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, March 11, 2020 at 12:00 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]

General Business Matters

Consideration of the Minutes of the February 12, 2020 Board of Supervisors’ Meeting
Ratification of Payment Authorizations 107 -- 109
Ratification of Requisitions 2018-120 -- 2018-122
Ratification of Requisitions 2019-75 -- 2019-79
Review of District Financial Statements

Other Business

Staff Reports
District Counsel
District Engineer
Update of the Site Map
District Manager
Audience Comments
Supervisors Requests

Adjournment 

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of the Minutes of the February 12, 2020 Board of Supervisors’ Meeting

MINUTES OF MEETING

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT BOARD OF SUPERVISORS MEETING MINUTES
Wednesday, February 12, 2020 5800 Lakewood Ranch Blvd.
Sarasota, FL 34240
12:15 P.M.

Board Members Present:

Pete Williams	Chairperson		
Dale Weidemiller	Vice Chairperson		
Kevin Johnson	Assistant Secretary		
John Blakley	Assistant Secretary		
Jerald Dell	Assistant Secretary		
Also present:			
Vivian Carvalho	District Manager-PFM Group Consulting, LLC	
Venessa Ripoll	PFM Group Consulting, LLC		
Michael Dennis	PFM Financial Advisors, LLC		
Jim Schier	Neal Communities		
Pam Curran	Neal Communities		
John Leinaweaver	Neal Communities		
Ed Bulleit	MBS Capital Markets, LLC		
Sete Zare	MBS Capital Markets, LLC	(via phone)	
Ed Vogler	District Counsel- Vogler Ashton		
	(via phone)		
Kim Ashton	District Counsel- Vogler Ashton		
	(via phone)		
Misty Taylor	Bryant Miller Olive	(via phone)	
Kevin Plenzler	PFM Financial Advisors, LLC	(via phone)	

FIRST ORDER OF BUSINESS		Organizational Matters Call to Order and Roll Call
Ms. Carvalho called to order at 12:18 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 public comments at this time.

SECOND ORDER OF BUSINESS	General Business Matters

Consideration of the Minutes of the January 8, 2020 Board of Supervisors Meeting

The Board reviewed the Minutes of the January 8, 2020 Board of Supervisors Meeting.

On MOTION by Mr. Williams, seconded by Mr. Weidemiller, with all in favor, the Board approved the January 8, 2020 Board of Supervisors Meeting.

Ratification	of	Payment Authorizations 104-106

The Board reviewed Payment Authorizations 104-106.

On MOTION by Mr. Williams seconded by Mr. Johnson, with all in favor, the Board Ratified Payment Authorizations 104-106.

Ratification of Requisitions 2018- 118 – 2018-119

The Board reviewed Requisitions 2018-118 – 2018-119

On MOTION by Mr. Williams, seconded by Mr. Weidemiller, with all in favor, the Board Ratified Requisitions 2018-118 – 2018-119.

Ratification of Requisitions 2019- 68 – 2019-74

The Board reviewed Requisitions 2019-68 – 2019-74.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board Ratified Requisitions 2019-68 – 2019-74.

Review	of	District	Financial Statements

The Board reviewed the District Financial Statements through January 31, 2020.

On MOTION by Mr. Williams, seconded by Mr. Weidemiller, with all in favor, the Board accepted the District Financial Statements for January 31, 2020.

THIRD ORDER OF BUSINESS		Other Business Staff Reports
District Counsel – No Report

District Engineer – Not Present

District Manager – Ms. Carvalho stated at the last meeting the Board discussed creating a site map for the District responsibilities. There is now a draft circulating through District Counsel’s Office for review. The District should have a map by the next meeting. Ms. Ashton noted District Counsel’s Office has not seen a draft. Ms. Carvalho will make sure they get a copy of it. She noted the next meeting is scheduled for March 11, 2020 at 12:00 p.m.

FOURTH ORDER OF BUSINESS	Audience Comments and
Supervisors Requests

There were no Supervisor requests or audience comments.

FIFTH ORDER OF BUSINESS	Adjournment

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

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the February 12, 2020 Meeting of the Board of Supervisors of the Blackburn Creek Community Development District was adjourned at 12:23 P.M.

Secretary/Assistant Secretary	Chairperson/Vice Chairperson

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Payment Authorizations 107 -- 109

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorizations 107-109

No.107	CRI - $2,000.00 PFM- $174.50	$2,174.50	
No.108	Sarasota Herald- $ 143.00
Supervisor Fees- $1,000 Vogler Ashton- $582.00	$1,725.00	
No. 109	PFM Group	$2,221.83	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 107
2m2020

Item	

Payee	

Invoice	

General	
No.		No.	Fund	

1	
Carr Riggs & Ingram			
	FY 2019 Audit	16826881	$	2,000.00	
2	PFM Group Consulting
Reimbursables: November 2019	
OE-EXP-00544	
$	174.50	
				
		TOTAL	$	2,174.50	

'Secretary/AssisSecretary

�	-

IL

Chairman I Vice Chairman

RECEIVED FEB 1 0 2D2D

--/J.

CRI INGRAM

l:G::

CPAs and Advisors

500 Grand Boulevard, Suite 210 Miramar Beach, FL 32550
850-837-3141
Federal ID 72-1396621

Blackburn Creek Community Development District c/o PFM
12051 Corporate Blvd.
Orlando, FL 32817

RECEIVED FEB O 3 2020

Invoice No. Date
Client No.

16826881 (include on check) 01/31/2020
20-05507. 000

Professional services rendered as follows:

Initial progress billing on audit of financial statements
as of September 30, 2019.	$_   ='.2...,0..0  0.._0..o._

0-30	31- 60	61 - 90	91 - 1:ZO	Over 120	Balance	
2 000.00	0.00	0.00	0.00	0.00	2,000.00	

We accept most major credit cards. Please complete the following information or contact our office to submit your payment over the phone.

Invoice Date: 01/31/2020	Client No: 20-05507
Invoice Number:  16826881    Total Amount Due:  $	2,000.00	Blackburn Creek Community Development District
Name as it appears onca r d:    	

Billing       Address:----------------------------------
Card# 	Exp Date: 	Security# 	_

Payment Amount: 	Signature: 	_

Carr, Riggs & Ingram, LLC reserves the right to assess finance charges on past due balances up to the maximum amount allowed under State law.

pfm

Date	Invoice Number
January 22, 2020	OE-EXP-00544
Payment Terms	Due Date
Upon Receipt	January 22, 2020

Bill To:

Blackburn Creek CDD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817 United States of America

Remittance Options:
YlaACH (preferred):

RE:	November 2019 Postage - $161.70 November 2019 Fedex - $12.80

Total Amount Due

Ym..Wlm;

RECEIVED FEB 0 3 2020

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

Federal Tax ID: 81-1642478

�
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

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Account Summary Report
Date Range: November 1, 2019 to November 30, 2019
Meter Group: All Meters
Meter lWOO - 1376538 OLD at ORLANDO, FL
 Meter 4WOO • 0347354 at ORLANDO, Fl	
Meter Details

ORLANDO, FL
ORLANDO, FL

Me:tecNamo	stdlt Numtaer: PbP Attount Number
1W00 • 0347)54	0347354	2497&170
1 WOO - 1376538 OLD   ;1376538	24978470

Account Summary
c:_		ACCJ\i/.
Blackburn Creel< COO

Sub Account	Ploce,
18

TotalCharllQd	(
5161.700

Grand ToiaJ	$161  .7 00

BLACKBURN CREEK
COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 108
2/14/2020

item	Payee	Invoice	General	
No.		No .	Fund	
1	
Sarasota Herald-Tribune			
	Legal Advertising on 02/05/2020	SC52G0RWV9	$	143.00	
2	Supervisor Fees - 02/12/2020 Meeting			
	Dal e Weidemiller		$	200.00	
	Pete Williams		$	200.00	
	John Blakley		$	200.00	
	Kevin Johnson		$	200.00	
	Jerald Dell		$	200.00	
3	Vogler Ashton			
	General Counsel Through 01/31/2020	5235	$	582.00	
				
		TOTAL	$	1,725.00	

ll	
Secretary / Assistant Secretary

Chairman / Vice Chairman

Ckc:

RECEIVED FEB 1 8 2020

0	Herald-Tribune
CLASSIFIED ADVERTISING RECEIPT

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

ORLANDO, FL 32817

Account: 10038491
Phone:	(407)723-5900 P.O.#:
Ad Taken By:	SC52
Receipt printed:	01/30/2020

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
Description	
SC52GORWV9	0001	02-05-20	02-05-20	2	52	NOTICE OF PUBUC MEETING BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT A meeting of
the Board of Supervisors of the Blackbum Creek Community Development District will be held, February 12, 2020, at 12:15 p.m. at 5800 Lakewood
Ranch Blvd. Sarasota FL	

Payment Detail	I	Pav Date	I	Tvoe	I	Card or Check	#	I	Card	I	Exp	Amount	
Current Payment	I	I	I	I	I		
Order Price	$ 143.00	
Total Payments	-	$ 0.00	
Balance	=	$143.00	

Sarasota Herald-Tribune
(941) 953-5555 Classified (941) 361-4098 Fax
http1/ / www .HeraldTribune.com
1777 Main St.
Sarasota, FL 34236

RECEIVED FEB 0 7 2020

Sarasota  Herald-Tribune's Copy

PFM GROUP CONSULTING LLC Venessa VENESSA RIPOLL 12051 CORPORATE BLVD

Account: 10038491
Phone:	(407)723-5900 P.O.#:

ORLANDO, FL 32817

Ad Taken By: Receipt printed:

SC52
01/30/2020

Order Number	Class Number	Start Run	End Run	Run Times	
Lines	
Description	
SC52GORWV 9	0001	02-05-20	02-05-20	2	52	NOTICE OF PUBUC MEETING BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT A meeting of
the Board of Supervisors of the Blackburn Creek Community Development District will be held, February 12, 2020, at 12:15 p.m. at 5800 Lakewood
Ranch Blvd., Sarasota FL	

Pavment Detail I Pav Date I	Tvpe	I	Card or Check#	I Card  I	Exo		Amount	
Current Pavment   I	I		I		I	I			
	
Order Price	$ 143.00	
Total Pavmen ts					-	$ 0.00	
Balance					-	$143.00	

- - - - ~

Taken By:	 	SC52	Columns:

2
1

Balance:
Lines:

$143.00
52

Scheduel :

2/5 lx, 2/5 1x, , ,

-

-

01/30/2020

Taken On:

Insertions-:-

Venessa

Caller.

$ 0.00

Payments:

02/05/2020

Stop Date:

VENESSA RIPOLL,

Name:

$ 143.00

List Price:

02/05/2020

Start Date:

10038491

Account:

$ 0.00

Charges:

0001

I Class:

(407)723-5900

Phone:

LE

Rate:

4,10

Pubs:

SC52GORWV9

Order:

0	Herald-Tribune

NOTICE OF PUBLIC MEETING BIACKBURN CREEK COMMUNITY DE• VELDPMENT DISTRICT

he! .f:o bru..-y U1

A flll!efing of lhe Basrd or SuPOJVisors of the Blackburn Creek Communllr o e,al­ opmenl Dlslrld will bO
2020, et 12;15 p.m. at oow LaKowooa
Ronch Blvd, Sarasota. FL 3'12 0. r 11a meat ng la opon to thO pl.!blfc and will be conducted' In ea:ordanoo \\ith the pull nent p10    •lcos of  f1"'1tl<l Lew for Carn•
!" unity Devolopmonl Olaltlct._ Tho moot•
,ng may be conllnuod to o doto, limo, nnd place to bo s pocillod on tho roeo<d ot tho mooUng, A co py of tho 0911nda f°' the mooting may be obtained fr om PFM Group Con sullln 9, UC, 12051 Cof))otata Blvd., OrlA(ld0, Florida 32817.

There may be occasions whvn one or mare Supervi ora will part)clpote by lalc­ pt,ono, At the abo, e Jotatlon there wll bo prQ9ent a speaker !$phone so lhel any ll! teresled person can otland the meeting a t the above location and be tu!ly ln­ t01mod or the dtscusslont laldr,g preee g,.
thOr In person or by telophooo e<immunl­
ta llo,i .

Any pcraon ro(lu ing spocio.l accommo­ deliont ol this mooting boca.m, of a di ability or physical lmpalrmont should C)0I>.. tact tho Ois irkt  Of!ito  I (407) 723-5900
el least 3 cs!ondAr days p or lo thn mnaf-
ing.
Each person who decides to appeal any decision made by the Boerd with respect to any matter considered Ill tho meeting is advind lt) at per1on wlll (l08d a record ol lho proceocings an<t !hat aCCOldlngty, lho parson may nood to onaure that a verba­ tim rocora or too proceoolnos to mado, In• eluding Iha  testimony end evidence upon which such eppo!II Is lo be bued.
Vivian Carvalho
Dislricl Manager
Date of pub: February 5, 2020

Attention: 	_	fax:_ _ _ _ _ _ _ _ _ _ _ _

This is a final proof. If any information is incorrect, please contact your sales representative prior to the deadline of the first insertion. Oth­ erwise your order is accepted as having been approved.

Blackburn Creek COMMUNITY DEVELOPMENT DISTRICT

Date of Meeting:-2/1-2/20-	-	-
($200.00 per Supervisor per Meeting)

Board Members:	Present	Absent	Fee
Dale Weidemiller	/	JRco.oD
Pete Williams	v;	iilf)o rP
John Blakley	I,	Jt7ro.rfu
Kevin Johnson	I	4·2ca.oO
Jerald Dell	 	§ 2.,co. tD	
Total: $ L GDO OD

 J	

Approved For Payment:

Chairman / Secretary	'	e
February 12, 2020
Date

RECEIVED FEB 1 3 2020

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

Blackburn Creek Community Development District		Page  1
02/13/2020	
c/o Neal Communities of Southwest	Account No:	1-33006	
Florida, LLC	Statement No:	5235	

Sarasota FL 34240
us
Attn: District Manager

Blackburn Creek CDD District Counsel

RECEIVED FEB 1 3 2020

For Legal Services Rendered January 1, 2020, through January 31, 2020

Previous Balance

Fees		

Hours	$316.00	
01/08/2020				
EV	Attendance at Board Meeting		0.40	172 00	
KA	Prepare for and attend COD meetings via tele conference		0 50	205.00	
KA	E-mail to Bill C. re: COD map and O&M matters		0.40	164.00	
01/29/2020				
KA	Review draft agenda		0 10	41 00	
For Current Services Rendered		1 40	582 00	
Recapitulation				
Timekeeper	Hours	Rate		Total	
Edward Vogler II	0 40	$430 00		$172 00	
Kimberly Ashton	1.00	410.00		410 00	

Total Current Work	582 00

Payments

02/12/2020	Payment	-316 00

Balance Due	$582.00

Payments Due Upon Receipt Please

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 109
2/21/2020

Item
No.	Payee	Invoice
No.	General
Fund		

1	
PFM Group Consulting				
	OM Fee: February 2020	DM-02-2020-0008	$	2,083.33		
	Website Fee: February 2020	DM-02-2020-0009	$	125.00		
	Reimbursables: December 2019	OE-EXP-00600	$	13.50		
					
		TOTAL	$	2,221.83		

Secretary  /  Assistant  Secretary	Chairman / Vice Chairman

RECEIVED FEB 2 � 2020

pfm

Date			Invoice Number February 14, 2020	 	DM-02-2020-0008	
Payment Terms		Due Date Upon Receipt	February 14, 2020

BIii To:

�lackburn Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817
United States of America	

RECEIVED FEB 1 8 2020

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100
Federal Tax ID: 81-1642478

Remittance Options:
Vja ACH /preferred):

�	�
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

RE:	District Management Fee: February 2020

Total Amount Due

$2,083.33

of

pfm

Date		Invoice Number February 14, 2020	DM-02-2020-0009
Payment Terms		Due Date Upon Receipt	February 14, 2020

Bill To:

Blackburn Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817
United States of America	

RECEIVED FEB 1 8 2020

Company Address:
1735 Market Street 43rd Floor
Philadelphia, PA 19103
+1 (215) 567-6100
Federal Tax ID: 81-1642478

Remittance Options:
Via ACH (preferred}:

RE:	Website Fee - February 2020

Total Amount Due

Via Wire:

Via Mail·
PFM Group Consulting LLC PO Box 65126
Baltimore, MD 21264-5126
United States of America

of	1

pfm

Da1e	Invoice Numbet February 3, 2020	OE-EXP-00600
Payment Terms	Due Date
Upon Receipt	February 3, 2020

SIIITo:

Blackbum Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd
Orlando, FL 32817 United States of America

RECEIVED FEB

1 8 2020

Company Address:
1735 Market Street 43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

Federal Tax ID: 81-1642478

Remittance Options:
ViaACH (preferred):

�	�
PFM Group Consulting LLC
PO Box 65126
Baltimore, MD 21264-5126 United States of America

RE:	December 2019 Postage - $5.00 December 2019 Fedex - $8.50

Total Amount Due

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p<tncyl>own>

Account Summary Report
Date Rango: Docombor 1 , 2019 to Docombor 31, 2019
Meter Group: All Meters
Meter tWOO - 1376538 OLD at ORLANDO, FL
 Meter 4WOO • 03473Sq at ORLANDO, FL	

l.ilWlDJI

ORU\/1100, Fl

HetecName
4WOO • 0347354

Phe:Accaunt Number

03 7354

Meter Details
Of\LAl'IOO, fl	! WOO · l376S38 OLD 1376S38

Aa:Ount

Subµcount

Pl«es	!

