%1

960	Manholes 0' - 6'	I	4	EA  I	5,600.00	22,400.00	1.0	5,600.00	3.00	16,800.00	4.00	22,400.00	100.00%	

2		
	960	Manholes 6' - 8'	4	EA:	6,200.00	24,800.00	3.0	18,600.00	1.00	6,200.00	4.00	24,800.00	100.00%	
3	960	Manholes 8' - IO'	1	EA:	7,000.00	7,000.00	0.0	-	1.00	7,000.00	1.00	7,000.00	100.00%	
4	960	8" PVC (SDR 26) Gravity Sewer 0' - 6'	230	LF  I	34.00	7,820.00	230.0	7,820.00	0.00	-	230.00	7,820.00	100.00%	
5	960	8"  PVC (SDR 26) Gravity Sewer  6' - 8'	680	LF	52.00	35,360.00	416.0	21,632.00	264.00	13,728.00	680.00	35,360.00	100.00%	
6	960	8" PVC (SDR 26) Gravity Sewer 8' - 10' i	667	LF	70.00	46,690.00	280.0	19,600.00	387.00	27,090.00	667.00	46,690.00	100.00%	
	960	Double sewer service	43	EA	1,500.00	64,500.00	0.0	-	43.ool	64,500.00	43.00	64,500.00	100.00%	
	960	Connection  to  existing gravity sewer	2     EA	6,600.00	13,200.00  I	2.0	13,200.00	0.00i	-	2.00	13,200.00	100.00%	
960	Testingofgravityse-	-	0.00	-	I	0.001	-	0.00%	

2	1010
l010	8" PVC DR-18, C900 Water Main
12"PVC DR-18, C900 Water Main		2,120
720	LF
LF	28.00
44.00	59,360.00
31,680.00	0.0
636.0	-
27,984.00		2120.00
84.00	59,360.00
3,696.00	2120.00
720.00	59,360.00
31,680.00	l00.00o/	
3	l010	14"SDRl 1 Directional Drill		250	LF	220.00	55,000.00	250.0	55,000.00	:	0.00	-	250.00	55,000.00	l00.00%1	
4	1010	8" Gate valve and valve box		2:	EA	2,000.00	4,000.00	0.0	-	I	2.00	4,000.00	2.00	4,000.00	100.00%	
5	1010	12" Gate valve and valve box	
!	2	EA	3,100.00	6,200.00	0.0	-		2.00	6,200.00	2.00	6,200.00	100.00%	
6	1010	Fire Hydrant Assembly		3	EA!	6,000.00	18,000.00	0.0	-		3.00.	18,000.00	3.00	18,000.00	100.00%	
7	l010	Single water service (Short)		42	EA	1,000.00	42,000.00	0.0	-		42.00i	42,000.00	42.00	42,000.00	100.00%	

Project:	Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	4
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	8/1/2019
Engineer:	Kimley-Horn  and Associates, Inc.	Punta  Gorda, FL  33950	To:	8/31/2019	
ITEM	I
NO.	CODES	DESCRIPTION	I
OFWORK	I
_QUAN	I
iuNIT	UNIT    I
PRICE	
CONTRACT TOTAL	PREVIOUS WORK
I	QTY	VALUE	WORK THIS PERIOD
I  QTY	VALUE	WORK TO DATE
I	QTY	VALUE	PERCENT
COMPLETE
%	
8
9
IO
11   I
I
2
>----;i:·-··
 	5..	JOJO JOJO 1010
1010

1260
910
260
260	Single waterservice (Long) Tie-in to existing Water Main Pressure testing of main
Chlorination and bacteriological

IFloridaTrenchSafetyAct
:Materia1Pricelncreasesfor2019.
!Construction stakeout
!Record drawings/ As-Built Survey			44	EA
4	EA
3,090	LF
j	3,090.    LF

1'LS I LS
I LS 1 LS	

I	1,200.00	52,800.00	0.0j	44.00	52,800.00
2,500.00  '	10,000.00	1.01	2,500.00	l.00i	2,500.00
2.JO	6,489.00	0.0	0.00[	i
1.90	~··	5,871.00 :	o.o:	o.OOl
100.001	100.00 I	I.Qi	100.00	0.00	-	!
--53,020.00i	53,020.00	1.0:	53,020.00+---0 .0 0+-----
?5,600 001	25,600.00	--   0.61	15,360.00	0.401	;lfl,:'J.dcfJ.U·O·i
8,300.00J	8,300.00	0.01	i	0.00	-	I	44.001	52,800.00 !	J00.00%
2.001	5,000.00·	50.00%
0.001	·	0.00%
0.00	-- ··o.OOo/o
 	l.00i	J00.00 I	J00.00%
1,.vnnv1,	53.020.00··:·	100-.-0-0-%-
1.00	25,600.00  i	J00.00%	
								0.00	---	-	1	0.00%	
6	510	'Mobilization			I LS		50,000.00i	50,000.00 _	LOI	50,000.00 i	0.00j	- 	1.00		50,000.00 	'	J00.00%	
 			TOTAL						1197,472.00	719,724.00	360,976.00	1,080,700.00		90.25%	
							Summary of Work Classifications				
		PHASE3C									
		DRAINAGE					$	540,974.00	$	429,308.00	$	26,862.00	$	456,170.00		84.32%1	
		SANITARY SEWER					$	228,078.00	$	86,452.00	$	135,318.00	$	221,770.00		97.23%	
		WATER DISTRIBUTION					$	291,400.00	$	85,484.00	$	188,556.00	$	274,040.00		94.04%1'	
		MISCELLANEOUS					$	137,020.00	$	118,480.00	$	J0,240.00	$	128,720.00		93.94%1	
		TOTAL					$   1,197,472.00	$	719,724.00	$	360,976.00	$ 1,080,700.00		90.25%	

 	

 	 	

,

Project: Grand Palm Phase 2B East (CDD Portion) Owner: Blackburn Creek CDD
Engineer: Kimley-Horn and Associates, Inc.

Forsberg Construction, Inc.
645 Charlotte Street
Punta Gorda, FL 33950

Pay Request No. For work from: To:

4
8/1/2019
8/31/2019

ITEM NO.

DESCRIPTION OF WORK

_QUAN iuNIT

MATERIAL UNIT PRICE

PURCHASE ORDER TOTAL

PREVIOUS WORK

_QTY	VALUE

WORK THIS PERIOD

_QTY	VALUE

WORK TO DATE

_QTY	VALUE

PERCENT COMPLETE!
%

I

I.a   DRAINAGE (excludes FDOT final pipe inspectio,.n.,)	,	,	,	,	,
I	24" RCP	221' LF	24.78  I	5,476.38	75.00	1,858.50	146.001	3,617.88  !	221.00	5,476.38	100.00%1
2	30" RCP	'	348 i  LF	-35.13 ,	12,225.24 1	320.00	11, jl.60	28.00'	983.64 1	348.00	12:225.24	100.00%1
3	36" RCP	,	1,211,	LF	48.73  .	59,012.03	1211.()0	59,012.03 i	0.00:	-   _ 1	1211.00	59,01_2,03	100.00%1
4	142" RCP	177    LF	62.92	11,136.84	177.00	11,136.84:	0.00	-	177._00	11,136.84	100.00%
I	5	,3·4•'x53" RCP	475    LF	106.41	50,544.'75	475.00	50,544.75 1              _	0.00	-	4i5.00	50,5_44.75  .	io0.00%
6	!Grated Swale Inlet	3    EA	2,369.40  '	7,108.20	3.00	7,108.20 !	0.001	3.00	7,108.20	100.00%
-
7	!Type "F" Inlet 36" x 48" (inside size)	2    EA	1,943.04 !	3,886.08 j	0.00-	-	'	2.00i	3,886.08	2.00	3,886.08	100.00%
8	Type "F" Inlet 42" x 60" (inside size)	2    EA   ·	1,943.04 :	3,886.08  '	2.00	3,886.08	0.00:	-	2.00	3,886.08	JOQ.00%
9	!Type "M" Inlet 36" x 48" (inside size)	2    EA	_1,986.40  i	3,972.80  1	2.00i	3,972.80  ---	0.00 I	-	2.00   .	3,972.80	100.0Q I
10	Type"M"Inlet42"x60"(insidesize)	'	4:    EA	1,986.401	7,945.60 j	4.00:	7,945.60,	0.00i_	-	4.001	7,945.60	IO0.00o/"I

1

_1    1 	30"FlaredEndSection	2    EA	1,315.401.	2,630.80  I	2.0QI	2,630.80:	 <J.ool	-	2.001	2,630.80	IO0.00¾j
,	12	36"FlaredEndSection	3    EA	1,562.00 !	4,686.00 i	3.oo:	4,686.00 i	0.00I	-	3.00!	4,686.00	100.00%
'	13	42" Flared End Section	-·	I	EA	- 1,809.50	1,809.50	1.001	1,809.50	0.00	-	1.00	:    1,809.50	100.00%
14	34"x53" Flared End Section	2    EA	_1,962.10	3,924.20	2.00	3,924.2Q	0.00	-	2.00	3,924.20	100.00%
15	Small Control Structure	'	3	EA	2,339.89	7,019.67	3.00	7,019.67	0.00	..-	3.00	7,019.67	100.00%
16	Construct Swale	360    LF	-	-	0.00	-	360.00	-	360.00	-	100.00%
---17	Rip-Rap for Bubbler Structures	23    SY	-	-	0.00	-	23.00	-	23.00	-    ·:	100.00%
1-----------------·	-··	---
18	6" Roadside underdrain	-	i   LF	-	-	0.00	-	0.00	-	0.00	-	I	100.00%
  jUnderdrain cleanout	.....	-	I          EA	-	'I	-	0.00,	- -	0.00	-	0.00	-	i	100.0
20	16" Underdrain plug	-	EA	-	-	0.00,	-	0.00	-	0.00!	-	100.00%
21	jModifiedType"F"curb	3,230jLF	-	I	-	0.00'	_ _:_	-	0.00	-	0.00	-   :	100.00%

I----2-2	'Type"M"curb,includesalltransitions	4,550--

LF	-

. -	-	0.00•	-	0.00	--

-	0.00	-	100.0.0. %-

C_urb ramp	I	EA.	_	-	-	I	0.00	-	0.00!	-	0.00	-	i	100.00¾I
jl.b  SANITARY SEWER	..	i	_
1	IManholes0'-6'	,	4	EA	1,577.15 I	6,3     08.60 1	1.00	1,577.15	3.W	4,731.45	4.00	6,308.60	100.00%
2	I    Manholes 6' - 8'	4  I  EA  1	1,782.43. I	7,129.72 •	3.00	5,347.29	1.00·	1,782.43 1	4.00	7,129.72	100.00%
,	3	!Manholes 8' -10'	,	I  I  EA  I	1,791.22	1,791.22	0.00	-	I	1.00'	1,791.22	1.00	1,791.22	100.00%
'	4	8"PVC(SDR26)GravitySewer0'-6'    J      230: LF	3.97	913.10	23(),00	913.10,	 0,00i	-	230.00	913.10	l00.00%1

,	5	i8"PVC(SDR26)GravitySewer6'-8'	I	680' LF
1

3.97	2,699.60,	416.00	1,651.52:	264.00I	1,048.08,	680.00	2,699.60	100.00%

'	6	8"PVC(SDR26)GravitySewer8'-10'	667    LF   !	3.97,	2,647.99,    ...	280.00	1,111.60	387.00	1,536.39 i	667.00	-	2,647.99	100.00%
,	7	Double sewer service	43    EA	313.46 I	13,478.78 :	0.00	-	,	43.00	13,478.78	43.00i	13,478.78	100.00%
1	8	Connection to existing gravity sewer	2    EA -	-	-·	2.00	-	!	0.00	·	-	2.00:  -	-	0.00%
9	Testingofgravitysewer	:	1,577    LF   I	-	I	-	0.001	-_	I	0.00	-	0.00	-	0.00%
WATER DISTRIBUTION	I     -- -   -	i					I				,				 I	8"PVCDR-18,C900WaterMain	1·   2,120 I   LF   i	7.78	16,493.60	·o.oo	.:		:ff20.oo	1_6,493.60	2120.00'	16,493.60 I	I0<J.00%1
2	12" PVC DR-18, C900 Water Main	720  I   LF   '	19.92	14,342.40	636.00	12,669.12	84.00! 		1,673.28	720.00	14,342.40,	100.00%)
3   ,       14" SDRl 1 Directional Drill	250    LF	49.65	12,412.50	250.00	12,412.50	0.00	-	250.00	12,412.50 !	100.00%
4	8" Gate valve and valve box	2  I  EA	847.30	1,694.60 i	0.00	-	2.00	1,694.60  !	2.00	1,694.60  I	100.00%1
5	12" Gate valve and valve box	'	2  ! EA .	·-   1,551.68 i	3,_1_03.36 1	0.00	-	I	2.00	3,103.36 I	2.00	3,103.36 !	100.00%
I_	6	,F1reH)'.drantAssembly	I	3  !    EA   i	2,286.91  '	6,860.73	0.00	-	'	3,00'	6,860.73	_3.00	6,860.73  I	100.00%1

Project: Grand Palm Phase 2B East (CDD Portion)

Forsberg Construction, Inc.

Pay Request No.

4

ITEM NO.
7
8
9

OF WORK
Single water service (Short) Single water service (Long) Tie-in to existing Water Main Ferguson Adjustment
Cast Adjustment County Adjustment TOTAL

i

QUAN kThlIT
42 j             EA  I
44    EA! 4 I EA 1

PRICE

328.14 ·-

TOTAL 13,781.88
16,018.20

QTY
O.OO!
o.ocii

VALUE

-
-
325.75 _I
-
-
-
212,784.60

QTY
'	42.00
44.00
3.00
-1.00 -
-1.00 -
-1.00 -
$

VALUE 13,781.88 I
16,018.20
977.25
6,847.96
3,129.37
3,532.04
79,949.48

QTY

VALUE

42.007 	13,781.88 

--·

%
 I00.00% I00.00%

--··•--

(I) EA I
(I)    EA
(I)   EA     

364.05
325.75
6 		,847.96
3,129.37
3,:532.04  	
$

1,303.00 	1.00	

...

(6,847.96)
(3,129.37)
(3,532.04)
292,734.08

0.00.
0.00
0.00

44.00'
4.00
-1.001-
-1.00,.
 -1.00 -	
$

16,018.20
1,303.00 	I00.00%

6,847.96
3,129.37

I00.00% I00.00%

$

-

3,532.04 	I00.00%

292.734.08 I

I00.00%

Summary

Owner: Blackburn Creek CDD	645 Charlotte Street	For work from:	8/1/2019	
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

	MATERIAL	PURCHASE	PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT	
DESCRIPTION			UNIT	ORDER				COMPLETE	

Ferguson Waterworks	$	98,901.78	$	29,083.59	$	69,818.19	$	98,901.78	100.00%	
Cast Systems	$	45,918.60	$	36,856.79	$	9,061.81	$	45,918.60	100.00%	
County Materials	$	147,913.70	$	146,844.22	$	1,069.48	$	147,913.70	I00.00%	
6% State Sales Tax	$	17,564.04	$	12,767.08	$	4,796.97	$	17,564.04	I00.00%	
TOTAL	$	310,298.12	$	225,551.68	$	84,746.45	$	310,298.12	100.00%	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Conununity Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March I, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2018-111

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950

$3,420.00

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Grand Palm, Phase 2C Application No. 12 (See attached Invoice). This Application for Payment is approved based on a site and observation ofwork.

The undersigned hereby certifies that [obligations in the stated amount set forth  above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not  previously  been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim  affecting  the right to receive payment of, any of the moneys payable to the Payee set  forth  above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from  other than the Costs oflssuance  Account or for payment of capitalized interest, there shall be attached a resolut io n of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the  invoice(s)  from the vendor of the  property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By �	
Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payri1ent of capitalized interest, the undersigned Consulting Engineer hereby cettifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental lndenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

lJ

CONTRACTORS'  APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2C (CDD Portion)

ENGINEER	Kimle y-Horn and Associates, Inc.

OWNER	Blackburn Creek CDD
5800 Lakewood Ranch Boulevard
Sarasota, FL 34240	REQUEST N

NTP DATE
Contract Tim SUBSTANTI FINAL

CONT RACTO	O.

e AL

R	12

March 26, 2018
337 Days
February 26, 2019
March 26, 2019

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	7/1/2019	TO	8/31/2019	

CONTRACT  PAYMENT SUMMARY

Original Contract Amount Change Orders:	2,104,919.00	
Change Order Summary		
Numbe r	Date Approved	Additive	Deductive		
3	5/29/2018	9,012.00			
4	11/26/2018	171,420.00			
		-			
		-			
Subtotals	180,432.00	-		
Net ChangeOrder Subtotal (Additiveless Deductive) Current Contract Amount (Or iginal Amount + CO's)	180,432.00
2,285,351.00	

Value of Work in Place
Value of Material Purchased by Owner Total Earned(% & $)
Retainage(% & $)	PreviousStatus	Current Status		

78%
5%	2,268,962.50
487,825.48 l,781,137.02
89,056.85	99%	2,272,562.50
487,825.48
78%	1,784,737. 02
5%	89,236.85		
Net Earned (Total earned minus retainage) Total Previous Estimates
AMOUNT DUE THIS PERIOD		1,692,08 0.17	I,695,500.17	1,695,5001. 7
1,692,080.17
3,420.00	

CERTIFICATION OF CONTRACTOR

The undersigned Contractor hereby swears under penalty of perjury that (I ) all previous progress payments received from the Owner on account of Work perfonned under the Contract referred to above have been applied by the undersigned todischarge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 11 inclusive; and (2) all materials and equipment incorporated in sa id Project or otherwise  listed   in or covered  by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances; and (3) all Work covered by this Applicatio n for Payment is in accordancewith the Contract Documents and not defective as that tenn is defined in the Co   ract Documents.

Ashly Wester
Notary Public, State of Florida

My Commiss ionexpires Augu	<lft:>f\,"'-1'V',AI Y ...,..,,,...,fV Y'IA N,
Sworn and subscribedto me th' 5 th day of September AD 2019

(STAMP/ SEAL)

Punta Gorda, Florida 33950 Phone (941) 637 -8500
Fax (941) 639-1073

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

SIGNATURE	DATE

Engineer Owner

Project:	Grand  Palm  Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	12
Owner:	Blackbum Creek CDD	645 Charlotte Street	For work from:	7/1/2019
Engineer:	Kimley-Hom  and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

ITEM	
DESCRIPTION			
UNIT	
CONTRACT	PREVIOUS WORK	WORK TIDS PERIOD	WORK TO DATE	PERCENT
COMPLETE	
NO.	CODES	OFWORK	QUAN	iuNIT	PRICE	TOTAL	QTY	VALUE	QTY	VALUE	QTY	VALUE	%	

2	910	24" RCP	911	LF		65.00 I	59,215.00	911.0i	59,215.00	0.00	-	I	911.00	59,215.00	100.00%	
3		910	i30" RCP	1,041	LF	84.00	87,444.00	1041.0i	87,444.00	0.00	-	:	1041.00	87,444.00	100.00%	
4	910	36" RCP	256: LF	I16.00	29,696.00	256.0i	29,696.00	0.00	-		256.oo:	29,696.00 ·	100.00%	
5	910	42" RCP	1,295, LF	151.00	195,545.00	1295.0	195,545.00	0.00	-		1295. 001	195,545.00 "	100.00%	
6	910	34"x53" RCP	381' LF	226.00	86,106.00	381.0	86,106.00	0.00	-	I	381.00	86,106.oo I	100.00%	
7	910	Grated Swale Inlet	I! EA	3,400.00	3,400.00	1.0	3,400.00	0.00	-		1.00	3,400.00	100.00%	
8	910	Type "F" Inlet 36" x 48" (inside size)	21 EA	4,200.00	8,400.00	2.0	8,400.00	0.00	-		2.00	8,400.00 '	100.00%	
9	910	Type "M" Inlet 36" x 48" (inside size)			181 EA I	4,200.00	75,600.00	18.0	75,600.00	0.00	-		18.00	75,600.00	100.00%	
10	910	Type "M" Inlet 42" x 60" (inside size)	
!	4	EA 1	6,900.00	27,600.00	4.0	27,600.00	0.00	-		4.00	27,600.00	100.00%	
II	910	24" Flared End Section		4 EA!	4,100.00	16,400.00	4.0	16,400.00	0.00	-		4.00	16,400.00	100.00%	
12	910	30" Flared End Section		6 EA;	4,500.00	27,000.00	6.0	27,000.00	0.00	-		6.00	27,000.00	100.00%	
13	910	36" Flared End Section		2 EA I	5,800.00	11,600.00	2.0	11,600.00	0.00	-		2.00	11,600.00	100.00%	
14	910	42" Flared End Section	I	8 EA	6,600.00	52,800.00	8.0	52,800.00	0.00	-		8.00	52,800.00	100.00%	
15	I	910	34"x53" Flared End Section	!	2 EA	6,600.00	13,200.00	2.0	13,200.00	0.00	-		2.00	13,200.00	100.00%	
16	I	910	Junction Box	'	2 EA	7,200.00	14,400.00	2.0	14,400.00	0.00	-	2.00	14,400.00	100.00%	
17	I	910	Small Control Structure			I	EA	5,600.00	5,600.00	1.0	5,600.00	0.00	-	1.00	5,600.00	100.00%	
18	910	Medium Control Structure	2 EA	10,000.00	20,000.00 !	2.0	20,000.00	0.00	-	2.00	20,000.00	100.00%	
19	910	Swale from Bubbler to Wetland	221	LF	12.00	2,652.00 I	221.0	2,652.00	0.00	-		221.00	2,652.00	100.00%	
20	910	Rip-Rap at Bubbler	63	SY		100.00 I	6,300.00	63.0	6,300.00	0.00	-		63.00	6,300.00	100.00%	
21	910	Connect to Existing Structure	I	LS		5,000.00 I	5,000.00	1.0	5,000.00	0.00	-		1.00	5,000.00 i	100.00%	
25	910	Modified F Curb	1,700	LF		16.20 i	27,540.00	1700.0	27,540.00	0.00		-		1700.00	27,540.00 ,	100.00%	
26	910	TypeMCurb	12,600	LF		10.80 ,	136,080.00	12600.0	136,080.00	0.00		-		12600.00	136,080.00	100.00%	
27		910	Curb Ramp	10	EA		780.00 '	7,800.00	10.0	7,800.00	0.00		-	' i	10.00		7,800.00 !	100.00%	
0'-6'	121 EA	5,600.00	67,200.00	12.0	67,200.00	0.00	-	12.00	67,200.00	100.00%
2	960	IManholes 6' - 8'	JI EA	6,200.00	6,200.00	1.0	6,200.00	0.00	-	1.00	6,200.00	100.00%	
3	960	Manholes 8' - IO'		4'	EA	7,000.00	28,000.00	4.0	28,000.00	0.00	-	4.00	28,000.00	100.00%	
4	960	Manholes 10' - 12'	51 EA	7,800.00	39,000.00	5.0	39,000.00	0.00	-	5.00	39,000.00	100.00%	
5	960	Manholes 12' - 14'		4	EA	9,000.00	36,000.00	4.0	36,000.00 !	0.00	-	4.00	36,000.00	100.00%	
6	960	Manholes 14' - 16'		2	EA I	10,500.00	21,000.00	2.0	21,000.00 :	0.00	-	2.00	21,000.00	100.00%	
7	960	Manholes 16' - 18'		I	EA!	12,200.00	12,200.00	1.0	12,200.00	0.00	-	1.00	12,200.00	100.00%	
8	960	8" PVC SDR 26 Gravity Sewer O' - 6'	1,389		LF i	34.00	47,226.00	1389.0	47,226.00	0.00	-	1389.00	47,226.00	100.00%	
9	960	8" PVC SDR 26 Gravity Sewer 6' - 8'	952	LF	52.00	49,504.00	952.0	49,504.00	0.00	-	952.00	49,504.00	100.00%	
IO	960	8" PVC SDR26 Gravity Sewer 8' - 10'	!	909	LF	70.00	63,630.00	909.0	63,630.00	0.00	-	909.00	63,630.00	100.00%	
II	960	8" PVC SDR 26 Gravity Sewer IO' - 12'	858	LF	87.00	74,646.00 I	858.0	74,646.00	0.00	-	'	858.00:	74,646.00 i	100.00%	
12	960	8" PVC SDR 26 Gravity Sewer 12' - 14'	815	LF	101.00	82,315.00	815.0	82,315.00	0.00	-	815.00	82,315.00 1	100.00%	
13	960	8" PVC SDR 26 Gravity Sewer 14' - 16'	800	LF		130.00 ,	104,000.00	800.0	104,000.00	0.00	-	800.00	104,000.00	100.00%	
14	960	8" PVC SDR 26 Gravity Sewer 16' - 18'	355	LF		160.00 I	56,800.00	355.0	56,800.00	0.00	-	355.00	56,800.00	100.00%	
15	960	Single sewer service	21	EA	1,500.00	31,500.00	21.0	31,500.00	0.00	-	21.00	31,500.00	100.00%	
16	960	iDouble sewer service	52	EA	1,500.00	78,000.00	52.0	78,000.00	0.00	-	52.00	78,000.00	100.00%	
9/5n019	Page 1 of2	Schedule of Values

Project: Owner: Engineer:

ITEM

Grand Palm Phase 2C (CDD Portion) Blackburn Creek CDD
Kimley-Horn and Associates, Inc.

DESCRIPTION	I

I	I	UNIT	I

Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950

PREVIOUS WORK	WORK TIBS PERIOD
CONTRACT

Pay Request No. For work from: To:

WORK TO DATE

12
7/1/2019
8/31/2019

PERCENT COMPLETE

NO.	CODES

OFWORK

_QUAN iuNJT

PRICE

TOTAL	I  QTY	VALUE	I

QTY	VALUE

QTY	VALUE	%

17	960	Connectiontoexistinggravitysewer	2	EA	
18	960
,:	ITestingofgravitysewer
.i   ,I,' .I.-:- ,,	-   ...   11 1i11 ri	6,078
'1lii "111	"1:	LF I 
1(: :111i!ji!i1!1l!1i;i1!ijt	

6,600.00 I	13,200.00 I	2.0	13,200.00'	0.00I

6" PVC DR-18, C900 Water Main	5,360	LF I	26.00 I 	139,360.00;	5360.0	139,360.00	QcOO'.	'D°'  00.00	
8" PVC DR-18, C900 Water Main	2,000	LF	28.00 :	56,000.00	2000.0I	56,000.00	0.00'	 	'"uoo.001	

4.00	24,312.00	6078.0	24,312.00	0.00I

2.00
---  ,-6-078.00

13,200.00  : ... 100.00%1
24,312.00  I	100.00%

I	1010
2	1010

  i:ii fii'!ijii  ''f  il\!i!!!i!ii::":ii!:1:  !ii  l  ::j  ;)g!'.i  .:I:  :-tXi f '.''. /r, ?fid+sjJ}i:f<·;;:: J i   ;  f/e(  :: ',-:  :;;:  ;];At,i	·,-- ;;:.foi/ :: !iii::::i:: i ):i  ::::(:ii!  ' !ii1:ii !1;::i1i:;!iii1111:::!i:i:i:,ft ;..:·:,::  i:);1i:i:ii  i!ii\!i'1iif!.::,

_3 	l_ 1010	6"Gatevalveandvalvebox	11   EA	1,800.00	19,800.00·	11.01

 	---,

     11.0_oj 	

4	1010     i8"Gatevalveandvalvebox	4   EA	2,000.00	8,000.00	4 0
5	1010     1      Fire Hydrant Assembly	--··	7:  EA	6,000.00	42,000.00	7 0

 	4.00;
 	7.00 

-   ---  --	·-- ---·

6	1010    ,Singlewaterservice(Short)	79' EA I 

1,000.00	79,000.00     

O!

 	7--9.0--0 

--  ---  --	·-- ---··

7	1010    !Single water service (Long)	46   EA i 	1,200.00	55,200.00	46- 

46.00 ----

-- ---  --	· -- ----

8	1010  i8"x8" Tapping Sleeve and Valve	1   EA	7,800.00	7,800.00	I 0

IO
i---1--)_.		1010
1010	'Tie-in to existing Water Main Pressuretestingofmain	4:  EA
7,3601  LF	2,500.00
2.10- 	
12		1010	I Chlorination and bacteriological	7,360 LF	1.90
: :-i :	f rJ1t1;H]	

i---b-, I               1010  IBiowoff Assembly	2:  EA	1,200.00	2,400.00	2 0
10,000.00	3 0

1.00
2.00
3.00 	

15,456.00	73·6o..o
13,984.00	1945.0

3,695.50,

-73-6-0-.0, 0 '"I' '1'+::;.oo

"'"	--	'

·-- ,,.,

)	,
1	1260
3	260

:	,/'"	i"	'    1:i!: ! [i! i)!   ;]! il W:lji!l1 i!l!i,i.\l*l1 f   &:,11    :iiii! @! !ii!ii!im	lijlWii!il:ti !t;iitli!iiii ll Hi"ili::::11 } ; ;r ]J:iI f iir:\( 1.i:(; - l  ;i
Florida Trench Safety Act	I ILS	100 001I 	_ 100.00
Construction stakeout	I ILS    --+"-- 2=3 ,4 0 0 ·)0' 1  --=2'3-,400'.00-I  '-'--'--    --

.	1.00	100.00 	100.00% 
.	1.00	23,400.00 	100.00% 

t-. 4

260

-----,"-
Record drawings/ As-Built Survey	1 jLS	'

7, 2 000'0+1 -- '-'7-,2-0"0-.00  '

3,_600.00

1.00	7,200.00 	100.00% 

5	510

-""

Mobilization	1i  LS	50,000 00	50,000.00
TOTAL	2,285,351.00	2,268,962.50
Summary of Work Classifications

-
3,600.00

1.001	50,000.00 I
2,272,562.50

100.00%
99.44%

PHASE3C		
DRAINAGE	$	920,918.00	$	920,918.00	$	$	920,918.00	100.00%	
SANITARY SEWER	$	834,733.00	$	834,733.00	$	$	834,733.00	100.00%1	
WATER DISTRIBUTION	$	449,000.00	$	436,211.50	$	$	436,211.50	97.15%	
MISCELLANEOUS	$	80,700.00	$	77,100.00	$	3,600.00	$	80,700.00	100.00%	
TOTAL	$ 2,285,351.00	$ 2,268,962.50	$	3,600.00	$ 2,272,562.50	99.44%	

260
510
910
960
1010
1260

TOTAL

Summary of Accounting Codes

$	30,600.00	$	27,000.00	$	3,600.00	$	30,600.00	100.00%	
$	50,000.00	$	50,000.00	$	$	50,000.00	100.00%	
$	920,918.00	$	920,918.00	$	$	920,918.00	100.00%	
$	834,733.00	$	834,733.00	$	$	834.733.00	100.00%1	
$	449,000.00	$	436,211.50	$	$	436,211.50	97.15%	
$	100.00	$	100.00	$	$	100.00	100.00%	
$ 2,285,351.00	$ 2,268,962.50	$	3,600,00	$ 2,272,562.50	99.44%	

Project:    Grand Palm Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	12
Owner:    Blackburn Creek CDD	645 Ch•arlotte Street	For work from:	7/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

ITNIT	MATERIAL
UNIT PRICE	PURCHASE ORDER
TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT
COMPLETE
%	
	I.a DRAINAGE (excludes FDOT final pipe insoection) i		'
'			:		
I	18" RCP			28	LF		17.12	479.36	28.00	479.36	0.00	-			28.00	479.36		100.00%	
2	24" RCP	911	LF		22.85	20,816.35	911.00	20.816.35	0.00	-· -			911.00	20.816.35		100.00%	
3	'30" RCP		1,041
256	LF	32.38	33,707.58
11,594.24	1041.00		33,707.58
11,594.24	0.00	--·---	1041.00	33,707.58
11,594.24	100.00%	
4	36" RCP			LF	45.29		256.00			0.00	-
-	256.00			100.00%	
5	42"RCP	1,295	LF	56.19	72,766.05	1295.00	72,766.05	0.00		1295.00	72,766.05	100.00%	
6	34"x53" RCP	381 , LF	96.63	36,816.03 '	381.00	36,816.03	0.00	-	381.00	36,816.03 ·,	100.00%	
7	Grated Swale Inlet	I	EA	666.35	666.35	1.00	666.35		O.OO!	-	-·	1.00		666.35  , 	100.00%	
8	Type "F" Inlet 36" x 48" (inside size)	2: EA	905.83	1,811.66	2.00	1,811.66	0.00	-	2.00			
										1,811.66	100.00%	
9	Tvne "M" Inlet 36" x 48" (inside size)	18 i EA	1,330.91	23,956.38	18.00	23,956.38		o.oo:	-			18.00	23,956.38	100.00%	
10	Type "M" Inlet 42" x 60" (inside size)	4 I EA	1,330.91	5,323.64	4.00		5,323.64,		0.001	-			4.00	5,323.64	100.00%	
11	24" Flared End Section	4 ! EA	961.40	3,845.60	4.00	3,845.60:	0.00	-	4.00	3,845.60	100.00%	
12	30" Flared End Section	6 I EA	1,249.63	7,497.78	6.00	7,497.78  ·	0.00	-	6.00	7,497.78	100.00%	
13	36" Flared End Section	2 1 EA	1,483.90	2,967.80	2.00		2,967.80	i	0.00		-	'		2.00	2,967.80	100.00%	
14	42" Flared End Section	8	EA	1,719.03	13,752.24	8.00	13,752.24	0.00		-		i	8.00	13,752.24	100.00%	
15	34"x53" Flared End Section	2	EA	1,864.95	3,729.90	2.00	3,729.90	0.00		-	
!		2.00	3,729.90	100.00%	
16	Junction Box	2	EA	1,734.68	3,469.36	2.00	3,469.36	0.00	-	2.00	3,469.36	100.00%	
17	Small Control Structure	I	EA	1,572.63	1,572.63	1.00	1,572.63	0.00	-	1.00	1,572.63	100.00%	
18	Medium Control Structure	2	EA	2,782.59	5,565.18		2.001	5,565.18	0.00	-	2.00	5,565.18	100.00%	
	1.b SANITARY SEWER		i					'					
I	Manholes O' - 6'	12	EA	1,320.25	15,843.00		12.001	15,843.00	0.00	-			12.00'	15,843.00		100.00%	
2	Manholes 6' - 8'			I	EA	1,572.20	1,572.20	1.00	1,572.20	0.00	-	1.00	·-	1,572.20	100.00%	
3	Manholes 8' - IO'			4	EA		1,866.25	7,465.00	4.00	7,465.00	0.00	-	4.00		7,465.00:	100.00%	
4	Manholes 10' - 12'			5	EA'		2,152.00	10,760.00	5.00	10,760.00	0.00	-	5.00	10,760.00 !	100.00%	
5	!Manholes 12' - 14'	4	EA		2,243.00	8,972.00	4.00	8,972.00	0.00	-	4.00	8,972.00  •	100.00%	
6	Manholes 14' - 16'	2	EA	2,660.55	5,321.10	2.00	5,321.10	0.00	-	2.00		5,321.10		100.00%	
7	Manholes 16' - 18'	I	EA	2,809.00	2,809.00	1.00	2,809.00		O.OOj	-	1.00	2,809.00  I	100.00%	
8	8" PVC SDR 26 Gravity Sewer O' - 6'	1,389	LF	4.06	5,639.34	1389.00	5,639.34	0.00	-	1389.00	5,639.34	100.00%	
9	8" PVC SDR 26 Gravity Sewer 6' - 8'	952	LF	4.06	3,865.12 !	952.00	3,865.12	0.00	-	952.00	3,865.12	100.00%	
10	8" PVC SDR 26 Gravity Sewer 8' - I0'	909	LF	4.06	3,690.54 I	909.00	3,690.54		O.OO'	-	
'		909.00	3,690.54	100.00%	
11	8" PVC SDR 26 Gravity Sewer 10' - 12'	858	LF	4.06	3,483.48	858.00	3,483.48		O.OOj	-	'		858.00	3,483.48	100.00%	
12	8" PVC SDR 26 Gravity Sewer 12' - 14'	815	LF	4.06 I	3,308.90	815.00	3,308.90	0.00	-	815.00	3,308.90	100.00%	
13	8" PVC SDR 26 Gravity Sewer 14' - 16'	800	LF	4.06 j	3,248.00	800.00	3,248.00 :	0.00	-	800.00	3,248.00	100.00%	
14	8" PVC SDR 26 Gravity Sewer 16' - 18'	355	LF	4.06	1,441.30	355.00	1,441.30 i	0.00	-	355.00	1,441.30	100.00%	
15	Single sewer service	21 i EA	265.72	5,580.12	21.00	5,580.12	0.00	-	21.00	5,580.12	100.00%	
16	Double sewer service	52	EA	310.19	16,129.88	52.00	16,129.88	0.00	-			52.00,	16,129.88		100.00%	
	l.c WATERDISTRIBUTION												
I	6" PVC DR-18, C900 Water Main			5,360	LF	4.54	24,334.40	5360.00	24,334.40	0.00	-	5360.00	24,334.40	100.00%	
2	8" PVC DR-18, C900 Water Main			2,000	LF	9.10	18,200.00	2000.00	18,200.00	0.00	-	2000.00	18,200.00	100.00%	
3	6" Gate valve and valve box		I	11	EA	576.75	6,344.25	11.00	6,344.25	0.00	-	11.00	6,344.25  I	100.00%	
4	18" Gate valve and valve box			4	EA	I	839.13	3,356.52	4.00	3,356.52	0.00	-	4.00	3,356.52  '	100.00%	

Project: Grand Palm Phase 2C (CDD Portion)
Owner: Blackburn Creek CDD
Engineer: Kimley-Horn and Associates, Inc.

Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950

Pay Request No. For work from: To:

12
7/1/2019
8/31/2019

ITEM NO.

DESCRIPTION OF WORK

 	5	I Fire Hydrant Assembly
 	6	·!Single water se ice (Short)

QUAN  hJNIT
 	7    EA
79    EA

MATERIAL UNIT PRICE
2,222.21
310.20
356.79
1,767.97 '
89.62

PURCHASE ORDER TOTAL
15,555.47

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

QTY
7.00

VALUE
15,555.47

..

 	7	Single water service (Long)

24,505.80 	79.00	24,505,80
16,412.34 	46.00	16,412.34

QTY
o.oo!
0.001 0.001
Q,OOI
0.001
$

VALUE
-
-
-
-
-

I

QTY
7.00I

VALUE
15,_5_5JA1'

I 	79.00	24,505.80

PERCENT COMPLETE
%
I00.00% 100.00%

f---

  

8
IQ

8 x8" Tapping Sleeve and Valve Tie-in to existing Water Main
TOTAL

46   EA 1 I EA

    i 

4'

EA

!,767.97 I
358.48 : 460,302.34

1.00
3.00

1,767.97
268.86
460,212.72

.. --

$

$

-

I
!
I
'

46.00
1.00
3.00,  	
$

16,412.34 ,_
1,767.97  ,
268.86 i
460,212.72

100.00% I00.00% 75.00%
99.98%

Summary

Ferguson Waterworks	$	157,221.91	$	157,132.29	$	-	$	157,132.29	99.94%	
Cast Systems	$	95,107.50	$	95,107.50	$	-	$	95,107.50	I00.00%	
County Materials	$	207,972.93	$	207,972.93	$	-	$	207,972.93	100.00%	
6% State Sales Tax	$	27,618.14	$	27,612.76	$	-	$	27,612.76	99.98%	

TOTAL	$	487,920.48	$	487,825.48	$	-	$	487,825.48	99.98%	

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fott Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of March 1, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2018-112

Kimley-Horn and Associates, Inc.
P.O. Box 932520 Atlanta, GA 31193-2520

Amount Payable:	$11,502.33

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Payment of District Engineering Services related to the Bond Financed District Improvements. See attached invoice for detail.

The undersigned hereby certifies that [obligations in the stated amount set forth  above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for
Costs of Issuance payable from the Costs of Issuance Account that has  not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim  affecting  the right to receive payment of, any of the moneys payable to the Payee set  forth  above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such requ1s1t10n contains no item representing payment on account of any retained percentage which the  District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable .

Attached hereto are origina ls  of  the invoice(s)  from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRJCT

By    :		/ 
Authonzed Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract ; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

BLACKBURN CREEK COMMUNITY DEVELOP. DIST. CONSTRUCTION
ATTN: AMANDA LANE 12051 CORPORATE BLVD
ORLANDO, FL 32817

Please send payments to:
KIMLEY-HORN AND ASSOCIATES, INC.
P.O. BOX 932520 ATLANTA, GA 31193-2520

Federal Tax Id: 56-0885615

HOURLY	
Description	Current Amount Due	
SERVICES RENDERED	11,502.33	
Total HOURLY	11,502.33	

Invoice No:	14728301
Invoice Date:	Aug 31, 2019 Invoice Amount: $11,502.33
Project No:	148167000.2
Project Name:	BLACKBURN CR CDD DIST ENG
Project Manager: CONERLY, BILL
Client Reference: CONSTRUCTION FUND

For Services Rendered through Aug 31, 2019

Description of Services Performed:
- Coordination regarding resolution and provide contracts for Board to process payments for Capital Projects
- REQS 2018-98, 2018-103 thru 2018-110, 2019-24 thru 2019-32

Total Invoice: $11,502.33

If you have questions or concerns regarding this invoice, please call Joseph Marianacci at 561-840-0219.	31JJM

BLACKBURN CREEK COMMUNITY DEVELOP. DIST. CONSTRUCTION
ATTN: AMANDA LANE 12051 CORPORATE BLVD
ORLANDO, FL 32817

HOURLY	

Group	
Description	
Hrs/Qty	
Rate	Current Amount Due	
LABOR	ANALYST	19.5	104.65	2,040.72	
	PROFESSIONAL	10.0	139.81	1,398.08	
	SENIOR PROFESSIONAL I	2.0	161.03	322.05	
		32.0	223.99	7,167.74	
TOTAL LABOR	63.5		10,928.59	
EXPENSES	OFFICE EXPENSE			573.74	
TOTAL EXPENSES			573.74	
TOTAL LABOR AND EXPENSE DETAIL			11,502.33	

Invoice No:	14728301
Invoice Date:	Aug 31, 2019
Project No:	148167000.2

Project Name:

BLACKBURN CR CDD DIST ENG

Project Manager: CONERLY, BILL

This page is for informational purposes only. Please pay amount shown on cover page.

31JJM

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2019-24 & 2019-29 -- 2019-35

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2019-24 & 2019-29 -- 2019-35

2019-24	Ferguson Waterworks	$47,290.35	
2019-29	Neal Communities	$40,190.73	
2019-30	Kimley-Horn	$10,304.64	
2019-31	Cast Systems, LLC	$18,092.10	
2019-32	Forsberg Waterworks	$543.00	
2019-33	Cast System, LLC	$13,378.12	
2019-34	Cast Systems, LLC	$1,537.21	
2019-35	County Materials Corp.	$22,998.00	

Blackburn Creek Community Development District
FORM OF REQUISmON FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-24

Ferguson Waterworks FEI-PT. Charlotte #1705
18305 Paulson Drive Port Charlotte, FL 33954

Amount Payable:

$47,290.35

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(e). Purchase Order# 180501; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such reqms1t1on contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:

 		 	/'.\.	,,-----:
Auth

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made;  and  (iii)  the  repo1t  of  the  Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such repott shall
have been amended or modified on the date hereof.

Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 2A(e)

    Invoice #	Amount	
1432191	$1,142.00	
1432980	$7,728.50	
1432980-1	$2,032.78	
1433250	$6,470.00	
1432191-1	$946.00	
    1433637	$28,971.07 
Sub-Total	$47,290.35

FERGUSON ®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

JUL 1 0 2019

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1432191	$1,142.00	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
CIO FORSBERG CONSTRUCTION PO#180501
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE ST

SHIP
WHSE.
1705	SELL WHSE.
1705	TAX CODE

FLE	CUSTOMER ORDER NUMBER

180501 - WfR TAP/WIR	SALESMAN

TAE	JOB NAME

PH2AE SOURCE	INVOICE DATE

07/09/19	BATCH
10
81330	
ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	
Source Order#: 1415124
20	10   C1230BSF500	12GA 30MM 500 FT COP TRCR IMRE BLUE	- 89 . 000	
EA	
890.00	
11	9   PD3105B52737	3X1000 UG DET WTR BLUE
2	0   BUF10083PB	10LB T-SHRT MULTl COLORED RAGS BAG	8.000	EA
EA •	252.00
0.00	
INVOICE SUB-TOTAL			1142.00	

LEAD LAW WARNING: IT IS ILLE< Al TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH				
US FEDERAL < ROTHER APPLICABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION
PRODUCTS \/Ii TH •NP IN THE DESCR IPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLEDIN				
NON-POTABLE APPLICATIONS. UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.				

Thank you for your business				
TE RMS:	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE		$1,142.00	

V

FERGUSON®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

    INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1432980	$7,728.50	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION PO#180501
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE ST

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501

SALESMAN

TAE

JOB NAME

PH2AESOURCE

INVOICE DATE

07/16/19

BATCH
10
81371

ORDERED

5
5
5
5
s

SHIPPED

5
5
0
S S

ITEM NUMBER

I461SW  IMJBGPU AFC2606DLAFMM RBGVTMU AFCBB4BLAOLP

DESCRIPTION
Source Order#: 1415124
FIRE HYO ASSM (5) -
2PC SC Cl VLV BX 19-22 WTR
6 MJ C153 BLT GSKT PK UGLAND
6 DI MJ RWOL SS STEM VLV UA
3 BRS GATE VLV ID - 6
5-1/4 VO B84B HYO 4'0 OL L/A

INVOICE SUB-TOTAL

UNIT PRICE	UM

/   95 000	EA
,/    12.700	EA EA
,./       13.000	EA
/	1425.000	EA

AMOUNT

475.00
63.50
0.00
65.00
7125.00

7728.50 /

LEAD LAWWP RNING : IT IS ILLE < AL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I R OTHER APPLIC f",BLE LAWIN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH 'NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLEDIN
NON-POTABLI APPLICATIONS. BUYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

FERGUSON ®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

JUL 1 8 2tli9

    INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1432980-1	$2,032.78	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRANO PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION PO#180501
PUNTA GORDA, FL 33950

FORSBERG CONSTRUCTION INC OBSERVATION BLVD AND CENTER RD GRAND PALM PHASE 2AE
VENICE, FL 34292

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501

SALESMAN

TAE

JOB NAME

PH2AE SOURCE

INVOICE DATE

07/17/19

BATCH
10
81380

ORDERED

5

SHIPPED

5

ITEM NUMBER

AFC2606DLAFMM

DESCRIPTION
Source Order#: 1415124
- FIRE HYO ASSM (5) -
6 DI MJ RW OL SS STEM VLV UA

INVOICE SUB-TOTAL

UNIT PRICE	UM

;-, 06 . 5 5 5	EA

AMOUNT

2032.78 .,/

2032.78

LEAD LAWW/> RNING: IT IS ILLEl AL TO INSTALL PRODL CTS THAT ARE NOT ' LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I ROTHER APPLICiABLE LAWIN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH •NP IN THE DESCRIPTION ARE NOT L O FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. auYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

FERGUSON®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1433250	$6,470.00	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127
PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION PO#180501
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE ST

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501

SALESMAN

TAE

JOB NAME

PH2AE SOURCE

INVOICE DATE

07/16/19

BATCH
10
81371

ORDERED

10

SHIPPED

10

ITEM NUMBER AFC2608DLAFMM

DESCRIPTION
Source Order#: 1415124
8 DI MJ RWOL SS STEM VLV UA

INVOICE SUB-TOTAL

UNIT PRICE	UM

i/s  47.000	EA

AMOUNT

6470.00 V
6470.00

LEAD LAW WARNING: IT IS ILLE( AL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL <DR OTHER APPLIC!ABLE LAW IN POTAB LE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH "NP IN THE DESCRIPT	ION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLE APPLIC ATIONS. UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

FERGUSO*N
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Pleasecontact with Questions: 800-456-1488

JUL 1 5 2019	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1432191-1	$946.00	41953	1 of 1	

PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

 	SHIP TO:	

BLACKBURN CREEK COMMUNITY OEVE GRANO PALM PHASE 2AE
C/0 FORSBERG CONSTRUCTION P0#180501
PUNTA GORDA, FL 33950

FORSBERG CONSTRUCTION INC OBSERVATION BLVD AND CENTER RD GRAND PALM PHASE 2AE
VENICE, FL 34292

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501 - wrn TAP/WIR

SALESMAN

TAE

JOB NAME

PH2AE

INVOICE DATE

07/12/19

BATCH
10
81358

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	

10	
10	
C1230BSF500	Source Order#: 1415124
12GA 30MM 500 FT COP TRCR WIRE BLUE	
89.000	
EA	
890.00"/	
2	2	P03105B52737	3X1000 UG DET WTR BLUE	28.000	EA	56.00 •V	

..•.....••.•....•I-••••·••·············· .•...•...•...•.•...•.•.•.·.•················••········

INVOICE SUB-TOTAL

946.00 /'

LEAD LAW W.ARNING : IT IS I LLE < AL TO INSTALL PROOL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL OR OTHER APPLICABLE LAWIN POTABLE WATER SYSTEMS ANTICIPATEDFOR HUMAN CONSUMPTION PRODUCTS W TH *NP IN THE OE SCRIP TION ARE NOT L :AO FREE ANO CAN ONLY BE INSTALLED IN
NON-POTABLE APPLICATIONS . UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

FERGUSON®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

JUL 2 9 2019	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1433637	$28,971.07	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127 PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/0 FORSBERG CONSTRUCTION P0#180501
PUNTA GORDA, FL 33950

BLACK BURN CREEK COMMUNI TY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE ST

42	42	F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	102.610	
75	75	FBA43444WNL	LF 1 CTS X MTR ANG BV	87,340	

680	
SDR21BPK	Source Order#: 1415124
2 SDR21 CL200 PVC GJ BLUE PIPE	
0.550	
FT	
150	FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	1.260	EA	
84	FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	1.260	EA	
75	F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	102.610	EA	

42	FBA43444WNL	LF 1 CTS X MTR ANG BV	87.340	EA	3668.28	
75	FFB10004NL	LF 1 CCX CTS PJ BALL CORP	50.240	EA	3768.00	
42	FFB10004 NL	LF 1 CC X CTS PJ BALL CORP	50.240	EA	2110.08.	

10of	PEC9BG100
PEC9BG100	'EXC 1X100 CTS DR9 HOPE BLUE PIPE
'EXC 1X100 CTS DR9 HOPE BLUE PIPE	40.000
40,000	C
C	
300 ,	PEC9BG300	'EXC 1X300 CTS DR9 HOPE BLUE PIPE	40.000	C	
o,	PEC9BG300	'EXC 1X300 CTS DR9 HOPE BLUE PIPE		C	

SHIP WHSE.
1705

SELL
WHSE.
1705

TAX CODE

CUSTOMER ORDER NUMBER

SALESMAN

JOB NAME

FLE

180501

TAE

PH2AE SERVICE MATER

INVOICE DATE BATCH
10

07/25/19	81424

ORDERED

SHIPPED

ITEM NUMBER

DESCRIPTION

UNIT PRICE	UM

1680
150
54/
75

AMOUNT
374.00 V
189.00 I/
105,84 II//
7695.75

EA EA

6550.50

4309.62 ,.

42
75
42
100
100
1500
2400

/'

100 1

40.00
40.00
120.00
0.00

IN VOICE SUB-TOTAL

28971.07

LEAD LAWW/- NING: ITIS ILLE16AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH US FEDERAL I       R  O  TH  ER APPL, 11ABLE   LAWIN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTI  O N
PRODUC TS VI TH 'NP IN THE D SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN NON-POTABLI APPLICATIONS.' UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

'
I

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE	$28,971.07
All past due amounts are subject to a service charge of 1.5% per month, or the maximum allowed by law, if lowe r. If Buyer fails to pay within terms, then in addition to other remedies, Buyer agrees to pay Seller all costs of collection, including reasonable attorney fees. Complete terms and conditions are available upon request or at
https://www.ferguson.com/content/website-info/terms-ofs- ale, incorporated by reference. Seller may convert checks to ACH.

t'Ul<LH/'\ I:: Ul<Ut:I< l"\JO.	18050/	

Blackburn Creek Community Develo pm.ent District
c/o
Forsberg Construction, Inc.
645 ClrnrlotteStreet, Pun ta Go rda FL 33950 Phone: (941) 637-8500	fax: (941) 639-1073
Underground Utility License #C UC0557 I 6
Visit Us at ww,,·.for, bergconstru ctio n.com

Vendor. : Ferguson Waterworks Address: 18305 Paulson Drive
Port Charlo tte, FL 33954

--

Description

-·-- -

-

c-- - ·

·-

--- -

- ---

--·

·--

-

--

I

[
1---- ---

! 	

 	--		 	

--·

- ·

-·-

---·

-

----

. -

- -

-	 		-

-·-

. Prices are good for duration of the project.

-

·-

-	·

---

--
137,072.76 l

E_

 	 --

To   ta  l Project Subtotal	$
Sales Tax  @  6 %
Di scretion ary Tax@ 1.0 % on  I st $5,000.00
TOTAL $

tax exempt-

tax exempt

·---

137,072.76

- --

[ r roj ect D ration: January I , 2019 - January I , 2020

I

I
.I

--

-·-•·-

-

-·

-

I-----

-

with Exhibit "A" (p ages 1-3 )

137,07 2.76

$

$	13, 7 07 2.76

Piee, Valves, Fi ttin gs an	Appurtenances in accordance

LS

I

Total Price

Unit Price

Unit

Quantity

Attention: Tyler Evenson

Job No.: 18-05

P.O. Date: February 22, 2019 Project Name: Grand Palm Phase 2Ae

Proj ect Address: Ob ervation Blvd off of Cen ter Road

   Venice, Florida	                                   Legal Desc.: Sec: 19 & 20, Twp: 39S, Range 20E
County : Saraso ta

Payment Terms: Cut-off 25th; 2% by 10 th o f 2nd Month

Vendor Phone:- 94-1-6-2 4--34-94-   -   -   - - -   -   -   -   -
Vendor Fax:	941-627-3519

---·---

Blackburn Creek CDD

Cha i	

Authorized Agent{signature!

..J; >; If 
Dat e

Page	 I

of	- - 2

! IMPORTANT !
"SEESPECAI L PROVISIONS ABOVE.
-	ADDITIONAL TERMS AND CO NDI TION SON PAGE 2

TERMS AND CONDITIONS
l.	A lf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and sh all be satisfactory to meet approval of the Owner, Owner's representative and Purchaser.

When requested by Purchaser, Vendor will provide,at no additional cost to Purchas er, a complete set of shop drawings for Purchaser's rev iew  and approval.  Alf items supplied without prior approval. that do not meet Proj ect requirements. wi ll be returned to Vendor, by Vendor, at no charge to Purchaser.

Time is o f th e essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Vendor sha ll notify Purch aser 24 hours in advance of arrival to j obsit e to confirm delivery.

Material shall arrive in such time that it will allow for unloading befor e quitting time, or Vendor and/or transporter will be requiredto hold over until the following work day to be unloaded. Purchaser will not be resp o n sibl e for any demurrage charge for such hold over.

Should	th e Vendor fail to provide material as scheduled by Purchaser and Vendor , the Purchaser. upon 3 day written notice to Vendor. shall have the right  to procure  said  materials  elsew here without  further  responsibil ity to Vendor.

Quan titiesare approximate and subject to project requirements.

Vendor agreesto accept wi thou t charge to Purchaser, all extra. non-specialty materials in g ood concfition which remain after completion of work and will issue full credit for same.

Vendo r shall sign and return Purchas e Order within IO days of Purch ase Order date. Purchaser will return an executed PurchaseOrder to Vendor .