Account Summary

Blacktwm c, COO

10	S5.000

Grand Total	$5.000

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2018-120 -- 2018-122

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2018-120—208-122

2018-120	Forsberg Construction	$44,935.76	
2018-121	Forsberg Construction	$5,877.65	
2018-122	Kimley – Horn	$5,576.04	

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 pursuaut 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 Third Supplemental Trust Indenture from the District to the Trustee, dated as of March I, 2018 (the Master Indenture as amended aud supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meauing ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2018-120

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

Amount Payable:	$44,935.76

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

Grand Palm, Phase 2C Application No. 14 (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 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 Plau, 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 ce11ifies 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:
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 under signed 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 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 con-esponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respec t 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.

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Gra nd Palm Phase 2C (COD Portion)

ENGINEER	Kimley-Horn and Associates, Inc. OWNER	Blackburn Creek COD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240	REQUES

NTP DAT
Contract SUBSTAN FINAL

CONTRA	T NO.

E
Time TIAL

CTOR	14	FINAL

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	1/1/2020	TO	1/31/2020	

Original Contract Amount
Change Orders:	2,104,919.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
3	5/29/2018	9,012.00			
4	11/26/2018	171,420.00			
		-			
		-			
Subtotals	180,432.00	-		
Net Change Order Subtotal (Additive less Deductive)	180,432.00	
Current Contract Amount (Original Amount+ CO's)	2,285,351.00	
	Previous Status	Current Status		
Value of Work in Place		2,285,351.00	100%	2,285,351.00		
Value of Material Purchased by Owner		487,920.48		487,920.48		
Total Earned (%& $)
Retainage (%& $)	79%
2.5%	1,797,430.52
44,935.76	79% OJ)%	I,797,430.52
-		
Net Earned (Total earned minus retainage)		1,752,494.76		1,797,430.52	I,797,430.52	
Total Previous Estimates					1,752,494.76	
AMOUNT DUE THIS PERIOD					44,935.76	

CONTRACT  PAYMENT SUMMARY

·

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 todischarge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 13 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 isdefined in the Contract Documents.
 	
CONTRACTOR

My Commission expires August 23, 2020

Sworn and subscribed to me th,-"i.,,...,v,.	,.V'l.,.,l'VV".,,..,,,,._,"Y'V'.,.,.,,r,,t'V"?
31st day of December AD 202 (STAMP I SEAL)

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

Pay ment of the above AMOUNT DUE THIS APPLICATION is recommended.

Engineer Owner

DATE

 i.	to	

 "2.wzov;,	

Project:	Grand Palm Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	14	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

PREVIOUS WORK	I	WORK THIS PERIOD

WORK TO DATE

PERCENT COMPLETE

	910	18" RCP				1,540.00		1,540.00				1,540.00		
2	910	24" RCP		LF		59,215.00		59,215.00	0.00		911.00	59,215.00	100.00%	
3	910	30" RCP	1,041	LF	84.00	87,444.00	1041.0	87,444.00	0.00		1041.00	87,444.00	100.00%	
4	910	36" RCP	256	LF	116.00	29,696.00	256.0	29,696.00	0.00		256.00	29,696.00	100.00%	
5	910	42" RCP	1,295	LF	151.00	195,545.00	1295.0	195,545.00	0.00		1295.00	195,545.00	100.00%	
6	910	34"x53" RCP	381	LF	226.00	86,106.00	381.0	86,106.00	0.00		381.00	86,106.00	100.00%	
7	910	Grated Swale Inlet	1	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)	2	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)	18	EA	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	6;900.00	27,600.00	4.0	27,600.00	0.00		4.00	27,600.00	100.00%	
11	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	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	8	EA	6,600.00	52,800.00	8.0	52,800.00	0.00		8.00	52,800.00	100.00%	
15	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	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	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	221.0	2,652.00	0.00		221.00	2,652.00	100.00%	
20	910	Rip-Rap at Bubbler	63	SY	100.00	6,300.00	63.0	6,300.00	0.00		63.00	6,300.00	100.00%	
21	910	Connect to Existing Structure	1	LS		5,000.00	1.0	5,000.00	0.00		1.00	5,000.00	100.00%	
25	910	Modified F Curb		LF		27,540.00	1700.0	27,540.00	0.00		1700.00	27,540.00	100.00%	
26	910	TypeM Curb		LF		136,080.00		136,080.00	0.00			136,080.00	100.00%	
27		Curb Ramp				7,800.00		7,800.00				7,800.00	100.00%	
					5,600.00	67,200.00		67,200.00				67,200.00	100.00%	
2	960			EA	6,200.00	6,200.00		6,200.00	0.00		1.00	6,200.00	100.00%	
3	960	Manholes 8' - 10'	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'	5	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	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'	1	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 0' - 6'	1,389	LF	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%	
10	960	8" PVC SDR 26 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%	
11	960	8" PVC SDR 26 Gravity Sewer 10' - 12'	858	LF	87.00	74,646.00	858.0	74,646.00	0.00		858.00	74,646.00	100.00%	
12	960	8" PVC SDR26 Gravity Sewer 12' - 14'	815	LF	101.00	82,315.00	815.0	82,315.00	0.00		815.00	82,315.00	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	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	Double sewer service	52	EA	1,500.00	78,000.00	52.0	78,000.00	0.00		52.00	78,000.00	100.00%	

Project:	Grand Palm Phase 2C (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	14
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM
NO.	CODES	
DESCRIPTION OF WORK	

QUAN	

iUNIT	
UNIT PRICE	
CONTRACT TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
17	960	IConnection to existing gravity sewer	2 EA	6,600.00	13,200.00	2.0	13,200.00	0.00	-	2.00	13,200.00	100.00%	
18	960
iif:'.liif:lf ij I	Testing of gravity sewer
1-11»rir \:,",',', , .·: 'i...i:·:::"1: ,, ,,•,,.,.,,\,,,,,:11 : •; ,:ii :•:!'.·•;1 I
6" PVC DR-18, C900 Water Main	6,078    LF	4.00	24,312.00

5,	312.00

5360.0	139,360.00	0.00	-	6078.00I	24,312.00	100.00%
,.,,,	
"					::};",,,.::,:;(':,:.;	;	;,,	,;:1:;· ·r,ff.; 1,;f!;:.C,';.>:. :-,i,';r,'-,:i',:ff		
I	1010				o.ooi'''·"·""'	- Om'	','.•,
5360.00	139,360.00	100.00%	
2	1010	8" PVC DR-18, C900 Water Main	I	2,000
I	LF	28.00	56,000.00	2000.0	56,000.00	o.oo:	-	2000.00	56,000.00	100.00%	
3	1010	6" Gate valve and valve box	I	II	EA I	1,800.00	19,800.00	11.0	19,800.00	o.oo:	-	11.00	19,800.00	100.00%	
4	1010	8" Gate valve and valve box	I	4   EA  I	2,000.00	8,000.00	4.01	8,000.00	O.OOi	-	4.00'	8,000.00	100.00%	
5	1010	Fire Hydrant Assembly	!	71  EA',	6,000.00	42,000.00	7.0!	42,000.00	o.oo!,	-	i,	7.00\	42,000.00	100.00%	
6	1010	Single water service (Short)	79	EA	1,000.00 I	79,000.00	79.0	79,000.00	0.00	-	i	79.001	79,000.00	100.00%	
7	1010	Single water service (Long)	46	EA	1,200.00 I	55,200.00	46.0	55,200.00	0.00	-	i	46.00i	55,200.00	100.00%	
8	1010	8"x8" Tapping Sleeve and Valve	I	EA	7,800.00 i	7,800.00	1.0	7,800.00	0.00	-	i	1.00	7,800.00	100.00%	
9	1010	Blowoff Assembly	2 EA	1,200.00  i	2,400.00	2.0	2,400.00	0.00	-	I	2.00	2,400.00 !	100.00%	
10	1010	Tie-in to existing Water Main	I	4 EA	2,500.00 i	10,000.00	4.0	10,000.00	0.00	-	i	4.00	10,000.00	100.00%	
II	1010	Pressure testing of main	I	7,360	LF I	2.10	15,456.00	7360.0	15,456.00	0.00	-	i	7360.00	15,456.00	100.00%	
12	1010	Chlorination and ---·-· Jlogical	7,360	LF
&	1.90
Ill
100.00	13,984.00

100.00	7360.0

1.0	13,984.00	0.00	-	I	7360.00		13,984.00
""'"",,,,-;;;;;,,frl!(.
100.00	100.00%	
		,.,,
,,,.	,t •,I	;,' ''''""illll						·'	'fi t ,i:(1 ;:t:?':,!I,i::,: .....··'·.:,,...,	,,,:·,:,,,:,y ,,,				
	1260							100.00		1.00			;,,,	,,..,,,
100.00%	
I		Florida Trench Safety Act	I LS					0.00	-					
3	260	Construction stakeout	I LS	23,400.00	23,400.00	1.0	23,400.00	0.00	-	1.00	23,400.00	100.00%	
4	260	Record drawings / As-Built Survey	I LS	7,200.00	7,200.00	1.0	7,200.00	0.00	-	1.001	7,200.00	100.00%	
5	510	Mobilization	I LS	50,000.00	50,000.00	1.0	50,000.00	0.00	-	1.001	50,000.00	100.00%	
TOTAL	2 285,351.00	2,285,351.00	-	2,285,351.00	100.00%	
Summary of Work Classifications
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%
WATER DISTRIBUTION	$	449,000.00	$	449,000.00	$	-	$	449,000.00	100.00%
MISCELLANEOUS	$	80,700.00	$	80,700.00	$	-	$	80,700.00	100.00%
TOTAL	$   2,285,351.00	$   2,285,351.00	$	-	$   2,285,351.00	100.00%	
Summary of Accounting Codes

260	$	30,600.00	$	30,600.00	$	-	$	30,600.00	100.00%
510	$	50,000.00	$	50,000.00	$	-	$	50,000.00	100.00%
910	$	920,918.00	$	920,918.00	$	-	$	920,918.00	100.00%
960	$	834,733.00	$	834,733.00	$	-	$	834,733.00	100.00%
1010	$	449,000.00	$	449,000.00	$	-	$	449,000.00	100.00%
1260	$	100.00	$	100.00	$	-	$	100.00	100.00%
TOTAL	$   2,285,351.00	$   2,285,351.00	$	-	$   2,285,351.00	100.00%	

-	-

Project:   Grand Palm Phase 2C (CDD Portion)	Forsberg Co truction, Inc.	Pay Request No.	14
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

UNIT	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 inspection)										
1	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	LF	32.38	33,707.58	1041.00	33,707.58	0.00	-	1041.00	33,707.58	100.00%	
4	36" RCP	256	LF	45.29	11,594.24	256.00	11,594.24	0.00	-	256.00	11,594.24	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	1	EA	666.35	666.35	1.00	666.35	0.00	-	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	Type "M" Inlet 36" x 48" (inside size)	18	EA	1,330.91	23,956.38	18.00	23,956.38	0.00	-	18.00	23,956.38	100.00%	
IO	Type "M" Inlet 42" x 60" (inside size)	4	EA	1,330.91	5,323.64	4.00	5,323.64	0.00	-	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	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	EA	1,483.90	2,967.80	2.00	2,967.80	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	-	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	1	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	2.00	5,565.18	0.00	-	2.00	5,565.18	100.00%	
	Lb SANITARY SEWER												
1	Manholes O' - 6'	12	EA	1,320.25	15,843.00	12.00	15,843.00	0.00	-	12.00	15,843.00	100.00%	
2	Manholes 6' - 8'	1	EA	1,572.20	1,572.20	1.00	1,572.20	0.00	-	1.00	1,572.20	100.00%	
3	Manholes 8' - 10'	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'	1	EA	2,809.00	2,809.00	1.00	2,809.00	0.00	-	1.00	2,809.00	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' - 10'	909	LF	4.06	3,690.54	909.00	3,690.54	0.00	-	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	0.00	-	858.00	3,483.48	100.00%	
12	8" PVC SDR 26 Gravity Sewer 12' - 14'	815	LF	4.06	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	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	0.00	-	355.00	1,441.30	100.00%	
15	Single sewer service	21	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%	
	Le WATER DISTRIBUTION												
1	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	11	EA	576.75	6,344.25	11.00	6,344.25	0.00	-	11.00	6,344.25	100.00%	
4	8" Gate valve and valve box	4	EA	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)	Forsberg Construction, Inc.	Pay Request No.	14
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL  33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

UNIT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	,	PREVIOUS  WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
5	Fire Hydrant Assembly		7	EA	2,222.21	15,555.47 i	7.001	15,555.47	0.00	-	7.00	15,555.47	100.00%	
6	Single water service (Short)		79	EA	310.20	24,505.80 j	79.001	24,505.80 I	0.00	-	79.00	24,505.80	100.00%	
7	! Single water service (Long)		46	EA	356.79	16,412.34 I	46.001	16,412.34	0.00	-	46.00	16,412.34	100.00%	
8	l8"x8" Tapping Sleeve and Valve		I	EA	1,767.97	1,161.91 I	1.001	1,767.97	0.00	-	1.00	1,767.97	100.00%	
10	;Tie-in to existing Water Main	

I	4	1 EA	89.62	358.48 i	4.00i	358.48 I	0.00	-		4.00i	358.48	100.00%	
	TOTAL					$	460,302.34 l	$	460,302.34 I,		$	-	
II		$	460,302.34	100.00%	
						Summary								
	Ferguson Waterworks					$	157,221.91	$	157,221.91		$	-			$	157,221.91	100.00%	
	Cast Systems					$	95,107.50	$	95,107.50		$	-			$	95,107.50	100.00%	
	County Materials					$	207,972.93	$	207,972.93		$	-			$	207,972.93	100.00%	
	6% State Sales Tax					$	27,618.14	$	27,618.14		$	-			$	27,618.14	100.00%	
	TOTAL					$	487,920.48	$	487,920.48		$	-			$	487,920.48	100.00%	

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 te1ms 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 l, 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:

2018-121

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

Amount Payable:

$5,877.65

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. 7 (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 fo1th 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 ha5  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 requisitio n 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	!Zed 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 ce1tifies that this disburse ment 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  2. 018 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.

<"
   ,ft/
nlt ing Eng inee r

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2B East (CDD Portion)

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

NTPDATE
Contract Tim SUBSTANTIA FINAL

CONTRACTO	.

e L

R	7

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

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	1/1/2020	TO	1/31/2020	

CONTRACT  PAYMENT SUMMARY

Original Contract Amount (CHANGE ORDER #8)
Change Orders:	1,197,472.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
		-			
		-			
		-			
		-			
Subtotals	-	-		
Net Change Order Subtotal (Additive less Deductive)
Current Contract Amount (Original Amount+ CO's)	-
1,197,472.00	
	Previous Status	Current Status		
Value of Work in Place		1,180,414.00	99%	1,186,601.00		
Value of Material Purchased by Owner		310,298.12		310,298.12		
Total Earned(% & $)	73%	870,115.88	73%	876,302.88		
Retainage (%& $)	5%	43,505.79	5%	43,815.14		
Net Earned (Total earned minus retainage)		826,610.08		832,487.73	832,487.73	
Total Previous Estimates					826,610.08	
AMOUNT DUE THIS PERIOD					5,877.65	

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 Contractreferred 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 6 inclusive; and (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are fi"ee 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.

Ashly Wester
Notary Public, State of Florida

My Commission expires August 23, 2020 Sworn and subscribed to me!hi 31st day of January AD 2020

(STAMP/ SEAL)

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

Payment of the above AMOUNT DUE THIS APPLICATIONis recommended.

Engineer Owner

z.f,!,I zoio

DATE

Ok(J P c>

Project: Owner: Engineer:	Grand Palm Phase 2B East (CDD Portion) Blackburn Creek CDD
Kimley-Horn and Associates, Inc.	Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950		Pay Request No.
For work from:
To:	7
1/1/2020
1/31/2020	
PREVIOUS

	WORK	WORK nns PERIOD	WORK	TO DATE	PERCENT COMPLETE	

	910	24" RCP	221	LF		14,365.00		14,365.00				14,365.00		
2	910	30" RCP	348	LF	84.00	29,232.00		29,232.00				29,232.00		
3	910	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	2.0	8,400.00	0.00		2.00	8,400.00	100.00%	
8	910	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	0.00		2.00	8,400.00	100.00%	
IO	910	Type "M" Inlet 42" x 60" (inside size)	4	EA	6,900.00	27,600.00	4.0	27,600.00	0.00		4.00	27,600.00	100.00%	
11	910	30" Flared End Section	2	EA	4,500.00	9,000.00	2.0	9,000.00	0.00		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	0.00		3.00	17,400.00	100.00%	
13	910	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	100.00%	
15	910	Small Control Structure	3	EA	5,600.00	16,800.00	3.0	16,800.00	0.00		3.00	16,800.00	100.00%	
16	910	Construct Swale	360	LF	12.00	4,320.00	360.0	4,320.00	0.00		360.00	4,320.00	100.00%	
17	910	Rip-Rap for Bubbler Structures	23	SY	100.00	2,300.00	23.0	2,300.00	0.00		23.00	2,300.00	100.00%	
18	910	6" Roadside underdrain		LF	16.00		0.0		0.00		0.00		100.00%	
19	910	Underdrain cleanout		EA	450.00		0.0		0.00		0.00		100.00%	
20	910	6" Underdrain plug		EA	50.00		0.0		0.00		0.00		100.00%	
21	910	Modified Type "F" curb	3,230	LF	10.80	34,884.00	3230.0	34,884.00	0.00		3230.00	34,884.00	100.00%	
		Type "M" curb, includes all transitions	4,550											
		Curb ramp	1											
														
1						22,400.00		22,400.00				22,400.00		
2	960		4	EA		24,800.00		24,800.00	0.00		4.00	24,800.00		
3	960	Manholes 8' - 1O'	1	EA		7,000.00	1.0	7,000.00	0.00		1.00	7,000.00	100.00%	
4	960	8" PVC (SDR 26) Gravity Sewer O' - 6'	230	LF		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	680.0	35,360.00	0.00		680.00	35,360.00	100.00%	
6	960	8" PVC (SDR 26) Gravity Sewer 8' - 10'	667	LF		46,690.00	667.0	46,690.00	0.00		667.00	46,690.00	100.00%	
7	960	Double sewer service	43	EA		64,500.00	43.0	64,500.00	0.00		43.00	64,500.00	100.00%	
8	960	Connection to existing gravity sewer	2			13,200.00		13,200.00			2.00	13,200.00	100.00%	
		Testing of gravity sewer				6,308.00		6,308.00				6,308.00		
														
1	1010	8" PVC DR-18, C900 Water Main				59,360.00		59,360.00				59,360.00	100.00%	
2	1010	12" PVC DR-18, C900 Water Main				31,680.00		31,680.00				31,680.00	100.00%	
3	1010	14" SDRll Directional Drill	250	LF	220.00	55,000.00	250.0	55,000.00	0.00		250.00	55,000.00	100.00%	
4	1010	8" Gate valve and valve box	2	EA	2,000.00	4,000.00	2.0	4,000.00	0.00		2.00	4,000.00	100.00%	
5	1010	12" Gate valve and valve box	2	EA	3,100.00	6,200.00	2.0	6,200.00	0.00		2.00	6,200.00	100.00%	
6	1010	Fire Hydrant Assembly	3	EA	6,000.00	18,000.00	3.0	18,000.00	0.00		3.00	18,000.00	100.00%	
7	1010	Single water service (Short)	42	EA	1,000.00	42,000.00	42.0	42,000.00	0.00		42.00	42,000.00	100.00%	

Project:	Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	7	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	
PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT	
ITEM		DESCRIPTION			UNIT	CONTRACT								COMPLETE	
NO.	CODES	OF WORK	QUAN	UNIT	PRICE	TOTAL	QTY	VALUE	QTY	VALUE		QTY	VALUE	%	
8	1010	Single water service (Long)	44	EA	1,200.00	52,800.00	44.0	52,800.00	o.oo!		-	44.00	52,800.00	100.00¾i	
9	1010	Tie-in to existing Water Main	4	EA	2,500.00	10,000.00	2.0	5,000.00	0.00		-	2.00	5,000.00	50.00%1	
IO	1010	Pressure testing of main	3,090	LF	2.10	6,489.00	2120.0	4,452.00	970.00	2,037.00	3090.00	6,489.00	100.00%	
11	1010	Chlorination and bacteriological												

Summary of Work Classifications

I'	m
I
I	1260	Florida Trench Safety Act	
2		910	Material Price Increases for 2019	
I	1 LS I	53,020.00	53,020.00	1.0	53,020.00	0.00	-	1.00	53,020.00 I	100.00%	
4		260	Construction stakeout	i	I LS	25,600.00	25,600.00	1.0	25,600.00	0.00	-	1.00	25,600.00	100.00%	
5		260	Record drawings/ As-Built Survey	i	1 LS	8,300.00	8,300.00	0.5	4,150.00	0.50	4,150.00	1.00	s,300.00 I	100.00%	
6	I	510	Mobilization		1 iLS	50,000.00	50,000.00	1.0	50,000.00	0.00,	-	1.00	50,000.00	100.00%	
			TOTAL			1,197,472.00	111801414.00		6,187.00		1,186,601.00	99.09%	
			PHASE3C												
			DRAINAGE				$	540,974.00		$	540,974.00		$		$	540,974.00	100.00%	
			SANITARY SEWER				$	228,078.00		$	228,078.00		$		$	228,078.00	100.00%	
			WATER DISTRIBUTION				$	291,400.00		$	278,492.00		$	2,037.00		$	280,529.00	96.27%	
			MISCELLANEOUS				$	137,020.00		$	132,870.00		$	4,150.00		$	137,020.00	100.00%	
			TOTAL				$ 1,197,472.00		$ 1,180,414.00		$	6,187.00		$ 1,186,601.00	99.09%	

Project:    Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	7
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

IT	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 inspection)	!								
I	24" RCP	I	221 i LF	24.78	5,476.38	221.00	5,476.38	0.00	-	221.00	5,476.38	100.00%	
2	30" RCP	348 I LF	35.13	12,225.24	348.00	12,225.24	0.00	-	348.00	12,225.24	100.00%	
3	36" RCP	1,211	LF	I	48.73	59,012.03	1211.00	59,012.03	0.00	-	1211.00	59,012.03	100.00%	
4	42" RCP	177	LF	62.92	11,136.84	177.00	11,136.84	0.00	-	177.00	11,136.84	100.00%	
5	34"x53" RCP	I	475	LF	106.4 I	50,544.75	475.00		50,544.75 1 ,	0.00		-	I	475.00	50,544.75	100.00%	
6	Grated Swale Inlet	
I	3	EA	2,369.40	7,108.20	3.00		1,108.20 I	0.00		-	I	3.00		7,108.20 I	100.00%	
7	Type "F" Inlet 36" x 48" (inside size)	
I	2	EA	1,943.04	3,886.08	2.00		3,886.08 I	0.00	-	2.00		3,886.08 i	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 I	100.00%	
9	Type "M" Inlet 36" x 48" (inside size)	
i	2	EA	1,986.40	3,972.80	2.00	3,972.80	0.00	-		2.00,	3,972.80 I	100.00%	
10	Type "M" Inlet 42" x 60" (inside size)	4	EA	1,986.40	7,945.60	4.00	7,945.60	0.00	-		4.001	7,945.60 i	100.00%	
11	30" Flared End Section	
i	2	EA	1,315.40	2,630.80	2.00	2,630.80	0.00	-		2.00:	2,630.80 I	100.00%	
12	36" Flared End Section	l	3	EA	1,562.00	4,686.00	3.00;	4,686.00	0.00	-		3.00i.	4,686.00	100.00%	
13	42" Flared End Section	
i	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	
I	2 EA	1,962.10	3,924.20	2.00i	3,924.20	0.00	-	2.00	3,924.20	100.00%	
15	Small Control Structure	3 EA		2,339.89	7,019.67	3.ooi	7,019.67	0.001	-	3.00	7,019.67	100.00%	
16	Construct Swale	360 LF		-	-	360.00\	-	0.001	-	360.00	-	100.00%	
17	Rip-Rap for Bubbler Structures	23 SY		-	-	23.00	-	0.001	-	23.00	-	100.00%	
18	6" Roadside underdrain	-	LF		-	-	0.001	-		o.oo:	-		0.00	-	100.00%	
19	Underdrain cleanout		-	EA	-	-	0.00	-		0.00\	-		0.00	-	100.00%	
20	6" Underdrain plug		-	EA	-	-	0.00	-		o.ooi	-		0.00		-	!	100.00%	
21	Modified Type "F" curb		3,230	LF	-	-	3230.00	-		o.ooi	-		3230.00		-	i	100.00%	
22	Type "M" curb, includes all transitions		4,550	LF	-	-	4550.00	-	0.00	-	4550.00	-	100.00%	
23	!Curb ramp		1	EA	-	-	1.00	-		0.00:	-		1.00	-	I	100.00%	
jl.b SANITARY SEWER										
1	!Manholes 0' - 6'		4	EA		1,577.15	6,308.60	4.00	6,308.60		0.001	-		4.00	6,308.60	100.00%	
2	I Manholes 6' - 8'		4	EA		1,782.43	7,129.72	4.00	7,129.72		o.oo!	-	
i	4.00	7,129.72	100.00%	
3	I Manholes 8' - IO'		1	EA		1,791.22	1,791.22	1.00	1,791.22		0.001	-	I
!	1.00	1,791.22	100.00%	
4	8" PVC (SDR 26) Gravity Sewer 0' - 6'		230	LF		3.97	913.10	230.00	913.10 j	0.00	-	230.00	913.I0 I	100.00%	
5	8" PVC (SDR 26) Gravity Sewer 6' - 8'		680	LF		3.97	2,699.60	680.00	2,699.60 1	0.00		-	i	680.00:	2,699.60 !	100.00%	
6	8" PVC (SDR 26) Gravity Sewer 8' - 10'		667	LF	3.97	2,647.99	667.00	2,647.99 I	0.00		-	I'	667.00	2,647.99	100.00%	
7	Double sewer service	43	EA	1
,	313.46	13,478.78	43.00	13,478.78 i	0.00		-	',	43.00	13,478.78 I	100.00%	
8	Connection to existing gravity sewer	2	EA	-	-	2.00	-	0.00		-	:	2.00\	-	'
'	0.00%	
9	Testing of gravity sewer	1,577	LF	I	-	-	1577.00		-	I
'	0.00		-	
i	1577.00 !	-	!	0.00%	
	Le WATER DISTRIBUTION		I					I
I		

I		i	
1	8" PVC DR-18, C900 Water Main	2,120	LF	7.78	16,493.60	2120.00	16,493.60	0.00		-		2120.00	16,493.60	100.00%	
2	12" PVC DR-18, C900 Water Main	720 i LF	19.92	14,342.40	720.00	14,342.40	0.00	-		720.00	14,342.40	100.00%	
3	14" SDRl l Directional Drill	250 I LF	49.65	12,412.50	250.00	12,412.50	0.00	-		250.00i	12,412.50	100.00%	
4	8" Gate valve and valve box	21 EA	847.30	1,694.60	2.00	1,694.60		o.oo:	-			2.00	1,694.60	100.00%	
5	12" Gate valve and valve box	2 ! EA		1,551.68 i	3,103.36	2.00i	3,103.36	0.00	-	2.00!	3,103.36	100.00%	
6	Fire Hydrant Assembly	3 I EA	2,286.91	6,860.73	3.00[	6,860.73 •	0.001	-	i	3.00I	6,860.73 i	100.00%	

Project:    Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	7
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

tlJNIT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
7	Single water service (Short)		I	42	EA	328.14	13,781.88	42.00	13,781.88	0.00	-	42.00	13,781.88	100.00%	
8	Single water service (Long)		
I	44	EA	364.05 I	16,018.20	44.00	16,018.20	0.00	-	44.00	16,018.20	100.00%	
9	Tie-in to existing Water Main	4	EA	325.75	1,303.00	4.00	1,303.00	0.00	-	4.00	1,303.00	100.00%	
	Ferguson Adjustment			(1) EA	6,847.96	(6,847.96)	-1.00 -	6,847.96	0.00	-	-1.00 -	6,847.96	100.00%	
	Cast Adjustment			(1) EA	3,129.37	(3,129.37)	-1.00 -	3,129.37	0.001	-	-1.00 -	3,129.37	100.00%	
	County Adjustment			(1) EA	3,532.04	(3,532.04)	-1.00 -	3,532.04	O.OOi	-	-1.00 -	3,532.04	100.00%	
	TOTAL				$	292,734.08	$	292,734.08	$	-	$	292,734.08	100.00%	
						Summary							
	Ferguson Waterworks					$	98,901.78	$	98,901.78		$	-		$	98,901.78	100.00%	
	Cast Systems					$	45,918.60	$	45,918.60		$	-		$	45,918.60	100.00%	
	County Materials					$	147,913.70	$	147,913.70		$	-		$	147,913.70	100.00%	
	6% State Sales Tax					$	17,564.04	$	17,564.04		$	-		$	17,564.04	100.00%	
	TOTAL					$	310,298.12	$	310,298.12		$	-		$	310,298.12	100.00%	

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

The uudersigned, 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 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:

2018-122

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

Amount Payable:	$5,576.04

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 requ1S1t1on 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 prope1ty acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:
AuthonzeOfficer

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 specifi d 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.

Consulting 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	5,576.04	
Total HOURLY	5,576.04	

Invoice No:	15827138
Invoice Date:	Jan 31, 2020 Invoice Amount: $5,576.04
Project No:	148167000.2
Project Name:	BLACKBURN CR CDD DIST ENG
Project Manager: CONERLY, BILL
Client Reference: CONSTRUCTION FUND For Services Rendered through Jan 31, 2020

DESCRIPTION OF SERVICES PERFORMED:
FINISH REQUISITIONS 2018-118, 119, 2019-67, 68, AND 69 SEND OUT FOR PAYMENT.
CORRESPONDENCE WITH TAMI ON PREVIOUSLY SUBMITTED REQUISITIONS.
MAKE REQUISITIONS FOR CDD PAY APPS 2019-70,71,72.
UPDATING REQUISITIONS WITH PETE'S SIGNATURE, GOING OVER PAY APPS FROM FORSBERG FOR WHICH ONES CAN GO OUT AND WHICH NEED TO BE REDONE BASED ON FIELD VERIFICATIONS.
FINISH AND SEND OUT REQUISITIONS 2019-70, 71 AND 72.
REQ 2019-73 PROCESSED AND SENT OUT FOR PAYMENT.
REQUISITION 2019-74 PROCESSING AND SENT OUT FOR PAYMENT.