I 0. To insure prompt payment, Purchase Order number must appear on all invoicesand copies of sig n e d delivery slip s attached.

I l . Neith er party will change, alter, nor substitu te any part of this Purchase Order withou t consen t of the opposite party. All chang es so agreed to shall be initialed and dated by authorized agents o f both parties.

No in vo ices w ill be pr ocessed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Sh ip men t of a n y m aterials, before sig ning thi s Purchase Order, will be considered an acceptance of th is Purcl1ase Order.

If Vendor fails to proper ly exec u te and return Purchase Order within I O days, Purchasermay consider offer
rej ected.

1 5. This agreement shall be governed by the laws of the State of Flor ida with venue in Charlotte County, Florida.

The authorized age nt signing thi s Purchase Order for the Vendor must be duly authorized to do so on be f1alf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unen forceable by a court of competent j urisdict ion, then Purch aser and Vendor intend for th e remainin g terms and conditions to remain in full force and effect.

This Purcha se O rd er is th e only binding contract between Purchaser and Vendor for this project and the work described. This Purchase Order replacesall pr evious contracts and agre ements,  wh  ether written or  verbal, regardin g thi s project. No other docum ent will supersede th e requir ements of thi s Purchase Order u nlesssig n ed by an authorized agent of each party subsequent to the dale of this Purchase Order.

Page    2  o f	2	Fergu son l niti a	Blackburn Creek COD Int i!	.

FERGUSON
WATERWORKS

FEI-PT. CHARLOTTE WW 1705 18305 PAULSON DRIVE

J)eliverTo:
-=rom:	Tyler A Evenson omments:

PORT CHARLOTTE, FL 33954-0000

Phone: 941-624-3494
Fax: 941-627-3519

12:28:54 FEB 25 2019	Page 1 of 3
FEI-PORT CHARLOTTE #1705

Price Quotation Phone:941-624-3494 Fax: 941-627-3519

EXl-lflSIT	''A"

Bid No:	B247135	Cust Phone: 941 -637-8500
Bid Date:	02/25/19	Terms:	NET 10TH PROX
Quoted By: TAE

Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY GRAND PALM PHASE 2Ae		GRAND PALM PHASE 2Ae
645 CHARLOTTE ST	645 CHARLOTTE ST
PUNTA GORDA, FL 33950	PUNTA GORDA, FL 33950

Cust PO#:	180501	Job Name:	GRAND PALM PH 2Ae

Item	Description	Quantity	Net Price	UM	Total
 	
*SEWER*
====================== -
8" PVC GRAV SWR •

4158	3.980	FT	16548.84	
3	55.730	EA	167.19	
5	28.000	EA	140.00	
			16856.03	

11	
47.530	
EA	
522.83	
33	13.470	EA	444.51	
11	18.240	EA	200.64	
462	2.220	FT	1025.64	
11	36.570	EA	402.27	
11	11.720	EA	128.92	
11	8.950	EA	98.45	
11	3.000	EA	33.00	
22	6.930	EA	152.46	
			3008.72	

53	
47.530	
EA	
2519.09	
159	13.470	EA	2141.73	
53	18.240	EA	966 .72	
53	68.260	EA	3617. 78	
53	11.720	EA	621.16	
53	8.950	EA	474 .35	
159	6.930	EA	1101.87	
2226	2.220	FT	4941.72	
53	3.000	EA	159.00	
3	28.000	EA	84.00	

SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE H260908	8 PVC HW SWR GXG REP COUP *Z
PO3105G4737	3X1000 UG DET SWR GREE SUBTOTAL

SINGLE SWR SRV (11) -

MUL067248	8X6 PVC HW SWR GXGXG WYE
MUL067376	6 PVC HW SWR GXS 45 ELL
MUL067326	6 PVC HW SWR GXG 45 ELL SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE MUL067206	6 PVC HW SWR GXGXG WYE
MUL040952	6 PVC SWR HUB FEM CO ADPT
MUL040958	6 PVC SWR REC THRO CO PLUG
CYPSKPX	2X4X8 YELL PINE STUD
MUL043988	6 PVC SWR GSKT CAP SUBTOTAL

DBL SWR SRV (53) -

MUL067248	BXS PVC HW SWR GXGXG WYE
MUL067376	6 PVC HW SWR GXS 45 ELL
MUL067326	6 PVC HW SWR GXG 45 ELL
MUL067277	6 PVC HW SWR GXG DBL WYE
MUL040952	6 PVC SWR HUB FEM CO ADPT
MUL040958	6 PVC SWR REC THRO CO PLUG
MUL043988	6 PVC SWR GSKT CAP SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE CYPSKPX	2X4X8 YELL PINE STUD
PD3105G4737	3X1000 UG DET SWR GREE

t/JFERGUSON®

Fax: 941-627-3519

12:28:54 FEB 25 2019
Reference No: 8247135		

Item	Description	
Quantity	
Net Price	
UM	
Total		

WATER MAIN •						

- 6 " PVC WTR MAIN -						
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	300	3.860	FT	1158.00		
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00		
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00		
SPWPC6	6 SIGMA BELL REST F/ C900 •PVLOK	12	32.000	EA	384.00		
SUBTOTAL				1659.00		
- 6" GATE VLVASSM (1)-						
AFC2606DLAFMM	6 DI MJ RW OL SS STEM VLV UA	1	406.550	EA	406.55		
SSLCE6AP	6 PVC WDG REST •ONELOK W/A	2	34.040	EA	68.08		
1461SW	2PC SC Cl VLV BX 19-22 WTR	1	95.000	EA	95.00		
RBGVTMU	3 BRS GATE VLV ID - 6	1	13.000	EA	13.00		
SUBTOTAL				582.63		
- 8" PVC WTR MAIN -						
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	4620	6.700	FT	30954.00		
PD3105B52737	3X1000 UG DETWTR BLUE	5	28.000	EA	140.00		
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	10	89.000	EA	890.00		
SPWPC8	8 SIGMA BELL REST F/ C900 *PVLOK	57	50.050	EA	2852.85		
SUBTOTAL				34836.85		
- 8" FITTINGS -						
MJ2LAX	8 MJ C153 22-1/2 BEND UA	11	68.900	EA	757 .90		
MJ1LAX	8 MJ C153 11-1/4 BEND UA	2	65.150	EA	130.30		
MJTLAX	8 MJ C153 TEE UA	3	127.650	EA	382.95		
MJTLAXU	8X6 MJ C153 TEE UA	1	105.770	EA	105.77		
SSLCE6AP	8 PVC VVDG REST *ONELOK W/A	37	46.150	EA	1707.55		
SSLCE6AP	6 PVC WDG REST *ONELOK W/A	1	34.040	EA	34.04		
SUBTOTAL				3118.51		
- 8" GATE VLV ASSM (10) •						
AFC2608DLAFMM	8 DI MJ RW OL SS STEM VLV UA	10	647.000	EA	6470.00		
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	20	46.150	EA	923 .00		
1461SW	2PC SC Cl VLV BX 19-22 WTR	10	95.000	EA	950.00		
RBGVTMX	3 BRS GATE VLV ID- 8	10	13.000	EA	130.00		
SUBTOTAL				8473.00		
FIRE HYO ASSM (5) •						
MJSTLAXU	8X6 MJ C153 SWVL TEE UA	5	122.790	EA	613.95		
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	10	46.150	EA	461.50		
SSLCE6AP	6 PVC WOG REST *ONELOK W/A	10	34,040	EA	340.40		
IMJBGPU	6 MJ C153 BLT GSKT PK L/GLAND	5	12.700	EA	63 .50		
AFC2606DLAFMM	6 DI MJ RW OL SS STEM VLV LIA	5	406.555	EA	2032. 78		
1461SW	2PC SC Cl VLV BX 19-22 WTR	5	95.000	EA	475.00		
RBGVTMU	3 BRS GATE VLV ID - 6	5	13.000	EA	65.00		
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	80	3.860	FT	308.80		
AFCB84BLAOLP	5-1/4 VO B84B HYD 4'0 OL UA	5	1425.000	EA	7125.00		

Page 2 of3
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
'

==========================

ff FERGUSON
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation Fax: 941-627-3519

Page 3 of 3

12:28:54 FEB 25 2019
Reference No: B247135

Item

Description	Quantity	Net Price	UM 	Total 	
8X1 CCBRS SOL C900	75	102.610 EA"""	7695.75	
LF 1 CCX CTS PJ BALL CORP	75	50.240 EA	3768.00	
"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1500	40.000	C	600.00	
"EXC 1X100 CTS DR9 HOPE BLUE PIPE	100	40.000	C	40.00	
12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
3X1000 UG OET WfR BLUE	2	28.000	EA	56.00	
LF 1 CTS X MTR ANG BV	75	87:340	EA	6550.50	
1 CTS PET/ HDPE DR9 INS STFNR	150	1.260	EA	189.00	
2X4X8 YELL PINE STUD	75	. 3.000	EA	225.00	
11X18X12 BXWI Cl ROR LID SUD	75	68.000	EA	5100.00	
SUBTOTAL				24491.25	
- SINGLE LONG (42) -					
8X1 CC BRS SOL C900	42	102.610	EA	4309.62	
LF 1 CCX CTS PJ BALL CORP	42	50.240	EA	2110.08	
"EXC 1X300 CTS DR9 HOPE BLUE PIPE	2400	40.000	C	960.00	
*EXC 1X100 CTS DR9 HOPE BLUE PIPE	100	40.000	C	40.00	
12GA 30MM 500 FT COP TRCR WIRE BLUE	6	89.000	EA	534.00	
3X1000 UG DET WfR BLUE	3	28.000	EA	84.00	
LF 1 CTS X MTR ANG BV	42	87.340	EA	3668.28	
1 CTS PET/ HOPE DR9 INS STFNR	84	1.260	EA	105.84	
2X4X8 YELL PINE STUD	42	3.000	EA	126.00	
11X18X12 BX W/CI ROR LID SUD	42	68.000	EA	2856.00	
2 SDR21 CL200 PVC GJ BLUE PIPE	1680	0.550	FT	924.00	
SUBTOTAL				15717.82	
8X12 MJ C110 LONG SLV UA	
1	
123.300	
EA	
123.30	
8 PVC WDG REST *ONELOK W/A	2	46.150	EA	92.30	

FS90804 FFB10004NL PEC9BG300 PEC9BG100 C1230BHS500 PD3105B52737 FBA43444WNL FINSERT52 CYPSKPX CWA03111812

FS90804 FFB10004NL PEC9BG300 PEC9BG100 C1230BHS500 PD3105B52737 FBA43444VVNL FINSERT52 CYPSKPX CWA03111812 SDR21BPK

FBLSLAX SSLCE8AP

s u BTOTAL		215.60	
Net Total:		$137072.76	
Tax:		$0.00	
Freight:		$0.00	
Total:		$137072.76	

Quoted prices are based upon receipt of the totalquantity for immediate shipment (48 hours).  SHIPMENTS BEYOND 48 HOURS SHALL BE
AT THEPRICE IN EFFECT AT TIMEOF SHIPMENT UNLESS NOTED OTHERWISE. QUOTES FOR PRODUCTS SHIPPED FOR RESALE ARE NOT FIRM UNLESS NOTED OTHERWISE.
CONTACT YOUR SALES REPRESENTATNE IMMEDIATELY FOR ASSISTANCE WITH DBE/MBENVBE/SMALL BUSINESS REQUIREMENTS.
Seller not responsible for delays, lack of product or increase of pricing due to causes beyond our control, and/or based upon
Local, State and Federal laws governing type of products that can be sold or put into commerce. This Quote is offered contingent upon the Buyer's acceptance of Seller's terms andconditions. which are incorporated by reference and found either following this document, or
on the web at https:/www.ferguson.com/conteln/Website-infotterms-of-sale Govt Buyers: All items are open market unless noted otherwise.

LEAD LAW WARNING: It is illegal to install products that are not ' leadfree'  in accordance with US Federal or other applicable law in potable water systems anticipated for human consumptio.nProducts with"NP in the description are NOT lead free and can only be installed in non-potable applications. Buyer is solely responsible for prOduct selection.

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the CDD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the CDD is a paramount consideration. The CDD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The CDD is required to issue a Certificate of Entitlement to each vendor and to the CDD' s contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The CDD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0.affirms that the tangible personal property purchased pursuant to Purchase Order Number 180501 from Ferguson Waterworks (Vendor) on or after 2/22/19 (date) will be incorporated into or become a partof a public facility as part of a public works contract pursuant to contract # n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ae.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule 12A-1.094, F.A.C.:

)iou must initial each of the following requirements.
(__.Qt/1. The attached  Purchase  Order  is  issued  directly  to  the  vendor  supplying  the  tangible  personal p11{r0 theContractor will use in the identified  public works.
2	2. The vendor's invoice will be issued directly to Governmental Entity.
. 3. Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pu ic funds.
{3;f:J4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
5. Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-1.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Cert ifica te does not qualify for the exemption, Governmental Entity will be liabl e for any tax, penalty, and interest determined to be due.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By: -		 	.:

Its:  	

/ 	I

;                   ;.: 	,  :;.. 	

----'	DATE: -	 -c,,'l-J,L-/-L2.  L+1+?	;

Federal Employer Identification Number: -   -  - -	=  =  =	=-- - - - - - - -

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not send to the Florida Department of Revenue. This Certificate of Entitlement must be retained in the
vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 2013 (the "Master Indenture"), as amended and supplemented by the Fowth Supplemental Trnst Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized tenns used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-29

Neal Communities of Southwest Florida 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240

(C}	Amount Payable:	$40,190.73

(D) Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs of Issuance, if applicable):

Reimbursement of developer-funded Utility Construction Permit Fee for Grand Palm, Phase 2A(d)

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance  Account  or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By	
Authorized Officer

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

w	

Consulting Engineer

/"'

SARASOTA COUNTY GOVERNMENT
1001 Sarasota Center Blvd, Sarasota, Fl 34240 (941) 861-6678
4000 S.Tamiami Trail,Venice FL 34293	(941) 861-3029
1660 Ringling Blvd, Sarasota, FL 34232	(941) 861-5000

Receipt#   1514411	- June 11, 2019 RESOURCE CONSERVATION OF SARASOTA, LLC
5800 LAKEWOOD RANCH BLVD N LAKEWOOD RANCH FL 34240
Phone:

18 162853 00 UE

GRAND PALM PHASE 2A(d)		

Fee Description	
Payment Type	
Memo		Amount Paid	
Utility Acct Deposit	Check	1-00163909		$40,190.73	
			Total:	$40,190.73	

To request the installation of a water meter by Sarasota County Public Utilities after all applicable capacity/meter fees have been paid, please call (941) 861-6767 option 2.

Check review status,inspection status and pay fees on the IVR (941) 861-6441 and on the Web at https://building.scgov.net. Available 24/7

Blackburn Creek Community Development District

..	....

FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District  to  the Trustee, dated as of February 1, 2019 (the Master Indenture as  amended  and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-30

Kimley-Horn and Associates, Inc.
P.O. Box 932520 Atlanta, GA 31193-2520

$10,304.64

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Payment of District Engineering Services related to the Bond Financed District Improvements. See attached invoice for detail.

The undersigned hereby certifies that [obligations in the stated amount set forth  above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1on contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs oflssuance Account or  for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

AuorizedOfficer	:

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofJssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital 1mprovement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engine-erattachedas an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

Con�sulting Engineer	�	

BLACKBURN CREEK COMMUNITY DEVELOP. DIST. CONSTRUCTION
ATTN: AMANDA LANE 12051 CORPORATE BLVD
ORLANDO, FL 32817

Please send payments to:
KIMLEY-HORN AND ASSOCIATES, INC.
P.O. BOX 932520 ATLANTA, GA 31193-2520

Federal Tax Id: 56-0885615

HOURLY	
Description	Current Amount Due	
SERVICES RENDERED	10,304.64	
Total HOURLY	10,304.64	

Invoice No:	14428642
Invoice Date:	Jul 31, 2019 Invoice Amount: $10,304.64
Project No:	148167000.2
Project Name:	BLACKBURN CR CDD DIST ENG
Project Manager: CONERLY, BILL
Client Reference: CONSTRUCTION FUND For Services Rendered through Jul 31, 2019

Description of Services Performed:
Process REQ's 2019-15 through 2019-23; Coordinate with Chair & Trustee
Process REQ's 2018-95 through 2018-97 and 2018-99 through 2018-103; Coordinate with Chair & Trustee
Provide information for Audit
Provide As-Builts and Certifications

Total Invoice: $10,304.64

If you have questions or concerns regarding this invoice, please call Joseph Marianacci at 561-840-0219.	31JJM

BLACKBURN CREEK COMMUNITY DEVELOP. DIST. CONSTRUCTION
ATTN: AMANDA LANE 12051 CORPORATE BLVD
ORLANDO, FL 32817

HOURLY	

Group	
Description	
Hrs/Qty	
Rate	Current Amount Due	
LABOR	ANALYST	1.0	138.18	138.18	
		14.0	104.65	1,465.12	
	PROFESSIONAL	13.0	139.81	1,817.50	
	SENIOR PROFESSIONAL I	2.0	161.03	322.05	
		27.0	223.99	6,047.78	
TOTAL LABOR	57.0		9,790.63	
EXPENSES	OFFICE EXPENSE			514.01	
TOTAL EXPENSES			514.01	
TOTAL LABOR AND EXPENSE DETAIL			10,304.64	

Invoice No:	14428642
Invoice Date:	Jul 31, 2019
Project No:	148167000.2

Project Name:

BLACKBURN CR CDD DIST ENG

Project Manager: CONERLY, BILL

This page is for informational purposes only. Please pay amount shown on cover page.

31JJM

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition· for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District  to  the Trustee, dated as of February 1, 2019 (the Master Indenture as  amended  and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-31

Cast Systems,  LLC 19400 Peachland Blvd. Port Charlotte, FL 33948

$18,092.10

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order# 190403; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth  above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not  previously  been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim  affecting  the right to receive payment of, any of the moneys payable to the Payee set  forth  above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such requisition contains no  item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs oflssuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the  invoice(s) from the vendor of the  property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

A'edOfficer	:

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof

111	

Consulting Engineer

-=---

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Cast Systems
Project:	Grand Palm, Phase 2A(d)

    Invoice #		Amount	 40898	$201.99
40905	$5,462.40
40916	$5,696.85
 	40915	$6,730.86	
Sub-Total	$18,092.10

AUG 2 2 20!9	CAST SYST MS, LLC
18400 PEACHLAND BLVD PORT CHARLOTT!, PL 33848 Phone: (141) 825-3474
Fax: (841) 2815-8448

I MV1 >1

PY

lnvolot Number: 40898 lnvolot Dato:	8/22/2019

( , I

BIii to:	BLACKBURN CREE.K COMMUNITY OEVEI.OPMENT 12051CORPORATE BLVD
ORLANDO, Fl. 32817-1460
Contact:

Cuetomor ID:    BLACKBURNCREE

Ship Via:

Ship to: GRANO PALM 2Ad

Project Manager:
PO:	190,103
County: EXl!MPT
Salta i.1p:	ADAMROWAN

Tloktt Numbo:r

◄08 98

c111vory Datt:	aI2aI20111

Torm,:

NIT 30

Job Number:	14789

Load:

DUI Datt:

9/21/20111

Structure ID

8truotur1 Typ1
(PHASE 2Ad)  72" JUNCTION BOX W/UfJF# 170=1!
(PHAH   2Acl) 72'' JUNCTIONROX W/U8F# 170.G

i 1x11blo Non•TIXi ble

Amount Sa.390,93
$:!,U 0,93

S0,00
14,181.80
$4,781.811

T!IK	$0.00
lnvoloo Totll	S◄, 751.118
OH Copooll	S4,o7U'/'
-	·-   -	-	-
lrwolH ll1l1 nuo	U 01,H

AUG 2 6 2019

CAST SYSTEMS, LLC 19400PEACHLAND BLVD PORTCHARLOTTE, FL 33948 Ph one: (941) 625-3474
Fax: (941) 255-9448

INVOICE

Invoice Number: 40905
Invoice Date:	8/23/2019

Bill to:	BLACKBURN CREEK COMMUNITY DEVELOPMENT 12051 CORPORATE BLVD
ORLANDO, FL 32817-1450
Contact:

Customer ID: BLACKBURN CREE

Ship to: GRAND PALM 2Ad
US 41 RIGHT ON RIVER RD
Project Manager: ANDREW PO:	190403

Ship Via:				Sales Rep:
-  -  -	-	-	ADAM ROWAN	
Ticket Number:	40905	Delivery Date:	8/23/2019	Terms:	NET 30	
Job Number:	14759	Load :		Due Date:	9/22/2019	

County: EXEMPT

Structure ID 45-40
45-4E

45-4F

45-SA

Structure Type

(PHASE 2Ad) TYPE F INLET W/USF# 111OM (PH ASE 2Ad) TYPEF INLET W/USF# 111OM (PHASE 2Ad) D INLET W/USF# 6607 (PHASE 2Ad) TYPE M INLET W/USF# 111OM

... .... ..

---

Amount

$1,350.11

$1,350.11

$1,354.54

$1,407.64

Taxable	$0.00

---

Non-Taxable	$5,462.40

--

Sub Total	$5,462.40
-	---
Tax	$0.00
-	-	-
Invoice Total	$5,462.40
Less Deposit	$0.00
- - -
Invoi ce Balance	$5,462.40

f AS'l1
SYS'l,IUHS L.LC,

AUG2 7 2019

CAST SYSTEMS, LLC
19400 PEACHLAND BLVD PORT CHARLOTT!, FL 33948 Phone: (941) 820-3474
Fax: (941) 255-9448

IN VOICL

Customer Copy	Invoice Numbe:r 40916
Invoice Date:	8/26/2019

Blllto:	BLACKBURN CREEK COMMUNITYDEVELOPMENT 12051 CORPORATE BLVD
ORLANDO, FL 32817-14 0
Contact:

Customer ID: BLACKBURNCREE

Ship Via:

Ship to: GRANO PALM 2Ad
US 41 RIGHT ON RIVER RD LEFT ON HARNEY ST
Project Manager:    ANDREW PO:	190403
County: EXEMPT

Sales Rep:	ADAM ROWAN

Ticket Numbor:	40916	Delivery Date:	812612019	Nl: T O	
Job Numbor:	14759	Load:		9126/2019	

Structure ID	
Structure Type		
Amount	
45-68	(PHASE 2Ad) TYPE MINLETW/USF#111OM		$1,407.64	
CS-45	(PHASE 2Ad) CONTROL STRUCTUERW/USF# 8		$2,881.57	
46-6B	(PHASE 2Ad) TYPE MINLET WIUSF#111OM		$1,407.64	
		Taxable	$0.00	
		Non-Taxable	$0,6 98.86	
		Sub Total	$5,696.86	
		Tax	$0.00	
		lnvol ot Total	$5,696.86	
		l.011 Ot po1it	$0,00	
		Invoice Dalanc,	u,oeuo	

CAS'I'
SYS1'E)IS L.LC.

AUG 2 7 2019

CAST SYSTEMS, LLC 19400 PEACHLAND BLVD
PORT CHARLOTTE, FL 33948 Phone: (941) 82&-3474
Fax: (941) 2GG-9448

IN VOI U 

Customer Copy	Invoice Number: 40915
Invoice Date:	8/27/2019

Bill to :	BLACKBURN CREEK COMMUNITY DEVELOPMENT 12051 CORPORATE BLVD
ORLANDO, FL 32817-1450
Contact:

Customer 10: BLACKBURN CREE

Ship Via:

Ship to: GRAND PALM 2Ad
US 41RIGHT ON RIVER RO LEFT ON HARNEY ST
Project Manager: ANDREW PO:	190403
County: EXEMPT
Salee Rep:	ADAM ROWAN

Ticket Number:	40915	Delivery Date:	8/27/2019	Termt:	NET 30	
Job Number:	14759	Load:		Duo Date:	9/28/2019	

Structure ID	
Structure Type		
Amount	
45-1A	(PHASE 2Ad) TYPE M INLET W/USF# 111OM		$1,407.64	
45-1B	(PHASE 2Ad) TYPE M INLET W/USF# 1110M		$1,407.64	
45-2A	(PHASE 2Ad) TYPE M INLET W/USF# 111OM		$1,407.64	
45-28	(PHASE 2Ad) TYPE M INLET W/USF# 1110M		$1,407.84	
45-3BA	(PHASE 2Ad) 48" JUNCTION BOX W/USF# 170-E		$1,100.30	
		Taxable	$0,00	
		No-nTaxable	$6,730.86	
		Sub Total
-	-  -	-	$6,730.86
-  -	-	
		Tax
Invoice Total	
$6,730.89	
		I. on Oopo1lt	$0.00	
		lnvolot Balance	$6,730.88	

--	- -

--   -	-

$0,00

PURCHASE ORDER No. 	/90403	

Blackburn Creek Community Development District
c/ o
Forsberg Construction, Inc.
645 Charlotte S treet, Pun ta Go rda r:L 33950 Phone: (94 l) 637-8500	Fax: (941) 639-107 3
Und erground Utility License #C UC055 7 l6
Visit Us at www.forsbergconst ruction.com

Vendor: Cast Systems, LLC Address: 19400 Peachland Blvd
Port Charlotte. FL 33948

Quantity	Unit	Description	Unit Price	Total Price	
I		AH Manholes are per Sarasota County requirement s including 6" wall, CS- 5 5 interior and exterior coating, boots, doubl e ramnek, exterior joint wrap, precast inverts
and 170-CE-ORS Sarasota R&C				
						
5	EA	4' Dia Manhole 0-6	$	1,584.28		$	7,921.40	
3	EA	4' Dia Manhole 6-8	$	1,834.15		$	5,502.45	
4	EA	4' Dia Manhole 8-10	s	,2 177.11		$	8,708.44	
I	EA	4' Dia Man hol e I 0-12	$	2,550.72		$	2,550.72	
I	EA	Type C Inlet with USF #6210	$	734.06		$	734.06	
I	EA	Type D Inlet with USF #6607	$	1,354.54		$	1,354.54	
I	EA	48" Junction Box with #170-E	$	I, 100.30		$	I, 100.30	
2	EA	72" Junction Box with #170-E	$	2,390.93		$	4,78 1.86	
2	EA	Type F Inlet with USF # I I I OM	$	1,350.11		$	2,700.22	
12	EA	Type M Inlet with USF # I I I OM	$	, 1 407.64		$	16,89 1.68	
I	I	EA	Medium Control Structure with USF #6620	$	2,88 1.57		$	2,88 1.57	

						
!						
t
'						
						
		Prices ar e qood for duration of the project.				
		Project Du ration : April I 5, 2019 - April 15, 2020				
Total Project Subtotal	s	55,127.24	
Sales Tax @ 6 %	tax exempt	
			Discretionary Tax@ 1.0 % on  1st $5,0 00.0 0t		tax	e  xemp	t	
TOTAL	$	55,127.24	

Attention: Adam Rowan 239-595-4664

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: Obervation Blvd off of Center Road

  Venice, Florida	                               Legal Desc.: Sec 19 & 20, Twp: 395, Ran ge 20E

County: Sarasota Payment Terms: Net 30 days
Vendor Phone:  94 1-625-34 74 	                                  Vendor Fax:   941-255-9448	 

Cast Systems, LLC	Blackburn Creek COD

Vendor name

5-	- -c--- f/17!19

Au th oriz e d A g en t ( signature)	Date
Authorized Agent fprinte(\/ typed/ Pag e	I	of	2

 	-		/ 1¥11v
Authorized Agent (sig n atur e/	Date
! IMPORTANT !
" SEE SPECIAL FROV/S/O NS A BO VE

ADDITIONAL TERMS AND CONDITIONSON PAGE 2

TERMS AND CONDITIONS
I.	Alf material shall be as specified and warranted in accordance to the Project specifications,plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchaser.

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. All items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Tlme is of the essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will alfow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not be responsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-special ty materials in goodcondition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within l O days of Purchase Order date. Purchaser willreturn an executed Purchase Order to Vendor.

I 0. To insure prompt payment Purchase Order number must appear on alf invoices and copies of sign ed delivery slips attached.

I I.	Neither party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Order.

If Vendor fails to properly execute and return Purchase Order within IO days, Purchaser may consider offer rejected.

This agreement shall be governed by the laws of the State of Florida with venue in Charlotte County, Florida.

The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full forceand effect.

This Purchase Order is the only binding contract between Purchaser and Vendor tor this project and the work described . This Purchase Order replaces all previous contracts and agreements, whether written or verba,l regarding this project. No other document will sup ersede the requirements of this Purchase Order unless signed by an authorized agent of each party subsequent to the date of this Purchase Order .

Page   2  of	2

Cast System· s lnitial  ackburnCreek COD In ti

Florida Admin Rule 12A-l.094 Public Works Contracts and FS Sec. 212.08:

l . Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer's Certification of Exemption.

Direct Invoice . The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the COD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the CDD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the COD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The CDD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE OF ENT IT LEMENT
The undersigned authorized representa tive of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 190403 from Cast Systems, LLC (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule 12A-1.094, F.A.C.:

You must initial each of the following requirements.
l. The attached Purchase Order is issued direct ly to the vendor supplying the tangible personal prlµr,tytheContractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pub)if:Junds.
Governmental Entity will take title to the tangible personal property from the vendor at the time of purchase or of delivery by the vendor.
Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase  Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-1.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

B_y:		....,._.,_		-	-	-	   : 

Its: 	 	

C_/..,c/..-l')-f_/_.--

_	_	_	_	_	---'

Federal Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entit lemen t.

Do not send to the Florida Department of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trnst Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trnstee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trnst Indenture from the District to  the Trustee, dated as of Febrnary I, 2019 (the Master Indenture as  amended  and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-32

Ferguson Waterworks FEI-PT. Charlotte #1705
18305 Paulson  Drive Port Charlotte, FL 33954

Amount Payable:	$543.00

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs ofissuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(e). Purchase Order# 180501; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 20I9 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not  previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to  lien,  or  attachment  upon,  or  claim  affecting  the right to receive payment of, any of the moneys payable to the Payee set forth above,  which has not been released or will not be released simultaneously with the payment hereof.

Blackburn Creek Community Development District
The undersigned hereby further certifies that such reqms1t1011 contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the  invoice(s) from the vendor of the property acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:

/\_	/	
Autl	fficd'	"'"

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan , which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the repo1i of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as  such report  shall have been amended or modified on the date hereof

iJ	
sulting Engineer	/

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 2A(e)

    Invoice #	Amount	
    1437655	$543.00	
Sub-Total	$543.00

FERGUSON®
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

UG 2 2 20i9	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1437655	$543.00	41953	1 of 1	
PLEASE REFER TO INVOICE NUMBER WHEN MAKING PAYMENT AND REMIT TO:

FEL-FT. MYERS WATERWORKS #127
PO BOX 100286
ATLANTA, GA 30384-0286

SHIP TO:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION PO#180501
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PHASE 2AE
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE ST

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501

SALESMAN

TAE

JOB NAME

PH2AE SOURCE

INVOICE DATE

08/20/19

BATCH
10
81554

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	

11	
11	
CYPSKPX	Source Order#: 1415124 2X4X8 YELL PINE STUD	
3.000	
EA	
33.00	
53	53	CYPSKPX	2X4X8 YELL PINE STUD	3.000	EA	159.00	
75	75	CYPSKPX	2X4X8 YELL PINE STUD	3.000	EA	225.00	
42	42	CYPSKPX	2X4X8 YELL PINE STUD	3.000	EA	126.00	
				INVOICE SUB-TOTAL		643.00	

LEAD LAW WP NING : IT IS ILLE 6AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I R OTH E R APPLI( !ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH 'NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLEDIN
NON-POTABLI  APPLICATIONS.   UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE

TOTAL DUE	$543.00

All past due amounts are subject to a service charge of 1.5% per month, or the maximum allowed by law, if lower. If Buyer fails to pay within terms, then in addition to other remedies, Buyer agrees to pay Seller all costs of collection, including reasonable attorney fees. Complete terms and conditions are available upon request or at
https://www.ferguson.com/contenUwebsite-info/terms-of-sale,incorporated by reference. Seller may convert checks to ACH.

t'Ul<LH/'\ I:: Ul<Ut:I< l"\JO.	18050/	

Blackburn Creek Community Develo pm.ent District
c/o
Forsberg Construction, Inc.
645 ClrnrlotteStreet, Pun ta Go rda FL 33950 Phone: (941) 637-8500	fax: (941) 639-1073
Underground Utility License #C UC0557 I 6
Visit Us at ww,,·.for, bergconstru ctio n.com

Vendor. : Ferguson Waterworks Address: 18305 Paulson Drive
Port Charlo tte, FL 33954

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Description

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1---- ---

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. Prices are good for duration of the project.

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137,072.76 l

E_

 	 --

To   ta  l Project Subtotal	$
Sales Tax  @  6 %
Di scretion ary Tax@ 1.0 % on  I st $5,000.00
TOTAL $

tax exempt-

tax exempt

·---

137,072.76

- --

[ r roj ect D ration: January I , 2019 - January I , 2020

I

I
.I

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-·-•·-

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with Exhibit "A" (p ages 1-3 )

137,07 2.76

$

$	13, 7 07 2.76

Piee, Valves, Fi ttin gs an	Appurtenances in accordance

LS

I

Total Price

Unit Price

Unit

Quantity

Attention: Tyler Evenson

Job No.: 18-05

P.O. Date: February 22, 2019 Project Name: Grand Palm Phase 2Ae

Proj ect Address: Ob ervation Blvd off of Cen ter Road

   Venice, Florida	                                   Legal Desc.: Sec: 19 & 20, Twp: 39S, Range 20E
County : Saraso ta

Payment Terms: Cut-off 25th; 2% by 10 th o f 2nd Month

Vendor Phone:- 94-1-6-2 4--34-94-   -   -   - - -   -   -   -   -
Vendor Fax:	941-627-3519

---·---

Blackburn Creek CDD

Cha i	

Authorized Agent{signature!

..J; >; If 
Dat e

Page	 I

of	- - 2

! IMPORTANT !
"SEESPECAI L PROVISIONS ABOVE.
-	ADDITIONAL TERMS AND CO NDI TION SON PAGE 2

TERMS AND CONDITIONS
l.	A lf material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and sh all be satisfactory to meet approval of the Owner, Owner's representative and Purchaser.

When requested by Purchaser, Vendor will provide,at no additional cost to Purchas er, a complete set of shop drawings for Purchaser's rev iew  and approval.  Alf items supplied without prior approval. that do not meet Proj ect requirements. wi ll be returned to Vendor, by Vendor, at no charge to Purchaser.

Time is o f th e essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Vendor sha ll notify Purch aser 24 hours in advance of arrival to j obsit e to confirm delivery.

Material shall arrive in such time that it will allow for unloading befor e quitting time, or Vendor and/or transporter will be requiredto hold over until the following work day to be unloaded. Purchaser will not be resp o n sibl e for any demurrage charge for such hold over.

Should	th e Vendor fail to provide material as scheduled by Purchaser and Vendor , the Purchaser. upon 3 day written notice to Vendor. shall have the right  to procure  said  materials  elsew here without  further  responsibil ity to Vendor.

Quan titiesare approximate and subject to project requirements.

Vendor agreesto accept wi thou t charge to Purchaser, all extra. non-specialty materials in g ood concfition which remain after completion of work and will issue full credit for same.

Vendo r shall sign and return Purchas e Order within IO days of Purch ase Order date. Purchaser will return an executed PurchaseOrder to Vendor .

I 0. To insure prompt payment, Purchase Order number must appear on all invoicesand copies of sig n e d delivery slip s attached.

I l . Neith er party will change, alter, nor substitu te any part of this Purchase Order withou t consen t of the opposite party. All chang es so agreed to shall be initialed and dated by authorized agents o f both parties.

No in vo ices w ill be pr ocessed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Sh ip men t of a n y m aterials, before sig ning thi s Purchase Order, will be considered an acceptance of th is Purcl1ase Order.

If Vendor fails to proper ly exec u te and return Purchase Order within I O days, Purchasermay consider offer
rej ected.

1 5. This agreement shall be governed by the laws of the State of Flor ida with venue in Charlotte County, Florida.

The authorized age nt signing thi s Purchase Order for the Vendor must be duly authorized to do so on be f1alf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unen forceable by a court of competent j urisdict ion, then Purch aser and Vendor intend for th e remainin g terms and conditions to remain in full force and effect.

This Purcha se O rd er is th e only binding contract between Purchaser and Vendor for this project and the work described. This Purchase Order replacesall pr evious contracts and agre ements,  wh  ether written or  verbal, regardin g thi s project. No other docum ent will supersede th e requir ements of thi s Purchase Order u nlesssig n ed by an authorized agent of each party subsequent to the dale of this Purchase Order.

Page    2  o f	2	Fergu son l niti a	Blackburn Creek COD Int i!	.