Total Invoice: $5,576.04

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	84.18	84.18	
		8.5	106.15	902.26	
	PROFESSIONAL	2.0	139.81	279.62	
	SENIOR PROFESSIONAL I	18.0	223.99	4,031.85	
TOTAL LABOR	29.5		5,297.91	
EXPENSES	OFFICE EXPENSE			278.13	
TOTAL EXPENSES			278.13	
TOTAL LABOR AND EXPENSE DETAIL			5,576.04	

Invoice No:	15827138
Invoice Date:	Jan 31, 2020
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 2019-75 -- 2019-79

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2019-75-- 2019-79

2019-75	Ferguson Construction	$7,547.75	
2019-76	Ferguson Construction	$32,223.23	
2019-77	Forsberg Waterworks	$16,625.83	
2019-78	Forsberg Waterworks	$130.00	
2019-79	Forsberg Waterworks	$879.05	

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 l, 2013 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter refen-ed to as the "Indenture") (all capitalized ten-us used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-75

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

$7,547.75

Purpose for which paid or incun-ed (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):

Grand Palm, Phase 1B(a) Application No. 6 (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 forth above
have been incun-ed 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 fo1th above was incwred 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
,ight 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 requ1S1t1on 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:	�	
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.

 	-·,>=I
Consulting Engineer

c;;;.

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase IBa (CDD Portion)

ENGINEER	Kimley-Horn and Associates, Inc. OWNER	Blackburn Creek CDD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240	REQUEST NO

NTPDATE
Contract Tim SUBSTANTIA FINAL

CONTRACTO	.

e L

R	6

November 26, 2018
409 Days(270+141)
January 9, 2020
February 6, 2020

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	1/1/2020	TO	1/31/2020	

CONTRACT  PAYMENT SUMMARY

Original Contract Amount (CHANGE ORDER #6) Change Orders:	755,053.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
		.			
		-			
		-			
		.			
Subtotals	-	.		
Net Change Order Subtotal (Additive less Deductive)	.	
Current Contract Amount (Original Amount + CO's)	755,053.00	

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

67%
5%	668,106.00
161,366.85
506,739.15
25,336.96	90%

68%
i%	676,051.00
161,366.85
514,684.15
25,734.21		
Net Earned (Total earned minus retainage)		481,402.19		488,949.94	488,949.94	
Total Previous Estimates					481,402.19	
AMOUNT DUE THIS PERIOD					7,547.75	

CERTIFICATION OF CONTRACTOR

CONTRACTOR

By

The undersigned Contractor herebyswears 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 to discharge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 4 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 tenn isdefined in the Contract Documents.

Notary Public, State of Florida

My Commission expires Aultlli·t-';J,,,.;. N'Y'...,..,,,..,N"Y'Y"..,....

f .._,

Sworn and subscribed to me is,_.,.v Pvt,_ Notary Public State or Florida 31st day of January AD 202	't: Ashly Wester
c;	i! My Commission GG 008306
'>oi1.,_o"   Expire• 08/23/2020
(STAMP I SEAL)	i ,......,_,.,_,,..,.,,..,.v-.,,"¥°',r-,t...,,.  l"V'l,r,,,-"""c, -.,

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

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

Engineer Owner

DATE

i }wz.o:zo
,,ff✓.,      If'	&/ 

Project:
Owner: Engineer:	Grand Palm Phase lBa (CDD Portion)
Blackburn Creek CDD
Kimley-Horn and Associates, Inc.	Forsberg Construction, Inc.
645 Charlotte Street Punta Gorda, FL 33950		Pay Request No.
For work from: To:	6
1/1/2020
1/31/2020	
PREVIOUS

	WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT	

	910	18" RCP	32	LF		1,760.00		1,760.00				1,760.00		
2	910	24"RCP	611	LF		39,715.00		39,715.00				39,715.00		
3	910	30" RCP	173	LF	84.00	14,532.00	173.0	14,532.00	0.00		173.00	14,532.00	100.00%	
4	910	36" RCP	472	LF	116.00	54,752.00	472.0	54,752.00	0.00		472.00	54,752.00	100.00%	
5	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%	
6	910	Type "M" Inlet 36" x 48" (inside size)	5	EA	4,200.00	21,000.00	5.0	21,000.00	0.00		5.00	21,000.00	100.00%	
7	910	Type "M" 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%	
8	910	24" Flared End Section	2	EA	4,100.00	8,200.00	2.0	8,200.00	0.00		2.00	8,200.00	100.00%	
9	910	30" Flared End Section	1	EA	4,500.00	4,500.00	1.0	4,500.00	0.00		1.00	4,500.00	100.00%	
10	910	36" Flared End Section	3	EA	5,800.00	17,400.00	3.0	17,400.00	0.00		3.00	17,400.00	100.00%	
11	910	Small Control Structure	1	EA	5,600.00	5,600.00	1.0	5,600.00	0.00		1.00	5,600.00	100.00%	
15	910	Modified Type "F" curb (Islands)	220	LF	16.20	3,564.00	0.0		0.00		0.00		0.00%	
16	910	Type "M" curb, includes all transitions		LF	10.80	47,736.00	0.0		0.00		0.00		0.00%	
17		Curb ramp				3,120.00								
1						22,400.00		22,400.00				22,400.00		
2	960	Manholes 6' - 8'	4	EA		24,800.00	4.0	24,800.00	0.00		4.00	24,800.00	100.00%	
3	960	Manholes IO' - 12'	2	EA		15,600.00	2.0	15,600.00	0.00		2.00	15,600.00	100.00%	
4	960	8" PVC (SDR 26) Gravity Sewer O' - 6'	788	LF		26,792.00	788.0	26,792.00	0.00		788.00	26,792.00	100.00%	
5	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	553	LF	52.00	28,756.00	553.0	28,756.00	0.00		553.00	28,756.00	100.00%	
6	960	8" PVC (SDR 26) Gravity Sewer 8' - 10'	280	LF	70.00	19,600.00	280.0	19,600.00	0.00		280.00	19,600.00	100.00%	
7	960		382	LF	87.00	33,234.00	382.0	33,234.00	0.00		382.00	33,234.00	100.00%	
8	960	Single Sewer Service	4	LF	1,500.00	6,000.00	4.0	6,000.00	0.00		4.00	6,000.00	100.00%	
9	960	Double sewer service	26	EA	1,500.00	39,000.00	26.0	39,000.00	0.00		26.00	39,000.00	100.00%	
10	960	Connection to existing gravity sewer	1	EA	6,600.00	6,600.00	1.0	6,600.00	0.00		1.00	6,600.00	100.00%	
11	960	Open Cut Restoration and MOT	1	LS	11,300.00	11,300.00	0.75	8,475.00	0.25	2,825.00	1.00	11,300.00	100.00%	
		Testing of gravity sewer	2,003	LF	4.00	8,012.00								
														
1	1010	4" PVC DR-18, C900 Water Main	520	LF	24.00	12,480.00	520.0	12,480.00	0.00		520.00	12,480.00	100.00%	
2	1010	8" PVC DR-18, C900 Water Main	1,960	LF	28.00	54,880.00	1960.0	54,880.00	0.00		1960.00	54,880.00	100.00%	
3	1010	4" Gate valve and valve box	2	EA	1,500.00	3,000.00	2.0	3,000.00	0.00		2.00	3,000.00	100.00%	
4	1010	8" Gate valve and valve box	4	EA	2,000.00	8,000.00	4.0	8,000.00	0.00		4.00	8,000.00	100.00%	
5	1010	8"x8" Tapping Sleeve and Valve	2	EA	7,800.00	15,600.00	2.0	15,600.00	0.00		2.00	15,600.00	100.00%	
6	1010	Blowoff Assembly	1	EA	1,200.00	1,200.00	1.0	1,200.00	0.00		1.00	1,200.00	100.00%	
7	1010	HG-2 Automatic Flushing Device	I	EA	7,400.00	7,400.00	1.0	7,400.00	0.00		1.00	7,400.00	100.00%	
8	1010	Fire Hydrant Assembly	2	EA	6,000.00	12,000.00	2.0	12,000.00	0.00		2.00	12,000.00	100.00%	
9	1010	Single water service (Short)	34	EA	1,000.00	34,000.00	34.0	34,000.00	0.00		34.00	34,000.00	100.00%	
10	1010	Single water service (Long)	22	EA	1,200.00	26,400.00	22.0	26,400.00	0.00		22.00	26,400.00	100.00%	
11	1010	Tie-in to existing Water Main	2	EA	2,500.00	5,000.00	1.0	2,500.00	0.00		1.00	2,500.00	50.00%	
12	1010	Pressure testing of main	2,480	LF	2.10	5,208.00	0.0		0.00		0.00		0.00%	
13	1010	Chlorination and bacteriological	2,480	LF	1.90	4,712.00	0.0		0.00		0.00		0.00%	

Project: Owner: Engineer:

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

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

Pay Request No. For work from: To:

6
1/1/2020
1/31/2020

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

ITEM

PERCENT COMPLETE
%

4
5

260	Construction stakeout
260	!Record drawings/ As-Built Survey
510	IMobilization
TOTAL

I   LS
I   LS
1  LS

25,600.00
8,300.00
50,000.00

25,600.00
8,300.00
50,000.00

0.8
0.5
1.0

100.00
20,480.00
4,150.00
50,000.00

0.20
0.00
0.00

5,120.00

1.00
0.50
1.00

 	755 053.00	668,106.00	
Summary of Work Classifications

7,945.00

25,600.00
4,150.00
50,000.00
676,051.00

100.00%
100.00%
50.00%
100.00%
89.54%

PHASE3C
DRAINAGE	$	239,079.00	$	184,659.00	$	$	184,659.00	77.24%
SANITARY SEWER	$	242,094.00	$	231,257.00	$	2,825.00	$	234,082.00	96.69%
WATER DISTRIBUTION	$	189,880.00	$	177,460.00	$	$	177,460.00	93.46%
MISCELLANEOUS	$	84,000.00	$	74,730.00	$	5,120.00	$	79,850.00	95.06%

TOTAL

$	755,053.00

$	668,106.00

$

7,945.00

$	676,051.00

89.54%

Project:   Grand Palm Phase lBa  (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	6
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

UNIT	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 inspection)			I
'						
I	18" RCP	i	32	LF	16.05	513.60	32.00i	513.60	0.00	-	32.00	513.60	l00.00%	
2	24" RCP	I
I	611	LF	24.65	15,061.15	611.00 i	15,061.15	0.00	-	611.00	15,061.15	100.00%	
3	30" RCP		173	LF	35.33	6,112.09	173.00	6,112.09	0.00	-	173.00	6,112.09	l00.00%	
4	36" RCP		472	LF	48.53	22,906.16	472.00I	22,906.16	0.00	-	472.00	22,906.16	l00.00%	
5	Grated Swale Inlet	i
I	1	EA	650.54	650.54	1.00\	650.54	0.00	-	1.00	650.54	l00.00%	
6	Type "M" Inlet 36" x 48" (inside size)	i	5	EA	1,526.64	7,633.20	5.00i	7,633.20	0.00	-	5.00	7,633.20	l00.00%	
7	Type "M" Inlet 42" x 60" (inside size)	
I	2	EA I	1,526.64	3,053.28	2.00!	3,053.28	0.00	-	2.00	3,053.28	l00.00%	
8	24" Flared End Section	!	2	EA	1,012.00	2,024.00	2.00!	2,024.00	0.00	-	2.00	2,024.00	100.00%	
9	30" Flared End Section	!	I	EA	1,315.40	1,315.40	LOO!	1,315.40	0.00	-	1.00	1,315.40	l00.00%	
10	36" Flared End Section	
i	3	EA	1,562.00	4,686.00	3.00!	4,686.00	0.00	-	3.00	4,686.00	l00.00%	
11	Small Control Structure	!	I	EA	1,847.74	1,847.74	l.00!	1,847.74	0.00	-	1.00	1,847.74	100.00%	
	Lb SANITARY SEWER	
\					i
i						
I	Manholes 0' - 6'	I	4	EA	1,537.21	6,148.84  I	4.00!	6,148.84	0.00	-	4.00	6,148.84	l00.00%	
2	Manholes 6' - 8'	!	4	EA 1	1,754.51	7,018.04  !	4.00i	7,018.04	0.00	-	4.00	7,018.04	l00.00%	
3	Manholes 10' - 12'		2	EA	2,249.77	4,499.54  !	2.00:	4,499.54	0.00	-	2.00	4,499.54	l00.00%	
4	i8" PVC (SDR 26) Gravity Sewer O' - 6'	I	788	LF	4.06	3,199.28 !	788.00I	3,199.28	0.00	-	788.00	3,199.28	l00.00%	
5	8" PVC (SDR 26) Gravity Sewer 6' - 8'	!	553	LF	4.06	2,245.18	553.00	2,245.18	0.00	-	553.00	2,245.18	l00.00%	
6	8" PVC (SDR 26) Gravity Sewer 8' - 10'  I	280	LF i	4.06	1,136.80	280.00	1,136.80	0.00	-	280.00	1,136.80	l00.00%	
7	8" PVC (SDR 26) Gravity Sewer 10' - 12'j	382	LF I	4.06	1,550.92	382.00	1,550.92	0.00	-	382.00	1,550.92	l00.00%	
8	Single Sewer Service	i	4 I LF '	273.52	1,094.08	4.00	1,094.08	0.00	-	4.00	1,094.08 1
1	l00.00%	
9	Double sewer service	
I	26	EA i	314.29	8,171.54	26.00	8,171.54	0.00	-	26.00	8,171.54	l00.00%	
	Le WATERDISTRIBUTION	!		i							
I	4" PVC DR-18, C900 Water Main	520	LF I	3.19	1,658.80	520.00	1,658.80	0.00	-	520.00	1,658.80	l00.00%	
2	8" PVC DR-18, C900 Water Main	I
I	1,960	LF I	9.30	18,228.00	1960.00	18,228.00	0.00	-	1960.00	18,228.00	l00.00%	
3	4" Gate valve and valve box	
!	2	EA i	484.41	968.82	2.00	968.82	0.00	-	2.00	968.82	l00.00%	
4	8" Gate valve and valve box	4	EA	847.30	3,389.20	4.00	3,389.20	0.00	-	i	4.00	3,389.20	l00.00%	
5	8"x8" Tapping Sleeve and Valve	

I,	2	EA I	1,770.06	3,540.12	2.00	3,540.12	0.00	-	I	2.00	3,540.12	100.00%	
8	Fire Hydrant Assembly	2	EA	2,274.03	4,548.06	2.00	4,548.06	0.00	-	I	2.00	4,548.06  ·	l00.00%	
9	Single water service (Short)	34	EA	319.96	10,878.64	34.00	10,878.64	0.00	-	I	34.00	I0,878.64	l00.00%	
10	Single water service (Long)	22	EA	365.73	8,046.06	22.00	8,046.06	0.00	-	22.00	8,046.06	l00.00%	
II	Tie-in to existing Water Main	2	EA	l07.80	215.60	1.00	107.80	0.00	-	1.00	l07.80	50.00%	
TOTAL	$	152,340.68	$	152,232.88	$	-	$	152,232.88	99.93%	

Ferguson Waterworks Cast Systems
County Materials 6% State Sales Tax				Summary

$	68,871.10
$	30,851.18
$	52,618.40
$	9,140.44	

$	68,763.30
$	30,851.18
$	52,618.40
$	9,133.97		

$	-
$	-
$	-
$	-			

$	68,763.30
$	30,851.18
$	52,618.40
$	9,133.97	

99.84% l00.00% l00.00% 99.93%	

Project:    Grand Palm Phase  lBa (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	6
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

!UNIT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK.THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
	TOTAL				$	161,481.12	$	161,366.85	$	-	$	161,366.85	99.93%	

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 Third Supplemental Trust Indenture from the District to the Trustee, dated as of February !, 2019 (the Master Indenture as amended and supplemented is hereinafter refened to as the "Indenture") (all capitalized telTllS used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-76

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

Amount Payable:	$32,223.23

Purpose for which paid or incuired (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 Pahn, Phase 2A(d) Application No. 5 (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 forth  above have been incU1Ted by the District, that each disbursement set forth above is a proper charge against the Series 20l 9 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 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 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  prope1iy 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 fo1ih 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;,_,	

 	.q
Consulting Engineer

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2Ad (CDD Portion)

ENGINEER	Kimley-Horn and Associates, Inc.