FERGUSON
WATERWORKS

FEI-PT. CHARLOTTE WW 1705 18305 PAULSON DRIVE

J)eliverTo:
-=rom:	Tyler A Evenson omments:

PORT CHARLOTTE, FL 33954-0000

Phone: 941-624-3494
Fax: 941-627-3519

12:28:54 FEB 25 2019	Page 1 of 3
FEI-PORT CHARLOTTE #1705

Price Quotation Phone:941-624-3494 Fax: 941-627-3519

EXl-lflSIT	''A"

Bid No:	B247135	Cust Phone: 941 -637-8500
Bid Date:	02/25/19	Terms:	NET 10TH PROX
Quoted By: TAE

Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY GRAND PALM PHASE 2Ae		GRAND PALM PHASE 2Ae
645 CHARLOTTE ST	645 CHARLOTTE ST
PUNTA GORDA, FL 33950	PUNTA GORDA, FL 33950

Cust PO#:	180501	Job Name:	GRAND PALM PH 2Ae

Item	Description	Quantity	Net Price	UM	Total
 	
*SEWER*
====================== -
8" PVC GRAV SWR •

4158	3.980	FT	16548.84	
3	55.730	EA	167.19	
5	28.000	EA	140.00	
			16856.03	

11	
47.530	
EA	
522.83	
33	13.470	EA	444.51	
11	18.240	EA	200.64	
462	2.220	FT	1025.64	
11	36.570	EA	402.27	
11	11.720	EA	128.92	
11	8.950	EA	98.45	
11	3.000	EA	33.00	
22	6.930	EA	152.46	
			3008.72	

53	
47.530	
EA	
2519.09	
159	13.470	EA	2141.73	
53	18.240	EA	966 .72	
53	68.260	EA	3617. 78	
53	11.720	EA	621.16	
53	8.950	EA	474 .35	
159	6.930	EA	1101.87	
2226	2.220	FT	4941.72	
53	3.000	EA	159.00	
3	28.000	EA	84.00	

SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE H260908	8 PVC HW SWR GXG REP COUP *Z
PO3105G4737	3X1000 UG DET SWR GREE SUBTOTAL

SINGLE SWR SRV (11) -

MUL067248	8X6 PVC HW SWR GXGXG WYE
MUL067376	6 PVC HW SWR GXS 45 ELL
MUL067326	6 PVC HW SWR GXG 45 ELL SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE MUL067206	6 PVC HW SWR GXGXG WYE
MUL040952	6 PVC SWR HUB FEM CO ADPT
MUL040958	6 PVC SWR REC THRO CO PLUG
CYPSKPX	2X4X8 YELL PINE STUD
MUL043988	6 PVC SWR GSKT CAP SUBTOTAL

DBL SWR SRV (53) -

MUL067248	BXS PVC HW SWR GXGXG WYE
MUL067376	6 PVC HW SWR GXS 45 ELL
MUL067326	6 PVC HW SWR GXG 45 ELL
MUL067277	6 PVC HW SWR GXG DBL WYE
MUL040952	6 PVC SWR HUB FEM CO ADPT
MUL040958	6 PVC SWR REC THRO CO PLUG
MUL043988	6 PVC SWR GSKT CAP SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE CYPSKPX	2X4X8 YELL PINE STUD
PD3105G4737	3X1000 UG DET SWR GREE

t/JFERGUSON®

Fax: 941-627-3519

12:28:54 FEB 25 2019
Reference No: 8247135		

Item	Description	
Quantity	
Net Price	
UM	
Total		

WATER MAIN •						

- 6 " PVC WTR MAIN -						
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	300	3.860	FT	1158.00		
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00		
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00		
SPWPC6	6 SIGMA BELL REST F/ C900 •PVLOK	12	32.000	EA	384.00		
SUBTOTAL				1659.00		
- 6" GATE VLVASSM (1)-						
AFC2606DLAFMM	6 DI MJ RW OL SS STEM VLV UA	1	406.550	EA	406.55		
SSLCE6AP	6 PVC WDG REST •ONELOK W/A	2	34.040	EA	68.08		
1461SW	2PC SC Cl VLV BX 19-22 WTR	1	95.000	EA	95.00		
RBGVTMU	3 BRS GATE VLV ID - 6	1	13.000	EA	13.00		
SUBTOTAL				582.63		
- 8" PVC WTR MAIN -						
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	4620	6.700	FT	30954.00		
PD3105B52737	3X1000 UG DETWTR BLUE	5	28.000	EA	140.00		
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	10	89.000	EA	890.00		
SPWPC8	8 SIGMA BELL REST F/ C900 *PVLOK	57	50.050	EA	2852.85		
SUBTOTAL				34836.85		
- 8" FITTINGS -						
MJ2LAX	8 MJ C153 22-1/2 BEND UA	11	68.900	EA	757 .90		
MJ1LAX	8 MJ C153 11-1/4 BEND UA	2	65.150	EA	130.30		
MJTLAX	8 MJ C153 TEE UA	3	127.650	EA	382.95		
MJTLAXU	8X6 MJ C153 TEE UA	1	105.770	EA	105.77		
SSLCE6AP	8 PVC VVDG REST *ONELOK W/A	37	46.150	EA	1707.55		
SSLCE6AP	6 PVC WDG REST *ONELOK W/A	1	34.040	EA	34.04		
SUBTOTAL				3118.51		
- 8" GATE VLV ASSM (10) •						
AFC2608DLAFMM	8 DI MJ RW OL SS STEM VLV UA	10	647.000	EA	6470.00		
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	20	46.150	EA	923 .00		
1461SW	2PC SC Cl VLV BX 19-22 WTR	10	95.000	EA	950.00		
RBGVTMX	3 BRS GATE VLV ID- 8	10	13.000	EA	130.00		
SUBTOTAL				8473.00		
FIRE HYO ASSM (5) •						
MJSTLAXU	8X6 MJ C153 SWVL TEE UA	5	122.790	EA	613.95		
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	10	46.150	EA	461.50		
SSLCE6AP	6 PVC WOG REST *ONELOK W/A	10	34,040	EA	340.40		
IMJBGPU	6 MJ C153 BLT GSKT PK L/GLAND	5	12.700	EA	63 .50		
AFC2606DLAFMM	6 DI MJ RW OL SS STEM VLV LIA	5	406.555	EA	2032. 78		
1461SW	2PC SC Cl VLV BX 19-22 WTR	5	95.000	EA	475.00		
RBGVTMU	3 BRS GATE VLV ID - 6	5	13.000	EA	65.00		
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	80	3.860	FT	308.80		
AFCB84BLAOLP	5-1/4 VO B84B HYD 4'0 OL UA	5	1425.000	EA	7125.00		

Page 2 of3
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
'

==========================

ff FERGUSON
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation Fax: 941-627-3519

Page 3 of 3

12:28:54 FEB 25 2019
Reference No: B247135

Item

Description	Quantity	Net Price	UM 	Total 	
8X1 CCBRS SOL C900	75	102.610 EA"""	7695.75	
LF 1 CCX CTS PJ BALL CORP	75	50.240 EA	3768.00	
"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1500	40.000	C	600.00	
"EXC 1X100 CTS DR9 HOPE BLUE PIPE	100	40.000	C	40.00	
12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
3X1000 UG OET WfR BLUE	2	28.000	EA	56.00	
LF 1 CTS X MTR ANG BV	75	87:340	EA	6550.50	
1 CTS PET/ HDPE DR9 INS STFNR	150	1.260	EA	189.00	
2X4X8 YELL PINE STUD	75	. 3.000	EA	225.00	
11X18X12 BXWI Cl ROR LID SUD	75	68.000	EA	5100.00	
SUBTOTAL				24491.25	
- SINGLE LONG (42) -					
8X1 CC BRS SOL C900	42	102.610	EA	4309.62	
LF 1 CCX CTS PJ BALL CORP	42	50.240	EA	2110.08	
"EXC 1X300 CTS DR9 HOPE BLUE PIPE	2400	40.000	C	960.00	
*EXC 1X100 CTS DR9 HOPE BLUE PIPE	100	40.000	C	40.00	
12GA 30MM 500 FT COP TRCR WIRE BLUE	6	89.000	EA	534.00	
3X1000 UG DET WfR BLUE	3	28.000	EA	84.00	
LF 1 CTS X MTR ANG BV	42	87.340	EA	3668.28	
1 CTS PET/ HOPE DR9 INS STFNR	84	1.260	EA	105.84	
2X4X8 YELL PINE STUD	42	3.000	EA	126.00	
11X18X12 BX W/CI ROR LID SUD	42	68.000	EA	2856.00	
2 SDR21 CL200 PVC GJ BLUE PIPE	1680	0.550	FT	924.00	
SUBTOTAL				15717.82	
8X12 MJ C110 LONG SLV UA	
1	
123.300	
EA	
123.30	
8 PVC WDG REST *ONELOK W/A	2	46.150	EA	92.30	

FS90804 FFB10004NL PEC9BG300 PEC9BG100 C1230BHS500 PD3105B52737 FBA43444WNL FINSERT52 CYPSKPX CWA03111812

FS90804 FFB10004NL PEC9BG300 PEC9BG100 C1230BHS500 PD3105B52737 FBA43444VVNL FINSERT52 CYPSKPX CWA03111812 SDR21BPK

FBLSLAX SSLCE8AP

s u BTOTAL		215.60	
Net Total:		$137072.76	
Tax:		$0.00	
Freight:		$0.00	
Total:		$137072.76	

Quoted prices are based upon receipt of the totalquantity for immediate shipment (48 hours).  SHIPMENTS BEYOND 48 HOURS SHALL BE
AT THEPRICE IN EFFECT AT TIMEOF SHIPMENT UNLESS NOTED OTHERWISE. QUOTES FOR PRODUCTS SHIPPED FOR RESALE ARE NOT FIRM UNLESS NOTED OTHERWISE.
CONTACT YOUR SALES REPRESENTATNE IMMEDIATELY FOR ASSISTANCE WITH DBE/MBENVBE/SMALL BUSINESS REQUIREMENTS.
Seller not responsible for delays, lack of product or increase of pricing due to causes beyond our control, and/or based upon
Local, State and Federal laws governing type of products that can be sold or put into commerce. This Quote is offered contingent upon the Buyer's acceptance of Seller's terms andconditions. which are incorporated by reference and found either following this document, or
on the web at https:/www.ferguson.com/conteln/Website-infotterms-of-sale Govt Buyers: All items are open market unless noted otherwise.

LEAD LAW WARNING: It is illegal to install products that are not ' leadfree'  in accordance with US Federal or other applicable law in potable water systems anticipated for human consumptio.nProducts with"NP in the description are NOT lead free and can only be installed in non-potable applications. Buyer is solely responsible for prOduct selection.

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD' s Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the CDD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the CDD is a paramount consideration. The CDD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The CDD is required to issue a Certificate of Entitlement to each vendor and to the CDD' s contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The CDD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0.affirms that the tangible personal property purchased pursuant to Purchase Order Number 180501 from Ferguson Waterworks (Vendor) on or after 2/22/19 (date) will be incorporated into or become a partof a public facility as part of a public works contract pursuant to contract # n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ae.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule 12A-1.094, F.A.C.:

)iou must initial each of the following requirements.
(__.Qt/1. The attached  Purchase  Order  is  issued  directly  to  the  vendor  supplying  the  tangible  personal p11{r0 theContractor will use in the identified  public works.
2	2. The vendor's invoice will be issued directly to Governmental Entity.
. 3. Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pu ic funds.
{3;f:J4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
5. Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-1.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Cert ifica te does not qualify for the exemption, Governmental Entity will be liabl e for any tax, penalty, and interest determined to be due.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By: -		 	.:

Its:  	

/ 	I

;                   ;.: 	,  :;.. 	

----'	DATE: -	 -c,,'l-J,L-/-L2.  L+1+?	;

Federal Employer Identification Number: -   -  - -	=  =  =	=-- - - - - - - -

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not send to the Florida Department of Revenue. This Certificate of Entitlement must be retained in the
vendor's and the contractor's books and records.

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such tenn in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-33

Cast Systems, LLC 19400 Peachland Blvd. Port Charlotte, FL 33948

Amount Payable:

$13,378.12

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs of Issuance, if applicable):

Direct purchase of material for construction of Grand Pahn, Phase 2A(d). Purchase Order# 190403; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien. right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1on contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

B_y: _	_	_	_	_	:::::3	/	
s:::::::::.::-"

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment
of  capitalized   intere,st    the   undersigned  Consulting   Engineer  hereby  certifies   that this

w 4	

disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set f01th on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

C- onsulting Enginee!_r

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Cast Systems
Project:	Grand Palm, Phase 2A(d)

    Invoice #		Amount	 40928	$4,956.98
 	40937	$8,421.14	
Sub-Total	$13,378.12

AS'I'

SYS'l'lt)IS L,L.C,

AUG Z 9 2019

CAI T 8V8Tl!M8, LL.0
18400 Pl!ACHLAND l!ILVD PORT CHARL.OTTI!, PL  33Hll Phono: (141) 020·3474
Fi x: (141) 2H■t 448

,lt )Vt ll\ I

C	stoner Copy	lnvoloo Numbo:r 40837
lnvoloo Dato:	8/28/2019

Blll to:	BLACKBURN CRl!l K COMMUNITYCEVli LOPMli NT
12061 CORPOAATl! IU.VO ORLANDO, fil. 32811■1'460
C:o nt1 at1

e,u tomor ID: III.AOK6URN0Ri f

Ship Vie:

&hip to: GRANOPALM2Ad
US 41 RIGHT ON AIVl!R RD Lf:PT ON HARNEY ST

,0,

ProJoatMlln1a1r:    ANCRGW 1110. 0:i
County: liXt MPT'
II IH Rep:	AOAMROWAN

-  - -	-	---	-	- - ·-	--	-	-	-	-	-	-	-   - -	--	-- .

TlokotNumbo:r

40Q:S7

Dt llvoryD11to:	0/29/2018

Torm, :

Nl::'f 30

Job Number:	1471li

l truoturo 10

Load:

l truoturoTypo

Duo D1t1:

8128/2019

--	--	-

Amount
---

MH IH •D•11i MH 8•ti•D•10 MH 6,H, 11
MH li •O•ll •07
MH a,a,,a 11

(JilHAft  All) ,4811 II AMl'-'i W/Utlfi#170 01/01
...	.	.  ..	·- -	·•
(JilHA8fl 2Ad) 4811 &AMH W/U81't 170 00/00
(PMAH  2Ad) 411" SAMH W/U8rr# 170 00/011
(PHAH  2M) ,48" 8 AMH W/UBfi# 1?O 08/011
•	•	••	•	•     •   •    •	• · • •• e ••••• • •· ·•• •
(PHA81!2M) 48" 8AMHWIU6flt 11000/0Q

,	1,0M,1ff v"
...	..	.	-·  ..	.
11,H .t.an v
$1,HU V 11,113 4,1e
11,1@4.,H

Talllllll@
Ngn,f  i!Kllbl@

- -

H , 411,14
-
10,00

IOYQIOI TOtl l	'6 , 421.14
-	-	- ··-	-	---	-
LOH O@poalt	l(Ul(}

CA..4i'I,
SYS'fEIIS L,L,C,

AUG 2 8

A8T SYSTEMS, LLC
2 01 8400PEACHLAND BLVD PORT CHARLOTT!, FL 33848 Phono: (941) 828•3474
Fax: (941) 288•8448

Custorner Copy

IN Vt Ill I
Invoice Number: 40G28 Invoice Date:	8/28/2019

 	

Blllto:		BLACKBURN CREEK COMMUNITY DEVELOPMENT 120!51 CORPORATE BLVD
ORLANDO,  FL 32817-14!50
Contact:
Cu1tomor ID: BI.ACKDURN CREE

Ship Via:

Ship to: GRANO PALM 2Ad
US 41RIGHT ON RIVER RO LEFT ON HARNEY ST

ProJoct Managor: ANDREW
110:	1V0403
County: SXeMPT
81111 Rep:	ADAM ROWAN

Ticket Number: '40828
Job Number:	14789
ltruoture 10

Dollvery Datt:	8/28/2019
Load:

ltruaturt Typo

4UA
411•11C	(filHAH	Ad) i YPI! M INLH WIU8f!#1110M
(PHASE  d)  C INl.l!' f W/ U8fi# 11210		I U OM 4 v
..........
t'f3◄, oo	
40◄A	(PHASI: 2Ad) TYPI! M INLliT WIU31'# 111OM		1 1 ,407,84	
48.,iB	(PHASE2Ad)iY I! M INl.f!T W/USr # 1110M		$1,407.94¥	
		Tt1111blo
Non•Ti llllblo	,o .oo
t4,HU D	
		Oull 'fOIAI	i 4,iliU II	
		f1111	t tHlO	
		lnvolo11 Totlll	t•U I U I	

-	-	-	-	-

Terme:
Dut Datt:

Nl:T30 9/2712019

Amount

- - -

LOH Dopo1!t	 	10.00	

-	- •- ¥•
lnv@IH

li11l11n111

t◄,uou, /

PURCHASE ORDER No. 	/90403	

Blackburn Creek Community Development District
c/ o
Forsberg Construction, Inc.
645 Charlotte S treet, Pun ta Go rda r:L 33950 Phone: (94 l) 637-8500	Fax: (941) 639-107 3
Und erground Utility License #C UC055 7 l6
Visit Us at www.forsbergconst ruction.com

Vendor: Cast Systems, LLC Address: 19400 Peachland Blvd
Port Charlotte. FL 33948

Quantity	Unit	Description	Unit Price	Total Price	
I		AH Manholes are per Sarasota County requirement s including 6" wall, CS- 5 5 interior and exterior coating, boots, doubl e ramnek, exterior joint wrap, precast inverts
and 170-CE-ORS Sarasota R&C				
						
5	EA	4' Dia Manhole 0-6	$	1,584.28		$	7,921.40	
3	EA	4' Dia Manhole 6-8	$	1,834.15		$	5,502.45	
4	EA	4' Dia Manhole 8-10	s	,2 177.11		$	8,708.44	
I	EA	4' Dia Man hol e I 0-12	$	2,550.72		$	2,550.72	
I	EA	Type C Inlet with USF #6210	$	734.06		$	734.06	
I	EA	Type D Inlet with USF #6607	$	1,354.54		$	1,354.54	
I	EA	48" Junction Box with #170-E	$	I, 100.30		$	I, 100.30	
2	EA	72" Junction Box with #170-E	$	2,390.93		$	4,78 1.86	
2	EA	Type F Inlet with USF # I I I OM	$	1,350.11		$	2,700.22	
12	EA	Type M Inlet with USF # I I I OM	$	, 1 407.64		$	16,89 1.68	
I	I	EA	Medium Control Structure with USF #6620	$	2,88 1.57		$	2,88 1.57	

						
!						
t
'						
						
		Prices ar e qood for duration of the project.				
		Project Du ration : April I 5, 2019 - April 15, 2020				
Total Project Subtotal	s	55,127.24	
Sales Tax @ 6 %	tax exempt	
			Discretionary Tax@ 1.0 % on  1st $5,0 00.0 0t		tax	e  xemp	t	
TOTAL	$	55,127.24	

Attention: Adam Rowan 239-595-4664

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: Obervation Blvd off of Center Road

  Venice, Florida	                               Legal Desc.: Sec 19 & 20, Twp: 395, Ran ge 20E

County: Sarasota Payment Terms: Net 30 days
Vendor Phone:  94 1-625-34 74 	                                  Vendor Fax:   941-255-9448	 

Cast Systems, LLC	Blackburn Creek COD

Vendor name

5-	- -c--- f/17!19

Au th oriz e d A g en t ( signature)	Date
Authorized Agent fprinte(\/ typed/ Pag e	I	of	2

 	-		/ 1¥11v
Authorized Agent (sig n atur e/	Date
! IMPORTANT !
" SEE SPECIAL FROV/S/O NS A BO VE

ADDITIONAL TERMS AND CONDITIONSON PAGE 2

TERMS AND CONDITIONS
Alf material shall be as specified and warranted in accordance to the Project specifications,plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchaser.