OWNER	Blackburn CreekCDD
5800 Lakewood Ranch Boulevard Sarasota, FL 34240	REQUESTNO

NTP DATE
Contract Tim SUBSTANTI FINAL

CONTRACTO	.

e AL

R	s

March 21, 2019
360 Days
March IS, 2020
April 12, 2020

ForsbergConstruction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETEDFROM	1/1/2020	TO	1/31/2020	

CONTRACT PAYMENT SUMMARY

Original Contract Amount
Change Orders:	1,317,081.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
		-			
		-			
		-			
		-			
Subtotals	-	-		
Net Change Order Subtotal (Additive less Deductive)	-	
Current Contract Amount (Original Amount + CO's)	1,3 I7,081.00	

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

59%
5%	I,008,813.00
235,680.78
773,132.22
38,656.61	80%

61%
5%	1,047,673.00
240,621.59
807,051.41
40,352.57		
Net Earned (Tota l earned minus retainage)		734,475.61		766,698.84	766,698.84	
Total Previous Estimates					734,475.61	
AMOUNT DUE THIS PERIOD					32,223.23	

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 todischarge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 4 inclusive; and (2) all materials and equipment incorporatedin said Project or otherwise listed in or covered by this Applicationfor 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 theContract Documents.

Ashly Wester
Notary Public,State of Florida
My Commission expires August 23, 2020

Sworn and subscribed to me IMV1.'l .rw'V'   Y",N  'V' 'A  ,,,..._....,. 	A.,-..JO A.._
31stday of January AD 202 (STAMP I SEAL)

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

Payment of the above AMOUNT DUE THIS APPLICATION is recommended.

Engineer Owner

DATE

zJ )uno
4.3&:e ze,z.-a

Project:	Grand Palm Phase 2Ad (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

PERCENT

	910	18" RCP	217	LF	55.00	11,935.00	217.0	11,935.00			11,935.00		
2	910	24"RCP	769	LF	65.00	49,985.00	769.0	49,985.00			49,985.00		
3	910	30" RCP	741	LF	84.00	62,244.00	741.0	62,244.00	0.00	741.00	62,244.00	100.00%	
4	910	36" RCP	192	LF	116.00	22,272.00	192.0	22,272.00	0.00	192.00	22,272.00	100.00%	
5	910	54"RCP	400	LF	262.00	104,800.00	400.0	104,800.00	0.00	400.00	104,800.00	100.00%	
6	910	Grated Swale Inlet	2	EA	3,400.00	6,800.00	2.0	6,800.00	0.00	2.00	6,800.00	100.00%	
7	910	Type "F" Inlet 36" x 48" (inside size)	2	EA	4,200.00	8,400.00	2.0	8,400.00	0.00	2.00	8,400.00	100.00%	
8	910	Type "M" Inlet 36" x 48" (inside size)	II	EA	4,200.00	46,200.00	11.0	46,200.00	0.00	11.00	46,200.00	100.00%	
9	910	Type "M" Inlet 42" x 60" (inside size)	I	EA	6,900.00	6,900.00	1.0	6,900.00	0.00	1.00	6,900.00	100.00%	
10	910	24" Flared End Section	3	EA	4,100.00	12,300.00	3.0	12,300.00	0.00	3.00	12,300.00	100.00%	
II	910	30" Flared End Section	2	EA	4,500.00	9,000.00	2.0	9,000.00	0.00	2.00	9,000.00	100.00%	
12	910	36" Flared End Section	I	EA	5,800.00	5,800.00	1.0	5,800.00	0.00	1.00	5,800.00	100.00%	
13	910	54" Flared End Section	I	EA	9,200.00	9,200.00	1.0	9,200.00	0.00	1.00	9,200.00	100.00%	
14	910	Storm Junction Box	4	EA	7,200.00	28,800.00	4.0	28,800.00	0.00	4.00	28,800.00	100.00%	
15	910	Medium Control Structure	I	EA	10,000.00	10,000.00	1.0	10,000.00	0.00	1.00	10,000.00	100.00%	
16	910	Rip-Rap for Bubbler Structures	93	SY	100.00	9,300.00	93.0	9,300.00	0.00	93.00	9,300.00	100.00%	
17	910	Connect to Existing Storm Structure	3	EA	5,000.00	15,000.00	3.0	15,000.00	0.00	3.00	15,000.00	100.00%	
18	910	Remove Ex Storm Pipe & Structures	I	EA	3,500.00	3,500.00	1.0	3,500.00	0.00	1.00	3,500.00	100.00%	
22	910	Modified Type "F" curb	1,180	LF	10.80	12,744.00	0.0		0.00	0.00		0.00%	
23	910	Type "M" curb	6,410	LF	10.80	69,228.00	0.0		0.00	0.00		0.00%	
24	910	Modified Type "F" curb (Islands)	240	LF	16.20	3,888.00	0.0		0.00	0.00		0.00%	
25	910	Valley Crossing curb				8,208.00				0.00		0.00%	
26	910	Curb ramp				4,680.00							
	960					28,000.00		28,000.00			28,000.00		
2	960	Manholes 6' - 8'	3	EA		18,600.00	3.0	18,600.00		3.00	18,600.00	100.00%	
3	960	Manholes 8' - IO'	4	EA		28,000.00	4.0	28,000.00	0.00	4.00	28,000.00	100.00%	
4	960	Manholes IO' - 12'	I	EA		7,800.00	1.0	7,800.00	0.00	1.00	7,800.00	100.00%	
5	960	8" PVC (SDR 26) Gravity Sewer O' - 6'	568	LF		19,312.00	568.0	19,312.00	0.00	568.00	19,312.00	100.00%	
6	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	1,117	LF	52.00	58,084.00	1117.0	58,084.00	0.00	1117.00	58,084.00	100.00%	
7	960	8" PVC (SDR 26) Gravity Sewer 8' - IO'	377	LF	70.00	26,390.00	377.0	26,390.00	0.00	377.00	26,390.00	100.00%	

"''

873	LF	87.00	75,951.00	873.0	75,951.00	0.00		873.00	75,951.00	100.00%	

8	960
9	960	Single sewer service	16	EA	1,500.00	24,000.00	1.0	1,500.00	2.00	3,000.00	3.00	4,500.00	18.75%	
IO	960	Double sewer service	27	EA	1,500.00	40,500.00	3.0	4,500.00	10.00	15,000.00	13.00	19,500.00	48.15%	
		Connection to existing gravity sewer	2	EA	6,600.00	13,200.00		6,600.00			1.00	6,600.00	50.00%	
						11,740.00					0.00		0.00%	
														
I	1010	6" PVC DR-18, C900 Water Main	480	LF	26.00	12,480.00	30.0	780.00	450.00	11,700.00	480.00	12,480.00	100.00%	
2	1010	8" PVC DR-18, C900 Water Main	4,310	LF	28.00	120,680.00	4310.0	120,680.00	0.00		4310.00	120,680.00	100.00%	
3	1010	6" Gate valve and valve box	2	EA	1,800.00	3,600.00	2.0	3,600.00	0.00		2.00	3,600.00	100.00%	
4	1010	8" Gate valve and valve box	16	EA	2,000.00	32,000.00	16.0	32,000.00	0.00		16.00	32,000.00	100.00%	

Project:	Grand Palm Phase 2Ad (CDD Portion)	Forsberg Construction, Inc. Owner:	Blackburn Creek CDD		645 Charlotte Street

					PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT	
ITEM		DESCRIPTION				UNIT	CONTRACT								COMPLETE	
NO.	CODES	OF WORK		QUAN		PRICE	TOTAL	QTY	VALUE		QTY	VALUE	QTY	VALUE	%	
5	1010	IFire Hydrant Assembly		4	EA	6,000.00	24,000.00	4.0	24,000.00		0.00		4.00	24,000.00	100.00%	
6	1010	'Single water service (Short)		42	EA	1,000.00	42,000.00	0.0			I	0.00		0.00		0.00%	
7	1010	Single water service (Long)		28	EA	1,200.00	33,600.00	0.0			0.00		0.00		0.00%	
8	1010	Temporary Blow-off Assembly		1	EA	1,200.00	1,200.00	0.0			0.00		0.00		0.00%	
9	1010	Tie-in to existing Water Main		3	EA	2,500.00	7,500.00	1.0	2,500.00		0.00		1.00	2,500.00	33.33%	
IO	1010	Ditch Crossing		1	EA	6,600.00	i	6,600.00	0.0			1.00	6,600.00	1.00	6,600.00	100.00%	
11	1010 I	Pressure testing of main				2.10	10,059.00									
		Chlorination and bacteriological				1.90	9,101.00									
		,I,														
		Florida Trench Safety Act														
2	510	Material Price Increases for 2019	I	1	LS	i	57,500.00	57,500.00	1.0	57,500.00		0.00	-	1.00:	57,500.00	100.00%	
4	260	Construction stakeout	1  LS	i	25,600.00	25,600.00	0.8	20,480.00	0.10	2,560.00	0.90	23,040.00	90.00%
5	260	Record  drawings/ As-Built Survey	:	1       LS    !	8,300.00	8,300.00	0.0	-	0.00	-	0.00	-	0.00%
6	510	IMobilization/  General  Conditions	'1	1 !LS    i	50,000.00	50,000.00  !	LO!	50,000.00	0.00[	-	1.00	50,000.00	100.00%
TOTAL	1,317,081.00	1,008,813.00	38,860.00	1,047,673.00	79.55%
Summary of Work Classifications	

Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950

Pay Request No.	5
For work from:	1/1/2020
To:	1/31/2020

	

	

																

																

																

																

																

	

	

																

																

																

																

																

Project:    Grand Palm Phase 2Ad (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	1/1/2020
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

UNIT	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 inspection)					!	!	
I	18" RCP	217 i LF	13.62	2,955.54	217.00	2,955.54		0.001	-		217.00		2,955.54 i	100.00%	
2	24" RCP	769 i LF	24.67	18,971.23	769.00	18,971.23		0.001	-		769.00		18,971.23 i	100.00%	
3	30" RCP	741 i LF	34.87	25,838.67	741.00	25,838.67	0.00		-		741.00		25,838.67 !	100.00%	
4	36" RCP	192 ! LF	48.53	9,317.76	192.00	9,317.76	0.00		-		192.00	9,317.76	100.00%	
5	54" RCP	400 \ LF	98.03		39,212.00	400.00	39,212.00		0.001 ,	-		400.00	39,212.00	100.00%	
6	Grated Swale Inlet	2 I EA	1,044.30	2,088.60	2.00	2,088.60	0.00		-		2.00	2,088.60	100.00%	
7	Type "F" Inlet 36" x 48" (inside size)	2 I EA	1,350.11	2,700.22	2.00	2,700.22		o.oo!	-		2.00!	2,700.22	100.00%	
8	Type "M" Inlet 36" x 48" (inside size)	11 i EA	1,407.64	15,484.04	11.00	15,484.04	0.00		-		11.00I	15,484.04	100.00%	
9	Type "M" Inlet 42" x 60" (inside size)	I	EA	1,407.64	1,407.64	1.00	1,407.64	0.00		-	I	l.OOl	1,407.64	100.00%	
10	24" Flared End Section			3	1 EA	1,012.00	3,036.00	3.00	3,036.00	0.00		-	I
I	3.00i	3,036.00	100.00%	
11	30" Flared End Section	2	EA	1,315.40	2,630.80	2.00	2,630.80	0.00		-	
!	2.00i	2,630.80	100.00%	
12	36" Flared End Section	1	EA	1,562.00	1,562.00	1.00	1,562.00	0.00		-	I	1.001	1,562.00	100.00%	
13	54" Flared End Section	I	EA	4,086.70	4,086.70	1.00		4,086.70	
j	0.00	-			1.001	4,086.70	100.00%	
14	Storm Junction Box	I I	4	EA	1,470.54	5,882.16	4.00	5,882.16	0.00	-			4.00i	5,882.16	100.00%	
15	Medium Control Structure	I	I	EA	2,881.57	2,881.57	1.00	2,881.57 !	0.00	-			LOO!	2,881.57	100.00%	
	11.b   SANITARY SEWER	I		I			I	I
I		I			
I'·		
I	Manholes O' - 6'	!		5	EA	1,584.28	7,921.40	5.00	7,921.40	0.00	-			5.001	7,921.40	100.00%	
2	Manholes 6' - 8'	I
I	3	EA I	1,834.15	5,502.45	3.00	5,502.45	0.00	-			3.00i	5,502.45	100.00%	
3	Manholes 8' - IO'	I	4	EA I	2,177.11	8,708.44	4.00	8,708.44	0.00	-	4.00	8,708.44	100.00%	
4	Manholes 10' - 12'	I		1	EA	2,550.72	2,550.72	1.00	2,550.72	0.00	-	1.00	2,550.72	100.00%	
5	8" PVC (SDR 26) Gravity Sewer O' - 6'	568	LF	4.05	2,300.40	568.00	2,300.40	0.00	-	568.00	2,300.40	100.00%	
6	8" PVC (SDR 26) Gravity Sewer 6' - 8'	1,117	LF	4.05	4,523.85	1117.00	4,523.85	0.00	-	1117.00	4,523.85	100.00%	
7	8" PVC (SDR 26) Gravity Sewer 8' - 10'	377	LF	4.05	1,526.85	377.00'	1,526.85	0.00	-	377.00	1,526.85	100.00%	
8	8" PVC (SDR 26) Gravity Sewer IO' - 12'		873	LF	4.05	3,535.65	873.00	3,535.65	0.00	-	873.00	3,535.65	100.00%	
9	Single sewer service	16	EA	273.52	4,376.32	1.00	273.52	2.00	547.04	3.00	820.56	18.75%	
10	Double sewer service	27	EA	314.21	8,483.67	3.00	942.63	10.00	3,142.10	13.00	4,084.73	48.15%	
	l.c WATERDISTRIBUTION												
I	6" PVC DR-18, C900 Water Main	480	LF	2.16	1,036.80	30.00	64.80	450.00	972.00	480.00	1,036.80	100.00%	
2	8" PVC DR-18, C900 Water Main	4,310	LF	7.09	30,557.90	4310.00	30,557.90	0.00	-	4310.00	30,557.90	100.00%	
3	6" Gate valve and valve box	2	EA	280.65	561.30	2.00	561.30	0.00	-	2.00	561.30	100.00%	
4	8" Gate valve and valve box	I
1	16	EA i	370.70	5,931.20	16.00	5,931.20	0.00	-	16.00	5,931.20	100.00%	
5	Fire Hydrant Assembly	I I	4	EA	2,312.63	9,250.52	4.00	9,250.52	0.00	-	4.00	9,250.52	100.00%	
6	Single water service (Short)	I	42	EA	331.88	13,938.96	0.00	-	0.00	-	0.00	-	0.00%	
7	Single water service (Long)	I
I	28	EA	368.67	10,322.76	0.00	-	0.00	-	0.00	-	0.00%	
9	Tie-in to existing Water Main	I	3	EA	133.80	401.40	1.00	133.80	0.00	-	1.00	133.80	33.33%	
TOTAL	$	259,485.52	$	222,340.36	$	4,661.14	$	227,001.50	87.48%	

Ferguson Waterworks						Summary

$	96,747.58	

$	59,602.42			

$	4,661.14			

$	64,263.56	

66.42%	

I

Project: Grand Palm Phase 2Ad (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:	5
1/1/2020
1/31/2020	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	
UNIT	MATERIAL
UNIT PRICE	PURCHASE ORDER
TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
	Cast Systems County Materials 6% State Sales Tax

TOTAL				$	55,127.24
$	107,610.70
$	15,569.13

$	275,054.65	$	50,192.48
$	112,545.46
$	13,340.42

$	235,680.78	$	-
$	-
$	279.67

$	4,940.81	$	50,192.48
$	112,545.46
$	13,620.09

$	240,621.59	91.05%
104.59%
87.48%

87.48%	

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 Fomth 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 tenns used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-77

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

Amount Payable:

$16,625.83

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 Palm, Phase 2Ad. Purchase Order# 190401; See attached for invoice information

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 20I9 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 fmther 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 requ1s1t1on 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

Au0otiicer	:

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 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 con-esponding 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.

'

c	

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #		Amount	 1423818	$ 16,878.83
   CM089452	$	(253.00)
Sub-Total	$16,625.83

FERGUSON®
WATERWORKS
17 323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 407-816-6550

FEB O 6 2020

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1423818	$16,878.83	42175	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 PH2AD
C/O FORSBERG CONSTRUCTION INC PO#190401
PUNTA GORDA, FL 33950

SHIP WHSE .
1 705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 - WTR SERVICE

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

02/03/20

BATCH
10
82324

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	
			Source Order#: 1423639				
			SPLIT BOXES 1423818				
460	/ 460	SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	0.550	FT	253.00	
640	/ 140	P40BEPK20	2X20 FT PVC S40 BE PIPE	55.000	C	77.00	
84	0	FINSERT52	1 CTS PET / HOPE DR9 INS STFNR		EA	0.00	
56	/ 55	FINSERT52	1 CTS PET / HOPE DR9 INS STFNR	1.260	EA	69.30	
1500	1500	C1230BHS500	12GA 30MM COP TRCR WIRE BLUE	178 000	M	267.00	
35	v 35	F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	..,,- 1 02.610	EA	3591.35	
28	/	28	F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	/ 102.610	EA	2873.08	
70	67	FBA43444WNL	LF 1 CTS X MTR ANG BV	/	87.340	EA	5851.78	
28	0	FBA43444WNL	LF 1 CTS X MTR ANG BV		EA	0.00	
42	/	42	FFB10004NL	LF 1 CCX CTS PJ BALL CORP	/ 50.240	EA	2110.08	
28	26	FFB10004NL	LF 1 CCX CTS PJ BALL CORP	v	50.240	EA	1306.24	
1200	1200	PEC9BG300	'EXC 1X300 CTS DR9 HOPE BLUE PIPE	/	40.000	C	480.00	

INVOICE SUB-TOTAL	16878.83

LEAD LAW WARNING: IT IS ILLEC, AL TO INSTALL PRODLCTS THAT ARE NOT "LEAD FREE" IN ACCORD ANCE WITH
US FEDERAL< R OTHER APPLIC ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPAT ED FOR HUMAN CONSUMPTION PRODUCTS W TH' NP IN THE DE SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLE  APPLICATIONS. I  UYER IS SOLELY RESF O  NSIBLE FOR PRODUC T SELECTION.

Thank you for your business

T ERMS:	CASH ON DEMAND	ORIGINAL INVOICE	TOTAL DUE	$16,878.83

� FERGUSON®	FEB 11 2020
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 407-816-6550

     CREDIT MEMO NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	CM089452	-$253.00	42175	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:

BLACK BURN CREEK CO MMUNITY DEVE GRA ND PALM PH2AD
C/O FORS BERG CONSTRUCTION INC PO#190401
PUNT A GORDA, FL 33950

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 - WTR SERVICE

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

02/10/20

BATCH
IC CM0

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	
460	460
Cust PO: 190	SDR21BPK 01 - WTR S	2 SDR21 CL200 PVC GJ BLU 0 1: 1 423818
ERVICE Job Name: GRAND PALM PH2AD	0.550	FT	-253.00	

INVOICE SUB-TOTAL	-253.00

Thank you for your business

TERMS:	ORIGINAL INVOICE

TOTAL DUE	-$253.00

PURCHASE ORDER No.	190401

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
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: Ferguson Waterworks Address: 18305 Paulson Drive
Port Charlotte, FL 33954

Job No.: I 9-04

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: 39S, Range 20E
County: Sarasota

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

Vendor Phone:-94-1--624--3-49-4
Attention:  Tyler Evenson	Vendor Fax: 941-627-3519

- - - - - - - - -

Quantity	Unit	Description	Unit Price	Total Price	
						
I	LS	Pipe, Valves, Fittings and Appurtenances in accordance	$	96,747.57		$	96,747.57	
		with Exhibit "A" {paqes 1-3)				

						

						
						
I					

						
						
	' Prices are good for duration of the project.				
						
		Project Duration: April 15, 2019 - April 15, 2020				
Total Project Subtotal	s	96, 74 7.57	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st S5,000.00	tax exempt	
TOTAL	s	96,747.57	

Ferguson Waterworks
Vendor

Blackburn Creek COD
Chairman

 	I I	I	d(		0

ut	ized Agent (signature)
r	JCfv	b-vi..tfl
d	Agent {printed/typed)

Date

Aut	xt. W
! IMPORTANT!
"SEESPECIAL PROVISIONS ABOVE.

Page	of	2	ADDITIONAL TERMSAND CONDITIONS ON PAGE2

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

When requested by Purchaser, Vendor wifl 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.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter wirl 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-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.

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 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 rej ected.

This agreement shafl 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 force and effect.

'Ii

This Purchase Order is the only binding contract between Purchaser and Vendor for this project and the work described. This Purchase Ord er replaces all previous contracts and agreements, w h ether 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 Ord er.

Page   2  of	2	Ferguson Initial	Blackb urn Creek COD In tit

FERGUSONQt
WATERWORKS

FEI-PT. CHARLOTTE WW 1705

PeliverTo:
from:	Tyler A Evenson Comments:

18305 PAULSON DRIVE
PORT CHARLOTTE, FL 33954-0000

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

13:39:18 APR 12 2019	Page 1 of 3
FEI-PORT CHARLOTTE #1705

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

MIIIT	')...

Bid No:	B249292	Cust Phone:	407-382-3256	
Bid Date: Quoted By:	04/12/19
TAE	Terms:	NET 10TH PROX	
Customer:	
BLACKBURN CREEK COMMUNITY	Ship To:	
BLACKBURN CREEK COMMUNITY	
	GRAND PALM PH2Ad		GRAND PALM PH2Ad	
	C/O FORSBERG CONSTRUCTION		C/O FORSBERG CONSTRUCTION	
	PUNTA GORDA, FL 33950		PUNTA GORDA, FL 33950	
Cust PO#:		Job Name:	GRAND PALM PH2Ad	

Item	Description	Quantity	Net Price	UM	Total
•SEWER•

- 8" PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2940	3.980    FT	11701.20
H260908	8 PVC HW SWR GXG REP COUP •z	2	55.730    EA	111.46
PD3105G4737	3X1000 UG DET SWR GREE	3	28.000   EA	84.00
SUBTOTAL	11896.66
SINGLE SWR SRV (16) •
MUL067248	8X6 PVC HW SWR GXGXG WYE	16	47.530   EA	760 .48
MUL067376	6 PVC HW SWR GXS 45 ELL	48	13.470    EA	646.56
MUL067326	6 PVC HW SWR GXG 45 ELL	16	18.240    EA	291.84
SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE	672	2.220    FT	1491.84
MUL067206	6 PVC HW SWR GXGXG WYE	16	36.570    EA	585.12
MUL040952	6 PVC SWR HUB FEM CO ADPT	16	11.720   EA	187 .5 2
MUL040958	6 PVC SWR REC THRO CO PLUG	16	8.950    EA	143.20
CYPSKPX	2X4X8 YELL PINE STUD	16	3.000    EA	48.00
MUL043988	6 PVC SWR GSKT CAP	32	6.930    EA	221.76
SUBTOTAL	4376.32
DBL SWR SRV (27) -
MUL067248	8X6 PVC HW SWR GXGXG WYE	27	47.530    EA	1283.31
MUL067376	6 PVC HW SWR GXS 45 ELL	81	13.470   EA	1091 .07
MUL067326	6 PVC HW SWR GXG 45 ELL	27	18.240    EA	492.48
MUL067277	6 PVC HW SWR GXG DBL WYE	27	68.260    EA	1843.02
MUL040952	6 PVC SWR HUB FEM CO ADPT	27	11.720	EA	316.44
MUL040958	6 PVC SWR REC THRO CO PLUG	27	8.950   EA	241 .65
MUL043 9 88	6 PVC SWR GSKT CAP	81	6.930    EA	561.33
SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE	1134	2.220    FT	2517.48
CYPSKPX	2X4X8 YELL PINE STUD	27	3.000    EA	81.00
PD3105G4737	3X1000 UG DET SWR GREE	2	28.000     EA	56 .00
SUBTOTAL	8483.78
TOTAL SANITARY SEWER	24756.76

ff FERGUSONQP

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

Fax: 941-627-3519

13:39:18APR 12 2019
Reference No: B249292

Item	Description	Quantity	Net Price	UM	Total

WATER MAIN•
===================-======
6" PVC WfR MAIN -
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	180	3.860    FT	694.80
PD3105852737	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	7	32.000    EA	224.00
SUBTOTAL	1035.80
6" GATE VLV ASSM (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	3320	6.700    FT	22244.00
PD3105B52737	3X1000 UG DET WTR BLUE	4	28.000    EA	112.00
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	8	89.000    EA	712.00
SPWPC8	8 SIGMA BELL REST F/ C900 *PVLOK	65	50.050    EA	3253.25
SUBTOTAL	26321.25
8"/6" FITTINGS -
MJ4LAU	6 MJ C153 45 BEND UA	2	47.260    EA	94.52
MJ4LAX	8 MJ  C153 45 BEND UA	1	68.700     EA	68.70
MJ2LAX	8 MJ  C153 22-1/2 BEND LIA	15	68.900     EA	1033.50
MJ1LAX	8 MJ  C153 11-1/4 BEND LIA	6	65.150     EA	390.90
MJTLAX	8 MJ C153 TEE UA	1	127.650   EA	127 .65
MJTLAXU	8X6  MJ C153 TEE UA	1	105.TTO    EA	105.77
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	48	46.150    EA	2215.20
SSLCE6AP	6 PVC WDG REST *ONELOK W/A	5	34.040    EA	170.20
SUBTOTAL	4206.44
8" GATE VLV ASSM (7)-
AFC2608DLAFMM	8  DI MJ RWOLSSSTEMVLVUA	7	647.000    EA	4529.00
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	14	46.150    EA	646.10
1461SW	2PC SC Cl VLV BX 19-22 WTR	7	95.000   EA	665.00
RBGVTMX	3 BRS GATE VLV ID- 8	7	13.000    EA	91.00
SUBTOTAL	5931.10
FIRE HYD ASSM (4) -
MJSTLAXU	8X6 MJ C153 SWVL TEE LIA	4	122.790    EA	491.16
SSLCE8AP	8 PVC VVDG REST *ONELOK W/A	8	46.150    EA	369.20
SSLCE6AP	6 PVC VVDG REST *ONELOK W/A	8	34.040    EA	272 .32
IMJBGPU	6 MJ C153 BLT GSKT PK UGLAND	4	12.700    EA	50.80
AFC2606DLAFMM	6  DI MJ RWOL SSSTEM VLV UA	4	406.555    EA	1626.22
1461SW	2PC SC Cl VLV BX 19-22 WTR	4	95.000    EA	380.00
RBGVTMU	3 BRS GATE VLV 10 - 6	4	13.000    EA	52.00
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	80	3.860	FT	306.80
AFCB84BLAOLP	5-1/4 VO 884B HYD 4'0 OL UA	4	1425.000   EA	5700.00
SUBTOTAL	9250.50

ff FERGUSON®
WATERWORKS

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

Page 3 of 3

13:39:18APR 122019
Reference No: B249292

Item	Description	Quantity	Net Price	UM	Total	
	- SINGLE SHORT (42) -					
F202B962CC4	8X1 CC DBL STRP BRZ SDL DI/AC	42	102.610	EA	4309.62	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	42	50.240	EA	2110.08	
PEC9BG300	*EXC 1X300 CTS DR9 HOPE BLUE PIPE	900	40.000	C	360.00	
PEC9BG100	*EXC 1X100 CTS DR9 HOPE BLUE PIPE	200	40.000	C	80.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	42	87.340	EA	3668.28	
FINSERT52	1 CTS PET/HOPE DR9 INS STFNR	84	1.260	EA	105.84	
CYPSKPX	2X4X8 YELL PINE STUD	42	3.000	EA	126.00	
CWA03111812	11X18X12 BXWI Cl RDR LID SUD	42	68.000	EA	2856.00	
	SUBTOTAL				13938.82	
	- SINGLE LONG (28) -					
F2028962CC4	8X1 CC DBL STRP BRZ SDL DI/AC	28	102.610	EA	2873.08	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	28	50.240	EA	1406.72	
PEC9BG300	*EXC 1X300 CTS DR9 HOPE BLUE PIPE	1500	40.000	C	600.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267 .00	
PD3105B52737	3X1000 UG OET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	28	87.340	EA	2445.52	
FINSERT52 ..	1 CTS PET I HOPE DR9 INS STFNR	56	1.260	EA	70.56	
CYPSKPX	2X4X8 YELL PINE STUD	28	3.000	EA	84.00	
CWA03111812	11X18X12 BX WI Cl ROR LID SUD	28	68.000	EA	1904.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	1120	0.550	FT	616.00	
	SUBTOTAL				10322.88	
FBLSLAX	8X12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	2	46.150	EA	92.30	
	SUBTOTAL				215.60	
FBLSLAU	6X12 MJ C110 LONG SLV UA	1	117.710	EA	117,71	
SSLCE6AP	6 PVC 'NOG REST •oNELOK W/A	2	34.040	EA	68.08	
	SUBTOTAL				185.79	
Net Total:	$96747.57	
Tax:	$0.00	
Freight:	$0.00	
Total:	$96747.57	

Quoted prices are based upon receipt of the total quantity for immediate shipment (48 hours). SHIPMENTS BEYOND 48 HOURS SHALL BE AT THE PRICE IN EFFECT AT TIME OF SHIPMENT UNLESS NOTED OTHERWISE. QUOTES FOR PRODUCTS SHIPPED FOR RESALE ARE NOT FIRM UNLESS NOTED OTHERWISE.

CONTACT YOUR SALES REPRESENTATIVE IMMEDlATELY FOR ASSISTANGE WITH DBE/MBEM' BE/SMALLBUSINESS 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 and conditions, which are incorporated by reference and found either following this document. or
on the web at https://www.ferguson.com/content/website-info/terms-of-sale Govt Buyers: All items are openmarket unless noted otherwise.

LEAD LAW WARNING: It is illegal to install products that are not "lead free·in accordance with US Federal or other applicable law in potable water systems anticipated for human consumption. Products 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:

I. Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor wil1 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 wilJ be deemed to have assumed the risk ofloss 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 Develop ment 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 190401 from Ferguson Waterworks (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as partof 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-l.094, F.A.C.:

You must initial each of the following requirements.