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. All items supplied without prior approval, that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Tlme is of the essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will alfow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not be responsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-special ty materials in goodcondition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within l O days of Purchase Order date. Purchaser willreturn an executed Purchase Order to Vendor.

I 0. To insure prompt payment Purchase Order number must appear on alf invoices and copies of sign ed delivery slips attached.

I I.	Neither party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will beconsidered an acceptance of this Purchase Order.

If Vendor fails to properly execute and return Purchase Order within IO days, Purchaser may consider offer rejected.

This agreement shall be governed by the laws of the State of Florida with venue in Charlotte County, Florida.

The authorized agent signing this Purchase Order for the Vendor must be duly authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full forceand effect.

This Purchase Order is the only binding contract between Purchaser and Vendor tor this project and the work described . This Purchase Order replaces all previous contracts and agreements, whether written or verba,l regarding this project. No other document will sup ersede the requirements of this Purchase Order unless signed by an authorized agent of each party subsequent to the date of this Purchase Order .

Page   2  of	2

Cast System· s lnitial  ackburnCreek COD In ti

Florida Admin Rule 12A-l.094 Public Works Contracts and FS Sec. 212.08:

l . Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer's Certification of Exemption.

Direct Invoice . The vendor's invoice must be issued to the CDD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the COD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the CDD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk of loss if the COD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The CDD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE OF ENT IT LEMENT
The undersigned authorized representa tive of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 190403 from Cast Systems, LLC (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule 12A-1.094, F.A.C.:

You must initial each of the following requirements.
l. The attached Purchase Order is issued direct ly to the vendor supplying the tangible personal prlµr,tytheContractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pub)if:Junds.
Governmental Entity will take title to the tangible personal property from the vendor at the time of purchase or of delivery by the vendor.
Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase  Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-1.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

B_y:		....,._.,_		-	-	-	   : 

Its: 	 	

C_/..,c/..-l')-f_/_.--

_	_	_	_	_	---'

Federal Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

You must attach a copy of the Purchase Order to this Certificate of Entit lemen t.

Do not send to the Florida Department of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District

FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Conununity Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-34

Cast Systems, LLC 19400 Peachland Blvd. Port Charlotte, FL 33948

Amount Payable:

$1,537.21

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Palm, Phase 1B(a). Purchase Order# 180603; See attached for invoice information

The undersigned hereby ce1tifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such requisition contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By AuonzedOfficer=A_/	

CONSULTING ENGINEER'S APPROVAL FOR
NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such repo1t shall have been amended or modified on the date hereof.

 �	�	
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Cast Systems
Project:	Grand Palm, Phase 1B(a)

    Invoice #	Amount	
 	40927	$1,537.21	
Sub-Total	$1,537.21

CAS'I'

SYS'l'l )IS L,L.C,

AUG 2 8 2019

CAST SYSTEMS, LLC
19400 PEACHLAND BLVD PORT CHARLOTTE, FL 33948 Phone: (941) 620-3474
Fax: (941) 255-9448

IN Vi lit ' I

Custorner  Copy	Invoice Numbtr: 40927
Invoice Date:	8/28/2019
.	- ----- -- - - - - - - - - - - - - - - - - - - - - - - ---- -- - - ·

BIii to:	BLACKBURN CREEK COMMUNITY OEVELOPM5NT
12051 CORPORATE BLVO
ORLANDO,  FL 32817-1400
Contact:

Cu1tom1r ID: BLACKBURN CRl!E

Ship to: GRAND PALM PHASE 1B(a)

ProJoot Manager:
PO:	180803

Ship Via:				Salta Rop:	N/A		
Ticket Number.	40927	D1llv1ry Date:	8128/2019	Term,:		NET30	
Job Number:	14449	Load:		Due Dato:		9/27/2019	

County: ! X! MPT

Structure ID

-	-	-

8tructuro Typo

 	
Amount

MH 2-26-09	48"SAMH WIUSP# 170CE 00/08					$1,537,21	
					Taxable	$0,00	
					Non-Taxable	$1,537.21	
	Sub Total	$1,537,21	
	Tox	$0,00	
	Invoice Totll	$1,1537,21	
	LtH Cepoalt	$0,00	
	Invoice Balance	$1,537 .21	

v

PURCHASE ORDER No.	 	180603	

Blackburn Creek Com.munity Development District
c/o
Forsberg Constrnction, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (941) 637-8500	Fax: (941) 639-1073
Underground Utility Lice nse #CUC055716
Visit Us at www.forsbergco nstruction .com

Vendor: Cast Systems, LLC Address: 19400 Peachland Blvd
   Port Charlotte, FL 33948	

Attention: Adam Rowan 239-595-4664

Job No.: 18-06

P.O. Date: February 22, 2019

Project Name: Grand Palm Phase 1Ba	 Project Address:   Obervation Blvd off of Center Road	 
 Venice, Florida	

Legal Desc.: Sec: 19&20, Twe: 395, Range 20E County:  Sarasota	
Payment Terms: Net 30 days

Vendor Phone:  941-625-3474 	                                 Vendor Fax:    941-255-9448		

I Quantity

I	I

1 Unit

Description
All	Manholes are per Sarasota County requirements including 6" wall, CS-55 interior  and  exterior coating, boots, double ramnek, exterior joint wrap, precast inverts
and 170- CE-ORS Sarasota R&C

Unit Price
I	I

Total Price

4	I     EA   I4' Dia Manhole 0-6	' $	1,537.21
i	4	I  EA	4' Dia Manhole 6-8	s	1,754.51
2	EA	4· Dia Manhole I 0-12	$	2,249.77

-

-- 1	I      EA   Type C Inlet with USF #16610	$	650.54
7	I        EA	Type M Inlet with USF # I 11OM	$	1,526.64
I	EA	Small Control Structure with USF #6615	$	1,847.74
I	I
I	I	I

$	6,148.84
s	7,018.04
$	4,499.54
's	650.54
$	10,686.48
$	1,847.74

r
r I
I	
 --	

I
+-L

I	I	I
I	I	I
!- 	I	-

---

I	1Prices are good for duration of the project.	I

I	I	!ProjectDuration : January 1, 2019-January I, 2020
I I

Total Project Subtotal	$	30,851.18
Sales Tax @ 6 %	tax exempt

I	Discretionary Tax @ 1.0 % on  Ist S5,000.00	tax exempt

I ---

TOTAL  $	30,851.18

Cast Systems, LLC	Blackburn Creek COD

.3 I Z I	I 

..ff 71 11

Authorized Agenc (slgnarureJ

Date

Date	'

-			m	&,wqr1   	
Authorized Agent Jprinted/typed)
Page	of	2

! IMPORTANT!
SEESPECIAL PROVISIONS ABOVE.

AOO!TIONAL TERMSANO CONDITION S ON PAGE 2

TERMS AND CONDITIONS
I.		All material shall be as specified and warranted in accordance to the Project specifications, plans and addenda. Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchaser.

When requested by Purchaser, Vendor will provide. at no additional cost to Purchaser. a complete set of shop drawings for Purchaser's review and approval. All items supplied without prior approval. that do not meet Project requirements, will bereturned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading . Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

S. Material shall arrive in such time that it will allow for unloading before quitting time. or Vendor and/or transporter willberequired to hold over until the following work day to be unloaded. Purchaser will not be responsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser. upon 3 day writtery notice to Vendor. shall have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra. non -special ty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within IO days of Purchase Order date. Purcha ser will return an executed Purchase Order to Vendor.

I 0. To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

I I . Neither party will change. alter, nor substit ute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be initialed and dated by authorized agents of both parties.

No invoices will be processed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order. will be considered an acceptance of this Purchase Order.

If Vendor fails to properly execute and return Purchase Order wi thin IO days, Purchaser may consider offer
rejected.

This agreement shall be governed by the laws of the State of Florida with venue in Charlo tte County. Florida.

The authorized agent signing this Purchase Order for the Vendor must be duly authorizedto do so on behalf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

18 .	This Purchase Order is the only binding contract between Purchaser and Vendor for this project and the work described . This Purchase Order replaces all prev ious contracts and agreements, whether written or verbal, regarding this project. No other document will supersede the requirements of this PurchaseOrder unless signed by an authorized agent of each party subsequent to the date of this Purchase Order.

Page

2   of	2	Cast System·s Initial Ka	lackbumCreek CO_D Inti!	

Florida Admin Rule 12A-l.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The COD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer' s Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the COD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The CDD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the CDD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the CDD is a paramount consideration. The CDD will be deemed to have assumed the risk of loss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD' s purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The COD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 180603 from Cast Systems. LLC (Vendor) on or after 2/22/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08 (6), F.S., and Rule 12A-1.094, F.A.C.:

&'

You must initial each of the following requirements.
The attached Purchase Order is issued directly to the vendor supplying the tangible personal pr   ty thCeontractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor"s invoice will be made directly by Governmental Entity to the vendor from putilic funds.
£	4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
pu1 a;e orofdelivery by the vendor.
(fa.ls. Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached  Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-1.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony .

Under the penalties of perjury, I declare that I have read the foregoing Certificate of Entitlement and the facts stated in it are true.
Blackburn Creek Community  Development  District,  a  local  unit  of  special  purpose  government By: -  - -""--   ,c._-  -   -   -   -  -   -==  =  =	-='
,.,-, n	 	

Its:  	

..,,,k/l=-ucc,q'.,vl=--"-------------'	DAT_E:

_...3L..-/<2-+/_,_l  /,f---	-	-	

Federal Employer Identification Nu mbe r: -   -   -   - -   -   - -   -	-==	-   -   -	 ; You must attach a copy of the Purchase Order to this Certificate ofEntitlement.
Do not send to the Florida Department of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

Blackburn Creek Community Development District

FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-35

County Materials Corp.
P.O. Box435 Astatula, FL 34705

Amount Payable:	$22,998.00

Purpose for which paid or incurred (refer also to specific contract if amount is due and payable pursuant to a contract involving progress payments, or, state Costs oflssuance, if applicable):

Direct purchase of material for construction of Grand Pahn, Phase lB(a). Purchase Order# 180602; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount  set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously · been paid].

The undersigned hereby further certifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

The undersigned hereby further certifies that such reqms1t1on contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or approving the specific contract with respect to which disbursements pursuant to this requisition are due and payable.

Attached hereto are originals of the invoice(s) from the vendor of the property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

 	By.	r A	

CONSULTING ENGINEER'S APPROVAL FOR NON-COST OF ISSUANCE REQUESTS ONLY

If this requisition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital hnprovement Plan, which Cost does not exceed the amount specified for the category of improvement as set fo1th on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modified on the date hereof.

}J
Consulting Engineer

U-	-

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 1B(a)

    Invoice #	Amount	
148802-04	$5,056.16	
148802-05	$4,270.64	
148802-06	$4,270.64	
148802-07	$4,270.64	
   148802-08	$5,129.92	
Sub-Total	$22,998.00

COUNTY

. (866) 343-8488 Fax (352) 343-0 471
ASTATULA, FL 34705-0435

AUG 3 0 2019	INVOICE

SHIPPED	INVOI CE CA TE	I	ORDER NO.	
0 8 / 23/ 19	08/23/19	I	148802-04	
I	P.O. NO.		I	PAGE#	
44	I ct	180602		I 1 of 1	

MATERIALS CORPO RA T I O N

REMIT TO: PO BOX 38
CUS T# :	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 1Ba
SHIP TO: Sarasota County
Observati on Blvd of f Cent er Rd Venice FL 34292

BILL TO:

BLACKBURN CREE K COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA  FL 33950

I

LINE	PRODUCT
NO .	A N D D E SC RIPTION

I	iED

I	I

QTY.	UNIT
U/M	PRICE

A M OU NT (NET)

i

V

7	236380s	V     72. 00   LFT	48 . 53 V	3494 . 16 •

8	236s
36" RCCP GASKET SM ALL BELL #839236	9 . 00	EA	0. 00	0.	00	
11	236889s	/	1. 00	EA	1562. 00/	1 56 2.	00	
	36" FLARED END SECTION GB SMALL BELL						

36"	RCP CL3 SM ALL BELL

,/

Total	5056. 16 V
Invoice Total	5056. 16

COU NT Y

M ATE RI A L S C O RP O RAT I O N

. (866) 343-8 488 Fax (352) 343-0 471
ASTATULA , FL 3 4705 -0 43 5

REMIT TO: PO BO X 38

AUG 3 0 2019	IN VOICE

SHIPPED	INVOICE OATE	I	OROER NO.	
08 /23/1 9	08/23/1 9	I	14880 2-0 5	
I	P.O. NO.		I	PAGE #	
44	I ct	180602		I 1 of 1	

CUST#:	327   5	MARATHON, WI  54448 -0038
Grand Palm Phase 1Ba
SHIP ro: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUC TION 645 CHARLOTTE STREET
PUNTA GORD A FL 339 50

I

LINE	PRODUCT
N O .	AND DESCRIPTION

I	s i ED

I	I

/ I

Q TY.	U NI T
U/M	PRICE

A M O UN T (NETI

/

7	236380s	"'$8. 00  LFT	48 . 53	4270 . 64
36 " RCP CL3 SM ALL BELL
8	236 s	11. 00	EA	0 . 00	0 . 00
36" RCCP GASKET SMALL BELL #839236
Total	4270. 64
Invoice Total	42 70. 64

COU N T Y

MATERIALS CORPORATION
CUST #:	3275
Grand Palm Phase 1Ba

SHIPPED	INVOIC E DATE	I	ORDER NO .	
08/26/19	08/26/19	I	148802-06	
I	P.O. NO.		I	PAGE#	
44	I ct	180602		I 1 of 1	

SHIP TO: Sarasota County

(866) 343-8488 Fax (352) 343-047 1
ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38
MARATHON, WI 54448 -0038

AUG 3 0 2019	IN VOICE

Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURNCREEK COD
C/O FORSBERG CONSTRU CTION 645 CHARLOTTE STREET
PUNT A GORDA FL 33950

LINEI
NO.	
PRODUCT AND DESCRIPTION	I	QTY .
,$HIPPED	I	QT Y.	I
U/M	UNIT PRICE	t	AMOUNT (NET)	
7	236380s	88.	00	LFT	48.	53 17	4270 . 64	
	36" RCP CL3 SMALL BELL							
8	236s	11.	00	EA	0.	00	0. 00	
	36" RCCP GASKET SMALL BELL #839236							
				Tot al			4 270. 64	
				Invoice	Total		4270.64	

I

C OU N T Y
M ATE RI A LS   CO  RPO  RA  TI O N

(866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

AUG 3 0 201 N VOICE

SHIPPED	IN VOICE DATE	I	ORDER NO .	
0 8 /26/ 19	0 8 / 26/19	I	14880 2-07	
I	P.O. NO.		I	PAGE #	
44	I ct	180602		I 1 of 1	

CUS T  #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 1Ba
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA FL 33950

			sZ!Y.	I
PED
v 88. 00

11. 00	QTY.  I	UNI T
U/M	PRICE
LFT	48. 53

EA	0. 00

Total
Invoice Total	J	AMOUNT
{NET)	/
4270.64

0. 00

,
4270.64
4270.64	
LINEI
NO .	AND DESCRIPTION	I					
7	236380s						
	36" RCP CL3 SMALL BELL						
8	236s						
	36" RCCP GASKET SMALL BELL #839236						

V

COU N T Y

M ATE RI A LS C O RPO R AT I O N

. (866) 343-8488 Fax (352) 343-0 47 1
ASTATULA, FL 3 470 5-0 435

REM IT TO: PO BOX 38

AUG 3 0 201!J'IVOICE

SHIPPED	INVOICEDATE	I	ORDER NO .	
0 8/26 /19	08/26/19	I	148802-08	
I	P.O. NO.		I	PAGE#	
44	I ct	180602		I 1 of 1	

CU ST #:	3275	MARATHON, WI 54448 -0038
Grand Palm Phase 1Ba
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURNCREEK COD
C/0 FORS BERG CONSTRUC TION 645 CHARLOTTE STREE T PUNTA GORDA FL 33950

LINEI	PRODUCT 	I
NO.	AND DESCRIPTION	,;r;r,r·	I QTY.	I	 UNIT	,)	AMOUNT S      PED		U/M		PRICE			(NETJ
V  64. 00   LFT	48. 53 v	3105. 92

8. 00	EA	0. 00	0 . 00	
7	236380s
36" RCP CL3 SMALL BELL
8	236s
36" RCCP GASKET SM ALL BELL #839236
9	224889s
24" FLARED END SECTION GB SM ALL		
	I 2. oo  EA	10 12. oo/	2024.  00
Total	5129. 92
Invo ice Tot al	5129. 92	

/

V
V

PURCHASE ORDER No. 	180602	

Blackburn Creek Community Development District
c/o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (941) 637-8500	Fax: (941) 639-1073
Und erground Utility License #CUC 055716
Visit Us at www.forsbcrgconstruction.com

Vendor: County Materials Corporation Address: P.O. Box 435
   Astatula, FL 34705	

Job No.:   18 -06-----
P.O. Date: February 21, 2019

Project Name: Grand Palm Phase I Ba

Project Address: Obervation Blvd off of Center Road

   Venice, Florida	                                      Legal Desc.: Sec: 19 & 20, Twp : 39S, Range 20E
County: Sarasota

Payment Terms: _N:....:..::.e 3:t:..0:......::..da:::.yccs.._ 	_

Vendor Phone: _8_6_6'-·3_4_3_-8_4_8_8	_

Quantity	Unit		Description	Unit Price	Total Price	
							
32	+/-	LF	l8"RCP	s	16 . 0 5		s	5 13 . 60	
616	+/-	LF	24' RCP	$	24.45		$	15,061.20	
176	+/-	LF	30"RCP	s	34.73		s	6,112.48	
472	+/-	LF	36"RCP	s	48 . 53		$	22,906.16	
2	+/-	EA	24" Flared End Section	$	1,0 1 2.00		$	2,024.00	
I	+/-	EA	30" Flared End Section	$	1,315.40		$	1,315.40	
3	+/-	EA	36" Flared End Section	$	1,5 62.00		$	4,686 .00	

						
						
	I					
						
		Prices are qood for duration of the project.				
						