4-

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
The vendor's invoice will be issued direct ly to Governmental Entity.
a.,_ 3. Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from
puBlic funds.
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 Ent ity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the ta ngible 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, interes t, 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 sa les 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-:	""'"C..,...J,_..t,,.,&.....v..._'fv_M&--'-'-...._i,./'	_

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

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

Do not send to the Florida Department of Reve nue. This Cert ifica te ofEntitlement 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, F1orida, as trustee (the "Trnstee"), dated as of March I, 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:

2019-78

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

Amount Payable:

$130.00

Pmpose 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 Palm, Phase 2A(e). Purchase Order# 180501; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amount  set fo1th  above have been incurred by the District, that each disbursement set fo1th above is a  proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred iu 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 ot: any of the moneys payable to the Payee set fo1th 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 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

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 disbursementis 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.
,Jv' .	L7,--,
Consulting Engineer	J

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #	Amount	
    1458751	$130.00	
Sub-Total	$130.00

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

Please contact with Questions: 407-816-6550

FEB O 5 2020

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1458751	$130.00	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 CONSTRU CTION PO#180501
PUNTA GORDA, FL 33950

COUNTER PICK UP 18305 PAULSON DRIVE
PORT CHARLOTTE, FL 33954-0000

SHIP WHSE.
1705

SELL
WHSE .
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180501

SALESMAN

TAE

JOB NAME

PH2AE SOURCE

INVOICE DATE

02/05/20

BATCH
10
82340

ORDEREJ>

10

SHIPPED

10

ITEM NUMBER

RBGVTM X

DESCRIPTION
Source Order#: 1415124 3 BRS GATE VLV ID - 8

UNIT PRICE	UM
j 13.000	EA

AMOUNT	V
130.00"

***************** It<**  ************"'** **• 	•·•·**·**·*·**·***·**·******************** ****

INVOICE SUB-TOTAL

130.00

LEAD LAW WAR NING: IT IS ILLEI AL TO INSTALL PRODLCTS THAT ARE NOT"LEAD FREE" IN ACCORDANCE WITH
US FEDERAL (DR OTHER APPLICABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS WTH *NP IN THE DE SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABL E APPLICATIONS . UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE

TOTAL DUE	$130.00

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

--

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.

e 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.

II

FlORIDA

Consumer's Certificate of Exemption
Issued Pursuant to Chapter 2121 Florida statutes

DR•14 R.10/15

85·8015773053C-0	11/30/2016	11/30/2021	COUNTY GOVERNMENT

icata Number
This certifies that·

Effective Date	Eq,iratlon D te	ExemptlQn C tegory

BLACK8URNCREEK COMMUNITY
DEVELOPMENT DISTRICT 12051 CORPORATE BLVD
ORLANDO FL 32817-1450

Is exempt from the payment of Florida sales and use.tax on real property rented, transient rental property rented, tangible personal propeI1y purchased or rented, or services purchased.

II	Important Information for Exempt Organizations

DR-14
R,10/15

FLORIDA.

u must provideall vendors ndsuppliers with an exemption certificate before making tax-exempt purchases.
See Rule 12A-1.038, Florida Administrative Code (F.A.C.).

2.	Your Consumer's Certificate of Exemption Is tobe used solely by your organization for your organization's cuslomar)' nonprofit a.::tivitie s.

3.		Pt1rchases made by an Individual on behalf of the organization are taxable, evenIf the lndivldual wlll be reimbursedby the organization.

4.	This exemption applies only to purchases your organization makes. The sale or lease to others of tangible personal property, sleeping accommodations,or other real property is taxable. Your organization must reglsteri and collect andremit sales and use tax on such taxable transactions. Note: Churches are exempt from this requirement except when they are the lessor of real properiy (Rule 12A-1.070, F.A.C.).

5.	It Is acriminal offense ti, fraudulently present this certificate to evade the payment of sales tax. Under no circumstances should this certificate be used for the personal benefit of any Individual. Violators will be liable for payment of the sales tax plus apenalty of 200% of the tax, and may be subject to conviction of a third-degree felony. Any violation will require !he revocation of this certificate.

6.	If you have questions regarding your exempUon certificate, please contact the Exemption Unit of Account Management at 800-352-3671. From the available options, select "Registration of Taxes," then "Registration lnforrna ion." and finally "Exemption Certificates and Nonprofit Entities." The mailing address Is PO Box 6480, Tallaha ee, FL 32314·8'480.

RECEIVED NOV.1 11 lOfo

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 I, 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:

2019-79

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

Amount Payable:	$879.05

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 2Ad. Purchase Order# 190401; 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 Issnance Account that  has  not  previously been paid].

TI1e 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 clainl 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 reqms1t10n 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 prope1ty  acquired  or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:.    t'  d		­	
fficer

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 con-esponding 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.

 	....	
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #		Amount	 1423818-1	$		790.02
1457502	$	139.85
   CM089529	$	(50.82)
Sub-Total	$879.05

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

Please contact with Questions: 407-816-6550

FEB 1 3 2020

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1423 818-1	$790.02	42175	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 CREE K COMMUNITY DEVE GRAND PALM PH2AD
C/O FORSBERG CONSTRUCTION INC PO#190401
PUNTA GORD A, FL 33950

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 - WTR SERVICE

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

02/11/20

BATCH
10
82373

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	
			Source Order#: 1423639				

3	
./ 3	
FBA43444WNL	SPLIT BOXES 1423818
LF 1 CTS X MTR ANG BV	
,/ 87.340	
EA	
262.02	

460	
/	460	
SDR21 BPK	(3) SHIPPED ON MONDAY 2/3
2 SDR21 CL200 PVC GJ BLUE PIPE	
v' 0.550	
FT	
253.00	
500	500	P40BEPK20	2X20 FT PVC S40 BE PIPE	55.000	C	275.00	
86	0	FINSERT 52	1 CTS PET / HOPE OR9 INS STFNR		EA	0.00	
			INVOICE SUB-TOTAL			790.02	

LEAD LAW WARNING: IT IS ILLEC  AL TO INSTALL PRO DL CTS THAT ARE NOT "LEAD FREE" IN ACCORD ANCE WITH
US FEDE RAL ( R OTHER APPLIC ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH *NP IN THE DE SCRIPTIO N ARE NOT L  AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLE APPLICATIONS. BUYER IS SOLELY RE SF O NSIBLE FOR PRODUCT SELECTION.

Thank you for your business

T ERMS:	CASH ON DEMAND	ORIGINAL INVOICE

TOTAL DUE	$790.02

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

Please contact with Questions: 800-456-1488

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1457502	$139.82	42175	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 PH2AD
C/O FORSBERG CONSTRUCTION INC PO#190401
PUNTA GORDA, FL 33950

COUNTER PICK UP 18305 PAULSON DRIVE
PORT CHARLOTTE, FL 33954-0000

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

GRAND PALM

SALESMAN

TAE

JOB NAME

ORDERED	SHIPPE	ITEM NUMBER	DESCRIPTION		
•	UNIT ICE		., U""	AMOUNT	
	-'	1	C1230BSF500	12GA 30MM 500 FT COP TRCR WIRE BLUE			139.820		EA	139.82	

GRAND PALM PH2AD

i

INVOICE DATE

01/28/20

BATCH
10
82292

INVOICE SUB-TOTAL	139.82

LEAD LAW WP RNING: IT IS ILLE< t AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I DR OTHER APPLICABLE 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 INSTALLED IN
NON-POTABLI APPLICATIONS. BUYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE

TOTAL•DUE	$139.82

FERGUS ON®
WATERWORKS
17 323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 407-816-6550

FEB 1 9 2020

     CREDIT MEMO NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	CM089529	-$50.82	42175	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 CREE K COMMUNITY DEVE GRAND PALM PH2AD
C/O FORSBERG CONSTRU CTION INC PO#190401
PUNTA GORDA, FL 33950

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

GRAND PALM

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

02/18/20

BATCH
IC CMO

ORDERED

SHIPPED
1

ITEM NUMBER
C1230BSF500

DESCRIPTION
12GA 30MM 500 FT COP TRC 0 1: 1457502

UNIT PRICE	UM
50.820	EA

AMOUNT
-50.82

Cust PO: GR, ND PALM	Job Name: GRAND PALM PH2AD

INVOICE SUB-TOTAL	-50.82

Thank you for your business

TERMS:	ORIGINAL INVOICE

TOTAL DUE	-$50.82

PURCHASE ORDER No.	190401

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
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: Ferguson Waterworks Address: 18305 Paulson Drive
Port Charlotte, FL 33954

Job No.: I 9-04

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: 39S, Range 20E
County: Sarasota

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

Vendor Phone:-94-1--624--3-49-4
Attention:  Tyler Evenson	Vendor Fax: 941-627-3519

- - - - - - - - -

Quantity	Unit	Description	Unit Price	Total Price	
						
I	LS	Pipe, Valves, Fittings and Appurtenances in accordance	$	96,747.57		$	96,747.57	
		with Exhibit "A" {paqes 1-3)				

						

						
						
I					

						
						
	' Prices are good for duration of the project.				
						
		Project Duration: April 15, 2019 - April 15, 2020				
Total Project Subtotal	s	96, 74 7.57	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st S5,000.00	tax exempt	
TOTAL	s	96,747.57	

Ferguson Waterworks
Vendor

Blackburn Creek COD
Chairman

 	I I	I	d(		0

ut	ized Agent (signature)
r	JCfv	b-vi..tfl
d	Agent {printed/typed)

Date

Aut	xt. W
! IMPORTANT!
"SEESPECIAL PROVISIONS ABOVE.

Page	of	2	ADDITIONAL TERMSAND CONDITIONS ON PAGE2

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

When requested by Purchaser, Vendor wifl 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.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter wirl 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-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.

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 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 rej ected.

This agreement shafl 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 force and effect.

'Ii

This Purchase Order is the only binding contract between Purchaser and Vendor for this project and the work described. This Purchase Ord er replaces all previous contracts and agreements, w h ether 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 Ord er.

Page   2  of	2	Ferguson Initial	Blackb urn Creek COD In tit

FERGUSONQt
WATERWORKS

FEI-PT. CHARLOTTE WW 1705

PeliverTo:
from:	Tyler A Evenson Comments:

18305 PAULSON DRIVE
PORT CHARLOTTE, FL 33954-0000

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

13:39:18 APR 12 2019	Page 1 of 3
FEI-PORT CHARLOTTE #1705

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

MIIIT	')...

Bid No:	B249292	Cust Phone:	407-382-3256	
Bid Date: Quoted By:	04/12/19
TAE	Terms:	NET 10TH PROX	
Customer:	
BLACKBURN CREEK COMMUNITY	Ship To:	
BLACKBURN CREEK COMMUNITY	
	GRAND PALM PH2Ad		GRAND PALM PH2Ad	
	C/O FORSBERG CONSTRUCTION		C/O FORSBERG CONSTRUCTION	
	PUNTA GORDA, FL 33950		PUNTA GORDA, FL 33950	
Cust PO#:		Job Name:	GRAND PALM PH2Ad	

Item	Description	Quantity	Net Price	UM	Total
•SEWER•

- 8" PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2940	3.980    FT	11701.20
H260908	8 PVC HW SWR GXG REP COUP •z	2	55.730    EA	111.46
PD3105G4737	3X1000 UG DET SWR GREE	3	28.000   EA	84.00
SUBTOTAL	11896.66
SINGLE SWR SRV (16) •
MUL067248	8X6 PVC HW SWR GXGXG WYE	16	47.530   EA	760 .48
MUL067376	6 PVC HW SWR GXS 45 ELL	48	13.470    EA	646.56
MUL067326	6 PVC HW SWR GXG 45 ELL	16	18.240    EA	291.84
SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE	672	2.220    FT	1491.84
MUL067206	6 PVC HW SWR GXGXG WYE	16	36.570    EA	585.12
MUL040952	6 PVC SWR HUB FEM CO ADPT	16	11.720   EA	187 .5 2
MUL040958	6 PVC SWR REC THRO CO PLUG	16	8.950    EA	143.20
CYPSKPX	2X4X8 YELL PINE STUD	16	3.000    EA	48.00
MUL043988	6 PVC SWR GSKT CAP	32	6.930    EA	221.76
SUBTOTAL	4376.32
DBL SWR SRV (27) -
MUL067248	8X6 PVC HW SWR GXGXG WYE	27	47.530    EA	1283.31
MUL067376	6 PVC HW SWR GXS 45 ELL	81	13.470   EA	1091 .07
MUL067326	6 PVC HW SWR GXG 45 ELL	27	18.240    EA	492.48
MUL067277	6 PVC HW SWR GXG DBL WYE	27	68.260    EA	1843.02
MUL040952	6 PVC SWR HUB FEM CO ADPT	27	11.720	EA	316.44
MUL040958	6 PVC SWR REC THRO CO PLUG	27	8.950   EA	241 .65
MUL043 9 88	6 PVC SWR GSKT CAP	81	6.930    EA	561.33
SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE	1134	2.220    FT	2517.48
CYPSKPX	2X4X8 YELL PINE STUD	27	3.000    EA	81.00
PD3105G4737	3X1000 UG DET SWR GREE	2	28.000     EA	56 .00
SUBTOTAL	8483.78
TOTAL SANITARY SEWER	24756.76

ff FERGUSONQP

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

Fax: 941-627-3519

13:39:18APR 12 2019
Reference No: B249292

Item	Description	Quantity	Net Price	UM	Total

WATER MAIN•
===================-======
6" PVC WfR MAIN -
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	180	3.860    FT	694.80
PD3105852737	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	7	32.000    EA	224.00
SUBTOTAL	1035.80
6" GATE VLV ASSM (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	3320	6.700    FT	22244.00
PD3105B52737	3X1000 UG DET WTR BLUE	4	28.000    EA	112.00
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	8	89.000    EA	712.00
SPWPC8	8 SIGMA BELL REST F/ C900 *PVLOK	65	50.050    EA	3253.25
SUBTOTAL	26321.25
8"/6" FITTINGS -
MJ4LAU	6 MJ C153 45 BEND UA	2	47.260    EA	94.52
MJ4LAX	8 MJ  C153 45 BEND UA	1	68.700     EA	68.70
MJ2LAX	8 MJ  C153 22-1/2 BEND LIA	15	68.900     EA	1033.50
MJ1LAX	8 MJ  C153 11-1/4 BEND LIA	6	65.150     EA	390.90
MJTLAX	8 MJ C153 TEE UA	1	127.650   EA	127 .65
MJTLAXU	8X6  MJ C153 TEE UA	1	105.TTO    EA	105.77
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	48	46.150    EA	2215.20
SSLCE6AP	6 PVC WDG REST *ONELOK W/A	5	34.040    EA	170.20
SUBTOTAL	4206.44
8" GATE VLV ASSM (7)-
AFC2608DLAFMM	8  DI MJ RWOLSSSTEMVLVUA	7	647.000    EA	4529.00
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	14	46.150    EA	646.10
1461SW	2PC SC Cl VLV BX 19-22 WTR	7	95.000   EA	665.00
RBGVTMX	3 BRS GATE VLV ID- 8	7	13.000    EA	91.00
SUBTOTAL	5931.10
FIRE HYD ASSM (4) -
MJSTLAXU	8X6 MJ C153 SWVL TEE LIA	4	122.790    EA	491.16
SSLCE8AP	8 PVC VVDG REST *ONELOK W/A	8	46.150    EA	369.20
SSLCE6AP	6 PVC VVDG REST *ONELOK W/A	8	34.040    EA	272 .32
IMJBGPU	6 MJ C153 BLT GSKT PK UGLAND	4	12.700    EA	50.80
AFC2606DLAFMM	6  DI MJ RWOL SSSTEM VLV UA	4	406.555    EA	1626.22
1461SW	2PC SC Cl VLV BX 19-22 WTR	4	95.000    EA	380.00
RBGVTMU	3 BRS GATE VLV 10 - 6	4	13.000    EA	52.00
DR18BPU	6 C900 DR18 PVC GJ BLUE PIPE	80	3.860	FT	306.80
AFCB84BLAOLP	5-1/4 VO 884B HYD 4'0 OL UA	4	1425.000   EA	5700.00
SUBTOTAL	9250.50

ff FERGUSON®
WATERWORKS

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

Page 3 of 3

13:39:18APR 122019
Reference No: B249292

Item	Description	Quantity	Net Price	UM	Total	
	- SINGLE SHORT (42) -					
F202B962CC4	8X1 CC DBL STRP BRZ SDL DI/AC	42	102.610	EA	4309.62	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	42	50.240	EA	2110.08	
PEC9BG300	*EXC 1X300 CTS DR9 HOPE BLUE PIPE	900	40.000	C	360.00	
PEC9BG100	*EXC 1X100 CTS DR9 HOPE BLUE PIPE	200	40.000	C	80.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	42	87.340	EA	3668.28	
FINSERT52	1 CTS PET/HOPE DR9 INS STFNR	84	1.260	EA	105.84	
CYPSKPX	2X4X8 YELL PINE STUD	42	3.000	EA	126.00	
CWA03111812	11X18X12 BXWI Cl RDR LID SUD	42	68.000	EA	2856.00	
	SUBTOTAL				13938.82	
	- SINGLE LONG (28) -					
F2028962CC4	8X1 CC DBL STRP BRZ SDL DI/AC	28	102.610	EA	2873.08	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	28	50.240	EA	1406.72	
PEC9BG300	*EXC 1X300 CTS DR9 HOPE BLUE PIPE	1500	40.000	C	600.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	3	89.000	EA	267 .00	
PD3105B52737	3X1000 UG OET WTR BLUE	2	28.000	EA	56.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	28	87.340	EA	2445.52	
FINSERT52 ..	1 CTS PET I HOPE DR9 INS STFNR	56	1.260	EA	70.56	
CYPSKPX	2X4X8 YELL PINE STUD	28	3.000	EA	84.00	
CWA03111812	11X18X12 BX WI Cl ROR LID SUD	28	68.000	EA	1904.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	1120	0.550	FT	616.00	
	SUBTOTAL				10322.88	
FBLSLAX	8X12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST *ONELOK W/A	2	46.150	EA	92.30	
	SUBTOTAL				215.60	
FBLSLAU	6X12 MJ C110 LONG SLV UA	1	117.710	EA	117,71	
SSLCE6AP	6 PVC 'NOG REST •oNELOK W/A	2	34.040	EA	68.08	
	SUBTOTAL				185.79	
Net Total:	$96747.57	
Tax:	$0.00	
Freight:	$0.00	
Total:	$96747.57	

Quoted prices are based upon receipt of the total quantity for immediate shipment (48 hours). SHIPMENTS BEYOND 48 HOURS SHALL BE AT THE PRICE IN EFFECT AT TIME OF SHIPMENT UNLESS NOTED OTHERWISE. QUOTES FOR PRODUCTS SHIPPED FOR RESALE ARE NOT FIRM UNLESS NOTED OTHERWISE.