		Project Duration: January 2, 2019 - January 2, 2020				
Total Project Subtotal	$	52,618 .84	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ J .0 % on J st S5,000.00	tax exempt	
TOTAL	$	52,618 .84	

Attention : Johnny_ Smith 941-915-3671

Coun!}' Materials

't.

Venaorname
X '"-Ult	0 1 Q	i l 1- 3.;6 L

Vendor Fax: 352-343-0471

Blackburn Creek COD

Cha		C: 
3L1! L'f

Authorized Agent {signature)	CJ	Date
 	 		1haj	

/\Umonzea /\gent (signature)	Date
! IMPORTANT!

Authorized Agent 1printedftyped)
Page	I	of	2

�SEESPECIAL PROVISIONS ABOVE.
ADDITIONAL TERMS AND CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
All material shall be as specified and warranted in accordance to the Project specifications, plans and addenda.
Material shall be within accepted standards for workmanship and quality, and shall be satisfactory to meet approval of the Owner, Owner's representative and Purchaser .

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. All items supplied without prior approval, that do not meet Project requirements, will be returned to Vendor, by Vendor, at no charge to Purchaser.

Time is of the essence.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading . Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive In such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the fol/owing work day to be unloaded. Purchaser will not be responsible for any demurrage charge for such hold over.

Should the Vendor fail to provide material as scheduled by Purchaser and Vendor, the Purchaser, upon 3 day written notice to Vendor, shall have the right to procure said materials elsewhere without  further responsibility to Vendor.

Quantities are approximate and subject to project requirements.

Vendor agrees to accept without charge to Purchaser, all extra, non-specialty materials in good condition which remain after completion of work and will issue full credit for same.

Vendor shall sign and return Purchase Order within IO days of Purchase Order date. Purchaser will return an executed Purchase Order to Vendor.

I 0. To insure prompt payment, Purchase Order number must appear on all invoices and copies of signed delivery slips attached.

1 I .		Neither party will change, alter, nor substitute any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be initialed and dated by authorized agents of both parties.

No invoices will be processed or paid by Purchaser without receipt of a properly signed and acceptable Purchase Order.

Shipment of any materials, before signing this Purchase Order, will be considered an acceptance of this Purchase Order.

lf Vendor fails to properly execute and return Purchase Order within IO days, Purchaser may consider offer rejected.

I 5. This agreement shall be governed by the Jaws of the State of Florida with venue in Charlotte County, Florida.

The authorized agent signing this Purcfiase Order for the Vendor must be duty authorized to do so on behalf of the Vendor or on behalf of any such disclosed principal.

In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

18 .		This Purchase Order is the only binding contract between Purchaser and Vendor for this project and the work descri bed. This Purchase Order replaces all previous contracts and agreements, whether written or verbal, regarding this project. No other document will supersede the requirements of this Purchase Order unless signed by an authorized agent of each party subsequent to the date of this Purchase Order.

Page   2  of	2	County Materials Initial	Blackburn Creek COD lntital	,........

Florida Admin Rule 12A-1.094 Public Works Contracts and FS Sec. 212.08:

Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor will use and provide the vendor with a copy of the CDD's Florida Consumer's Certification of Exemption.

Direct Invoice. The vendor's invoice must be issued to the COD only, rather than to the contractor.

Direct Payment. The CDD must make payment directly to the vendor from public funds.

Passage of Title. The COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

Assumption of the Risk of Loss. Assumption of the risk of damage or loss by the COD is a paramount consideration. The COD will be deemed to have assumed the risk ofJoss if the CDD bears the economic burden of obtaining insurance covering damage or loss or directly enjoys the economic benefit of the proceeds of such insurance.

The COD is required to issue a Certificate of Entitlement to each vendor and to the CDD's contractor to affirm that the tangible personal property purchased from that vendor will go into or become a part of a public work. [Copy of Certificate of Entitlement is attached].

The CDD's purchase order for tangible personal property to be incorporated into the public works project must be attached to the Certificate of Entitlement.

The CDD must issue a separate Certificate of Entitlement for each purchase order.

CERTIFICATE OF ENTIT LEMEN T
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 180602 from County Materials (Vendor) on or after 2/21/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule 12A-1.094, F.A.C.:

You must initial each of the following requirements.
The attached Purchase Order is issued directly to the vendor supplying the tangible personal priper theContractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pubj½ u ds.
&l:f/4· Governmental Entity will take title to the tangible personal property from the vendor at the time of
pu ase orof delivery by the vendor.
5.	Governmenta l Entity assumes the risk of damage or loss at the time of purchase or delivery by the vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Cer tificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to bedue.

I understand that if I fraudulently issue this certificate to evade the payment of sales tax I will be liable for payment of the sales tax plus a penalty of 200% of the tax and may be subject to conviction of a third degree felony.

Under the penalties of perjury, 1 declare that I have read the foregoing Cer tifica te of Ent itle ment and the facts stated in it are true.

Blackburn Creek Community Development District, a local unit of special purpose government

By: -=	-	 ----=    =-...i.-"":L:		 :

Its-:

-     -	 -' s-:::'-'-= ..::...::::::...,c-_ _ _ _ _ _ _ _

,,,

Federal Employer Identification Number: --  -   -	=  =	=--  -   -   -   -   -   -   -	---	;

You must attach a copy of the Purchase Order to this Certificate of Entitlement.

Do not send to the Florida Department of Revenue. This Certificate of Entitlement mus t be retained in the vendor's and the contractor's books and records.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Review of District Financial Statements

Blackburn Creek CDD Statement of Financial Position As of 09/30/2019

General Fund

Debt Service -	Debt Service -	Debt Service -	Capital Proiects -		Capital	Capital Project	Long Term Debt 2013 & 2019		2015		2018		2013 & 2019	Projects - 2015		Fund - 2018		Group

Total

Current Assets
General Checking Account Prepaid Expenses
Debt Service Reserve 2013A Bond Debt Service Reserve 2019A Bond Revenue 2013A Bond
Revenue 2019A Bond Prepayment 2013A Bond Sinking Fund 2013A Bond
Capitalized Interest 2019A1 Bond Capitalized Interest 2019A2 Bond Debt Service Reserve 2015A1 Bond Debt Service Reserve 2015A2 Bond Revenue 2015A Bond
Prepayment 2015A1 Bond Prepayment 2015A2 Bond Sinking Fund 2015A1 Bond Revenue 2018A Bond Prepayment 2018A1 Bond
Debt Service Reserve 2018A1 Bond Prepayment 2018A2 Bond
Capitalized Interest Account 2018A2 Bond Acquisition/Construction 2013A Bond Acquisition/Construction 2019A Bond Acquisition/Construction 2015A Bond Aquisition/Construction 2018A Bond
Total Current Assets	

$60,294.75 9,811.84

$70,106.59	

$178,150.00 91,674.93
274,511.51
120.54
27,848.65
5,032.58
89,142.64
40,528.26

$707,009.11	

$233,662.50 106,406.25
104,433.05
17,337.91
108,327.61
25,022.10

$595,189.42	Assets

$344,921.56
2,562.00
172,479.96
105,530.00
177,796.50

$803,290.02	

$20,598.92 2,397,845.97

$2,418,444.89	

$190,323.62

$190,323.62	

$591,931.05
$591,931.05	

$0.00	

$60,294.75 9,811.84
178,150.00
91,674.93
274,511.51
120.54
27,848.65
5,032.58
89,142.64
40,528.26
233,662.50
106,406.25
104,433.05
17,337.91
108,327.61
25,022.10
344,921.56
2,562.00
172,479.96
105,530.00
177,796.50
20,598.92
2,397,845.97
190,323.62
591,931.05

$5,376,294.70	

Investments
Amount Available in Debt Service Funds Amount To Be Provided
Total Investments

Total Assets	

$0.00

$70,106.59	

$0.00

$707,009.11	

$0.00

$595,189.42	

$0.00

$803,290.02	

$0.00

$2,418,444.89	

$0.00

$190,323.62	

$0.00

$591,931.05	

$2,105,488.55 23,226,511.45
$25,332,000.00

$25,332,000.00	

$2,105,488.55 23,226,511.45

$25,332,000.00

$30,708,294.70	

General Fund		Debt Service - 2013 & 2019	

$99.07			
$99.07		$0.00	
$0.00

$99.07		$0.00

$0.00	

($3,421.82) 86,450.26
(13,020.92)			
		$575,494.76 131,514.35	

Blackburn Creek CDD Statement of Financial Position As of 09/30/2019

Current Liabilities Accounts Payable Retainage Payable Developer Advance Retainage Payable Retainage Payable
Total Current Liabilities

Long Term Liabilities
Revenue Bonds Payable - Long-Term Total Long Term Liabilities

Total Liabilities

Net Assets
Net Assets, Unrestricted
Net Assets - General Government
Current Year Net Assets - General Government

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Total Net Assets

Total Liabilities and Net Assets

$70,007.52	$707,009.11

$70,106.59	$707,009.11

Debt Service -	Debt Service - 2015		2018

Liabilities and Net Assets

$0.00		$0.00	
$0.00

$0.00		$0.00

$0.00	

$955,401.43 (360,212.01)		

$1,093,085.79 (289,795.77)	

 	
$595,189.42	$803,290.02

 	
$595,189.42	$803,290.02

Capital Proiects - 2013 & 2019

$62,755.92 13,827.00

$76,582.92

$0.00

$76,582.92

$3,044.36 2,338,817.61

$2,341,861.97

$2,418,444.89

Capital Projects - 2015

$16,006.15

$16,006.15

$0.00

$16,006.15

$173,818.38
499.09

$174,317.47

$190,323.62

Capital Project Fund - 2018

$127,756.94

$127,756.94

$0.00

$127,756.94

$4,539,286.80 (4,075,112.69)

$464,174.11

$591,931.05

Long Term Debt	Total Group

$0.00		$99.07 62,755.92
13,827.00
16,006.15
127,756.94
$220,445.08	

$25,332,000.00
$25,332,000.00

$25,332,000.00		

$25,332,000.00
$25,332,000.00

$25,552,445.08	

$0.00

$25,332,000.00		

($3,421.82) 86,450.26
(13,020.92)

575,494.76
131,514.35

955,401.43
(360,212.01)

1,093,085.79
(289,795.77)

3,044.36
2,338,817.61

173,818.38
499.09

4,539,286.80
(4,075,112.69)

$5,155,849.62

$30,708,294.70	

 	  	     

Blackburn Creek CDD Statement of Activities As of 09/30/2019

Debt Service -	Debt Service -	Debt Service -	Capital Proiects	Capital	Capital Project -	Long Term	
2013 & 2019	2015	2018	- 2013 & 2019	Projects - 2015	2018	Debt Group	

General Fund	Total

Revenues

On-Roll Assessments	$72,015.36																$72,015.36	
Off-Roll Assessments	10,560.73																10,560.73	
Other Income & Other Financing Sources	49.00																49.00	
On-Roll Assessments			$225,934.58														225,934.58	
Off-Roll Assessments			8,804.37														8,804.37	
Other Assessments			28,258.50														28,258.50	
Inter-Fund Group Transfers In			20,777.63														20,777.63	
Debt Proceeds			262,683.70														262,683.70	
On-Roll Assessments					$223,888.70												223,888.70	
Off-Roll Assessments					112,442.55												112,442.55	
Other Assessments					397,133.16												397,133.16	
Inter-Fund Group Transfers In					(14,211.51)												(14,211.51)	
On-Roll Assessments							$160,125.09										160,125.09	
Off-Roll Assessments							592,810.98										592,810.98	
Other Assessments							358,770.48										358,770.48	
Inter-Fund Transfers							(1,302.68)										(1,302.68)	
Inter-Fund Transfers In									($6,108.82)								(6,108.82)	
Debt Proceeds									4,382,516.30								4,382,516.30	
Inter-Fund Transfers													$845.38				845.38	
Total Revenues	$82,625.09		$546,458.78		$719,252.90		$1,110,403.87		$4,376,407.48		$0.00		$845.38		$0.00		$6,835,993.50	

Expenses

Supervisor Fees	$10,200.00	$10,200.00	
Insurance	2,364.00	2,364.00	
Trustee Services	9,743.55	9,743.55	
Management	22,916.63	22,916.63	
Engineering	1,318.97	1,318.97	
Dissemination Agent	12,500.00	12,500.00	
District Counsel	14,924.00	14,924.00	
Assessment Administration	7,500.00	7,500.00	
Audit	4,500.00	4,500.00	
Arbitrage Calculation	500.00	500.00	
Travel and Per Diem	33.06	33.06	
Telephone	160.71	160.71	
Postage & Shipping	421.08	421.08	
Copies	61.95	61.95	
Legal Advertising	2,874.89	2,874.89	
Office Supplies	191.11	191.11	
Web Site Maintenance	1,875.00	1,875.00	
Dues, Licenses, and Fees	175.00	175.00	
General Insurance	3,414.00	3,414.00	

Debt Service -	Debt Service -	Debt Service -	Capital Proiects	Capital	Capital Project -	Long Term	
2013 & 2019	2015	2018	- 2013 & 2019	Projects - 2015	2018	Debt Group	

Blackburn Creek CDD Statement of Activities As of 09/30/2019

Principal Payment - 2013A1, 2019A1	$100,000.00					100,000.00	
Interest Payments - 2013A1, 2019A1	308,852.59					308,852.59	
Interest Payments - 2019A2	15,959.22					15,959.22	
Principal Payments - 2015A1 bond		$325,000.00				325,000.00	
Principal Payments - 2015A2 bond		445,000.00				445,000.00	
Interest Payments - 2015A1 bond		255,125.00				255,125.00	
Interest Payments - 2015A2 bond		56,250.02				56,250.02	
Principal Payment - 2018A1 Bond			$277,000.00			277,000.00	
Principal Payment - 2018A2 Bond			404,000.00			404,000.00	
Interest Payment - 2018A1 Bond			641,781.00			641,781.00	
Interest Payment - 2018A2 Bond			79,325.50			79,325.50	
Trustee Services				$5,875.00		5,875.00	
Management				25,000.00		25,000.00	
Engineering				38,119.78		38,119.78	
District Counsel				62,000.00		62,000.00	
Trustee Counsel				5,250.00		5,250.00	
Bond Counsel				40,000.00		40,000.00	
Developer Advance Repayment				66,479.79		66,479.79	
Capital Expenditure				1,800,836.25		1,800,836.25	
Engineering Services					$39,854.95	39,854.95	
Capital Expenditure					4,043,727.95	4,043,727.95	
Total Expenses	$95,673.95		$424,811.81		$1,081,375.02		$1,402,106.50		$2,043,560.82		$0.00		$4,083,582.90		$0.00		$9,131,111.00	

Other Revenues (Expenses) & Gains (Losses)

General Fund

Total

Interest Income	$27.94																$27.94	
Interest Income			$9,867.38														9,867.38	
Interest Income					$1,910.11												1,910.11	
Interest Income							$1,906.86										1,906.86	
Interest Income									$5,970.95								5,970.95	
Interest Income											$499.09						499.09	
Interest Income													$7,624.83				7,624.83	
Total Other Revenues (Expenses) & Gains (Losses)	$27.94		$9,867.38		$1,910.11		$1,906.86		$5,970.95		$499.09		$7,624.83		$0.00		$27,807.16	

Change In Net Assets	
($13,020.92)		
$131,514.35		
($360,212.01)		
($289,795.77)		
$2,338,817.61		
$499.09		
($4,075,112.69)		
$0.00		
($2,267,310.34)	

Net Assets At Beginning Of Year	
$83,028.44		
$575,494.76		
$955,401.43		
$1,093,085.79		
$3,044.36		
$173,818.38		
$4,539,286.80		
$0.00		
$7,423,159.96	

Net Assets At End Of Year	
$70,007.52		
$707,009.11		
$595,189.42		
$803,290.02		
$2,341,861.97		
$174,317.47		
$464,174.11		
$0.00		
$5,155,849.62	

Blackburn Creek CDD	
Budget to Actual
For the Month Ending 9/30/2019	
Year To Date	
		
Actual			
Budget			
Variance	FY 2019
Adopted Budget	

Revenues												
On-Roll Assessments Off-Roll Assessments
Other Income & Other Financing Sources	$	72,015.36
10,560.73
49.00		$	123,955.00
-
-		$	(51,939.64)
10,560.73
49.00	$ 123,955.00
-
-	
Net Revenues	$	82,625.09		$	123,955.00		$	(41,329.91)	$ 123,955.00	
General & Administrative Expenses
Supervisor Fees
Public Officials' Insurance Trustee Services Management  Engineering Dissemination Agent District Counsel
Assessment Administration Audit
Arbitrage Calculation
Travel and Per Diem	

$	10,200.00
2,364.00
9,743.55
22,916.63
1,318.97
12,500.00
14,924.00
7,500.00
4,500.00
500.00
33.06		

$	

12,000.00
2,600.00
8,750.00
25,000.00
10,000.00
6,000.00
20,000.00
7,500.00
5,500.00
1,000.00
-		

$	

(1,800.00)
(236.00)
993.55
(2,083.37)
(8,681.03)
6,500.00
(5,076.00)
- (1,000.00)
(500.00)
33.06	

$	12,000.00
2,600.00
8,750.00
25,000.00
10,000.00
6,000.00
20,000.00
7,500.00
5,500.00
1,000.00
-	
Telephone
Postage & Shipping Copies
Legal Advertising Bank Fees Miscellaneous Office Supplies
Web Site Maintenance Dues, Licenses, and Fees Stormwater Management General Insurance
General Repair & Maintenance		160.71
421.08
61.95
2,874.89
-
-     191.11
1,875.00
175.00
- 3,414.00
-			150.00
500.00
200.00
1,500.00
150.00
2,400.00
200.00
1,500.00
250.00
10,000.00
3,755.00
5,000.00			10.71
(78.92)
(138.05)
1,374.89
(150.00)
(2,400.00)
(8.89)
375.00
(75.00)
(10,000.00)
(341.00)
(5,000.00)	150.00
500.00
200.00
1,500.00
150.00
2,400.00
200.00
1,500.00
250.00
10,000.00
3,755.00
5,000.00	
Total General & Administrative Expenses	$	95,673.95		$	123,955.00		$	(28,281.05)	$ 123,955.00	

Total Expenses	
  $	95,673.95		
   $		
123,955.00		
   $		
(28,281.05)	
   $ 123,955.00	
Income (Loss) from Operations	$	(13,048.86)		$	-		$	(13,048.86)		$	-	
Other Income (Expense)
Interest Income	

$	27.94	

$	-		

$	

27.94		

$	

-	
Total Other Income (Expense)	$	27.94	$	-		$	27.94		$	-	
Net Income (Loss)	$	(13,020.92)		$	-		$	(13,020.92)		$	-	

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