CONTACT YOUR SALES REPRESENTATIVE IMMEDlATELY FOR ASSISTANGE WITH DBE/MBEM' BE/SMALLBUSINESS 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 and conditions, which are incorporated by reference and found either following this document. or
on the web at https://www.ferguson.com/content/website-info/terms-of-sale Govt Buyers: All items are openmarket unless noted otherwise.

LEAD LAW WARNING: It is illegal to install products that are not "lead free·in accordance with US Federal or other applicable law in potable water systems anticipated for human consumption. Products 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:

I. Direct Purchase Order. The CDD must issue its purchase order in its name directly to the vendor supplying the materials the contractor wil1 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 wilJ be deemed to have assumed the risk ofloss 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 Develop ment 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 190401 from Ferguson Waterworks (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as partof 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-l.094, F.A.C.:

You must initial each of the following requirements.

4-

The attached Purchase Order is issued directly to the vendor supplying the tangible personal property the Contractor will use in the identified public works.
The vendor's invoice will be issued direct ly to Governmental Entity.
a.,_ 3. Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from
puBlic funds.
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 Ent ity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the ta ngible 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, interes t, 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 sa les 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-:	""'"C..,...J,_..t,,.,&.....v..._'fv_M&--'-'-...._i,./'	_

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

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

Do not send to the Florida Department of Reve nue. This Cert ifica te ofEntitlement must 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 Activities	
As of 2/29/2020	
	
Debt Service	
Debt Service	
Debt Service	
Capital Proiects	
Capital Proiects	
Capital Project	
Lont Term		
General Fund		Fund -						Total	
	Fund		Fund - 2018	Fund - 2013A	Fund - 2015A	Fund - 2018	Debt Group		
		2015A1&A2							

Revenues	
On-Roll Assessments Off-Roll Assessments On-Roll Assessments Other Assessments
Inter-Fund Group Transfers In On-Roll Assessments
Other Assessments On-Roll Assessments Other Assessments Inter-Fund Transfers Inter-Fund Transfers In Inter-Fund Transfers
Total Revenues	$83,931.54 42,845.10

$126,776.64	

$318,249.51
9,610.49
(1,010.83)

$326,849.17	

$273,892.98 165,167.38

$439,060.36	

$195,482.62 195,406.17
(70,175.11)

$320,713.68	

$1,010.83

$1,010.83	

$0.00	

$70,175.11

$70,175.11	

$0.00	$83,931.54 42,845.10
318,249.51
9,610.49
(1,010.83)
273,892.98
165,167.38
195,482.62
195,406.17
(70,175.11)
1,010.83
70,175.11

$1,284,585.79	
Expenses

Supervisor Fees
Public Officials' Insurance Trustee Services Management Dissemination Agent District Counsel Assessment Administration Audit
Postage & Shipping Legal Advertising
Web Site Maintenance Dues, Licenses, and Fees General Insurance
Principal Payment - 2013A1, 2019A1 Interest Payments - 2013A1, 2019A1 Interest Payments - 2019A2 Principal Payments - 2015A1 bond Principal Payments - 2015A2 bond Interest Payments - 2015A1 bond Interest Payments - 2015A2 bond Principal Payment - 2018A2 Bond Interest Payment - 2018A1 Bond Interest Payment - 2018A2 Bond Engineering
Capital Expenditures Engineering Services Capital Expenditure
Total Expenses	

$4,800.00 2,423.00
7,412.71
10,416.65
2,500.00
1,411.50
15,000.00
2,000.00
210.77
434.50
625.00
175.00
3,499.00

$50,908.13	

$25,000.00 223,092.50
40,460.00

$288,552.50	

$30,000.00 180,000.00
93,700.00
43,125.01

$346,825.01	

$210,000.00 274,900.00
70,269.00

$555,169.00	

$13,342.83 1,263,099.18

$1,276,442.01	

$0.00	

$11,784.55 227,669.18

$239,453.73	

$0.00	

$4,800.00 2,423.00
7,412.71
10,416.65
2,500.00
1,411.50
15,000.00
2,000.00
210.77
434.50
625.00
175.00
3,499.00
25,000.00
223,092.50
40,460.00
30,000.00
180,000.00
93,700.00
43,125.01
210,000.00
274,900.00
70,269.00
13,342.83
1,263,099.18
11,784.55
227,669.18

$2,757,350.38	

Blackburn Creek CDD Statement of Activities As of 2/29/2020	

General Fund		
Debt Service Fund		
Debt Service Fund - 2015A1&A2		
Debt Service Fund - 2018		
Capital Proiects Fund - 2013A		
Capital Proiects Fund - 2015A		
Capital Project Fund - 2018		
Lont Term Debt Group		

Total	
Other Revenues (Expenses) & Gains (Losses)																		
Interest Income Interest Income Interest Income Interest Income Interest Income Interest Income			$2,014.73		
$295.50		

$291.48		

$949.07		

$96.17		

$194.54				$2,014.73 295.50
291.48
949.07
96.17
194.54	
Total Other Revenues (Expenses) & Gains (Losses)	

$0.00		

$2,014.73		

$295.50		

$291.48		

$949.07		

$96.17		$194.54		$0.00		$3,841.49	
Change In Net Assets	$75,868.51		$40,311.40		$92,530.85		($234,163.84)		($1,274,482.11)		$96.17		($169,084.08)		$0.00		($1,468,923.10)	

Net Assets At Beginning Of Year	
$67,522.90		
$707,719.95		
$595,275.08		
$803,405.05		
$2,109,192.56		
$174,345.63		
$379,490.73		
$0.00		
$4,836,951.90	

Net Assets At End Of Year	

$143,391.41		

$748,031.35		

$687,805.93		

$569,241.21		

$834,710.45		

$174,441.80		

$210,406.65		

$0.00		

$3,368,028.80	

Blackburn Creek CDD Statement of Financial Position As of 2/29/2020

General Fund

Debt Service Fund

Debt Service Fund -

Debt Service Fund - 2018

Capital Proiects Fund -

Capital Proiects Fund - 2015A

Capital Proiects Fund -

Long Term Debt Group

Total

2015A1&A2	2013A	2018

Assets	
Current Assets
General Checking Account Assessments Receivable Prepaid Expenses Assessments Receivable Due From Other Funds
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 2019A-1 Bond Capitalized Interest 2019A-2 Bond Assessments Receivable
Due From Other Funds
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 Due from Other Funds
Assessments Receivable Acquisition/Construction 2013A Bond Acquisition/Construction 2019A Bond Acquisition/Construction 2015A Bond Acquisition/Construction 2018A Bond Restricted Acq/Construction 2018A Bond
Total Current Assets	

$165,763.90 60,823.46
320.26

$226,907.62	

$359,557.99
9,169.28
172,929.21
91,809.05
451,262.50
46.38
17,499.09
5,061.64
174.75
79.45

$1,107,589.34	

$53,325.77 7,891.30
232,181.25
99,375.00
265,196.23
992.21
57,131.49
25,038.45

$741,131.70	

$189,990.74
2,562.00
172,592.63
90,936.17
107,527.50
5,632.17
623,155.38

$1,192,396.59	

$21,730.83 953,156.37

$974,887.20	

$190,447.95

$190,447.95	

$184,137.02 70,084.77
$254,221.79	

$0.00	

$165,763.90 60,823.46
320.26
359,557.99
9,169.28
172,929.21
91,809.05
451,262.50
46.38
17,499.09
5,061.64
174.75
79.45
53,325.77
7,891.30
232,181.25
99,375.00
265,196.23
992.21
57,131.49
25,038.45
189,990.74
2,562.00
172,592.63
90,936.17
107,527.50
5,632.17
623,155.38
21,730.83
953,156.37
190,447.95
184,137.02
70,084.77

$4,687,582.19	

Blackburn Creek CDD Statement of Financial Position As of 2/29/2020

General Fund

Debt Service Fund

Debt Service Fund -

Debt Service Fund - 2018

Capital Proiects Fund -

Capital Proiects Fund - 2015A

Capital Proiects Fund -

Long Term Debt Group

Total

2015A1&A2	2013A	2018

Investments
Amount Available in Debt Service Funds Amount To Be Provided
Total Investments	

$0.00		

$0.00		

$0.00	

$0.00		

$0.00		

$0.00		

$0.00		
$1,982,385.74 22,904,614.26
$24,887,000.00		
$1,982,385.74 22,904,614.26
$24,887,000.00	
Total Assets	$226,907.62		$1,107,589.34		$741,131.70	$1,192,396.59		$974,887.20		$190,447.95		$254,221.79		$24,887,000.00		$29,574,582.19	

Current Liabilities Accounts Payable Deferred Revenue Deferred Revenue Deferred Revenue Deferred Revenue Retainage Payable Developer Advance Retainage Payable Retainage Payable
Total Current Liabilities	

$22,692.75 60,823.46

$83,516.21		

$359,557.99

$359,557.99	

Liabilities and Net Assets

$53,325.77
$623,155.38

 	
$53,325.77	$623,155.38		

$126,349.75 13,827.00

$140,176.75		

$16,006.15

$16,006.15		

43,815.14
$43,815.14		

$0.00		

$22,692.75 60,823.46
359,557.99
53,325.77
623,155.38
126,349.75
13,827.00
16,006.15
43,815.14
$1,319,553.39	

Long Term Liabilities
Revenue Bonds Payable - Long-Term Total Long Term Liabilities	

$0.00		

$0.00	

$0.00		

$0.00		

$0.00		

$0.00		

$0.00		

$24,887,000.00
$24,887,000.00		

$24,887,000.00
$24,887,000.00	
Total Liabilities	$83,516.21		$359,557.99	$53,325.77		$623,155.38		$140,176.75		$16,006.15		$43,815.14		$24,887,000.00		$26,206,553.39	

Blackburn Creek CDD Statement of Financial Position As of 2/29/2020

	
General Fund		Debt Service Fund		Debt Service Fund - 2015A1&A2		Debt Service Fund - 2018		Capital Proiects Fund - 2013A		Capital Proiects Fund - 2015A		Capital Proiects Fund - 2018		Long Term Debt Group		
Total	
Net Assets																		
Net Assets, Unrestricted
Net Assets - General Government	($3,421.82)
70,944.72																($3,421.82)
70,944.72	
Current Year Net Assets - General Government	75,868.51																75,868.51	
Net Assets, Unrestricted			$707,719.95														707,719.95	
Current Year Net Assets, Unrestricted			40,311.40														40,311.40	
Net Assets, Unrestricted					$595,275.08												595,275.08	
Current Year Net Assets, Unrestricted					92,530.85												92,530.85	
Net Assets, Unrestricted							$803,405.05										803,405.05	
Current Year Net Assets, Unrestricted							(234,163.84)										(234,163.84)	
Net Assets, Unrestricted									$2,109,192.56								2,109,192.56	
Current Year Net Assets, Unrestricted									(1,274,482.11)								(1,274,482.11)	
Net Assets, Unrestricted											$174,345.63						174,345.63	
Current Year Net Assets, Unrestricted											96.17						96.17	
Net Assets, Unrestricted													$379,490.73				379,490.73	
Current Year Net Assets, Unrestricted													(169,084.08)				(169,084.08)	
Total Net Assets	$143,391.41		$748,031.35		$687,805.93		$569,241.21		$834,710.45		$174,441.80		$210,406.65		$0.00		$3,368,028.80	
																		
Total Liabilities and Net Assets	$226,907.62		$1,107,589.34		$741,131.70		$1,192,396.59		$974,887.20		$190,447.95		$254,221.79		$24,887,000.00		$29,574,582.19	

Blackburn Creek CDD
Budget to Actual
For the Month Ending 2/29/2020	
Year To Date	
	
Actual			
Budget	
Variance	FY 2020
Adopted Budget	

Revenues											
On-Roll Assessments Off-Roll Assessments	$	83,931.54
42,845.10	$	60,314.60
-		$	23,616.94
42,845.10	$	144,755.00
-	
Net Revenues	$	126,776.64	$	60,314.60		$	66,462.04	$	144,755.00	
General & Administrative Expenses
Supervisor Fees
Public Officials' Insurance Trustee Services Management  Engineering Dissemination Agent District Counsel
Assessment Administration Reamortization Schedules Audit
Arbitrage Calculation Telephone
Postage & Shipping Copies
Legal Advertising Office Supplies
Web Site Maintenance Dues, Licenses, and Fees Stormwater Management General Insurance
General Repair & Maintenance	

$	4,800.00
2,423.00
7,412.71
10,416.65
- 2,500.00
1,411.50
15,000.00
- 2,000.00
-
- 210.77
- 434.50
- 625.00
175.00
- 3,499.00
-		

$	

5,000.00
1,083.35
6,666.65
10,416.65
4,166.65
4,166.65
8,333.35
6,250.00
416.65
1,875.00
416.65
83.35
187.50
62.50
2,083.35
83.35
1,125.00
83.35
4,166.65
1,564.60
2,083.35		

$	

(200.00)
1,339.65
746.06
- (4,166.65)
(1,666.65)
(6,921.85)
8,750.00
(416.65)
125.00
(416.65)
(83.35)
23.27
(62.50)
(1,648.85)
(83.35)
(500.00)
91.65
(4,166.65)
1,934.40
(2,083.35)	

$	12,000.00
2,600.00
16,000.00
25,000.00
10,000.00
10,000.00
20,000.00
15,000.00
1,000.00
4,500.00
1,000.00
200.00
450.00
150.00
5,000.00
200.00
2,700.00
200.00
10,000.00
3,755.00
5,000.00	
Total General & Administrative Expenses	$	50,908.13		$	60,314.60		$	(9,406.47)	$	144,755.00	

Total Expenses	
  $	50,908.13 		
   $		
60,314.60 		
   $		
(9,406.47)	
  $	144,755.00 	
Net Income (Loss)	$	75,868.51	$	-		$	75,868.51		$	-	

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