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, November 13, 2019 at 12:15 p.m. at the 5800 Lakewood Ranch Blvd, Sarasota, FL 34240. The following is the agenda for this meeting.

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

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

General Business Matters

Consideration of the Minutes of the October 9, 2019 Board of Supervisors’ Meeting
Consideration of Resolution 2020-02, Annual Appropriations and Adopting the Revised Budget for Fiscal Year 2019
Ratification of Payment Authorizations 94 -- 98
Ratification of Requisitions 2018-113 – 2018-114
Ratification of Requisitions 2019-36 -- 2019-52
Review of District Financial Statements

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

Adjournment 

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of the Minutes of the October 9, 2019 Board of Supervisors’ Meeting

MINUTES OF MEETING

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT BOARD OF SUPERVISORS MEETING MINUTES
Wednesday, October 9, 2019 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		
Also present:			
Vivian Carvalho	District Manager- PFM Group Consulting, LLC	
Bill Conerly	District Engineer- Kimley-Horn	(via phone)	
Jim Schier	Neal Communities		
John Leinaweaver	Neal Communities		
Pam Curran	Neal Communities		
Jerry Dell	Audience Member		

FIRST ORDER OF BUSINESS		Organizational Matters Call to Order and Roll Call
Ms. Carvalho called to order at 12:19 p.m. the meeting of the Board of Supervisors of the Blackburn Creek Community Development District and proceeded with roll call. The persons in attendance are as outlined above.

Public Comment Period

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

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

District Staff received a resume from Mr. Dell. He provided an overview of his experience.

On MOTION by Mr. Williams, seconded by Mr. Weidemiller, with all in favor, the Board approved appointment of Mr. Dell to fulfill Seat 2 in which the term expires November 2022.

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

Ms. Carvalho administer the oath of office to Mr. Dell. She asked him if he would like to receive or waive compensation. He chose to receive compensation. Ms. Carvalho provided an overview of the Sunshine Law and Public Records Laws. It was recommended that he create a subfolder in his email to keep District related emails separate to his personal email.

SECOND ORDER OF BUSINESS	General Business Matters

Consideration of Resolution 2020- 01, Election of Officers

Ms. Carvalho stated the current slate of Officers are as follows; Mr. Williams as Chairperson, Mr. Weidemiller as Vice Chairperson, Ms. Carvalho as Secretary, Ms. Ripoll as Assistant Secretary, Ms. Walden as Assistant Secretary, the remaining Board as Assistant Secretary along with Mr. Schier as Assistant Secretary, Ms. Glasgow as Treasurer, and Ms. Lane as Assistant Treasurer. Ms. Carvalho asked if the Board wanted to keep the slate of officers the same with the understanding that Mr. Dell will be added as an Assistant Secretary.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board approved Resolution 2020-01, Election of Officers, as outlined above.

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

The Board reviewed the Minutes of the September 11, 2019 Board of Supervisors Meeting.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board approved the September 11, 2019 Board of Supervisors Meeting.

Ratification	of	ADA	Auditing Services Agreement

Ms. Carvalho stated that the Board previously discussed an ADA Auditing Services Proposal. The proposal is part of this agreement. This agreement materializes the proposal that the Board previously approved.

The proposal was for continued auditing services to ensure that the websites are ADA compliant including a quarterly technical and human audit report. The agreement is to formalize the actual proposal.

On MOTION by Mr. Weidemiller, seconded by Mr. Williams, with all in favor, the Board ratified the ADA Auditing Services Agreement.

District staff explained the ADA issues that started this process.	Lengthy discussion ensued.

Ratification	of	Payment Authorizations 91-93

The Board reviewed Payment Authorizations 91-93.

On MOTION by Mr. Williams, seconded by Mr. Johnson, with all in favor, the Board Ratified Payment Authorizations 91-93.

Ratification of Requisitions 2018- 109 – 2018-112

The Board reviewed Requisitions 2018-109 – 2018-112.

On MOTION by Mr. Weidemiller, seconded by Mr. Williams, with all in favor, the Board Ratified Requisitions 2018-109 – 2018-112.

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

The Board reviewed Requisitions 2019-24 & 2019-29 – 2019-35.

On MOTION by Mr. Weidemiller, seconded by Mr. Williams, with all in favor, the Board Ratified Requisitions 2019-24 & 2019-29 – 2019-35.

Review	of	District	Financial Statements

The Board reviewed the District Financial Statements through September 30, 2019. Ms. Carvalho stated that Ms. Lane will be in the process of closing the books for the District FY and if there is any reclassification she will update accordingly. In addition, Ms. Carvalho stated that if there is a Budget amendment it will occur at the November meeting. If it is over by 10% or $10,000.00 then it must be done via resolution.

On MOTION by Mr. Williams, seconded by Mr. Blakley, with all in favor, the Board accepted the District Financial Statements for September 30, 2019.

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

District Engineer – Mr. Conerly informed the Board that he has requisitions that are being processed that will be presented at the next meeting for ratification.

District Manager – Ms. Carvalho stated that this District meets on the second Wednesday of each month. The next meeting is scheduled for November 13, 2019

Audience	Comments	and Supervisors Requests

There were no Supervisor requests or audience comments.

FOURTH ORDER OF BUSINESS	Adjournment

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

On MOTION by Mr. Weidemiller, seconded by Mr. Johnson with all in favor, the October 9, 2019 Meeting of the Board of Supervisors of the Blackburn Creek Community Development District was adjourned at 12:41 P.M.

Secretary/Assistant Secretary	Chairperson/Vice Chairperson

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Consideration of Resolution 2020-02, Annual Appropriations and Adopting the Revised Budget for Fiscal Year 2019

RESOLUTION 2020-02

THE REVISED ANNUAL APPROPRIATION RESOLUTION OF THE BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT (THE “DISTRICT”) RELATING TO THE REVISED ANNUAL APPROPRIATIONS AND ADOPTING THE REVISED BUDGET FOR THE FISCAL YEAR BEGINNING OCTOBER 1, 2018, AND ENDING SEPTEMBER 30, 2019

WHEREAS, the Blackburn Creek Community Development District Board of Supervisors (the “Board”) previously approved and adopted an annual budget for the fiscal year beginning October 1, 2018 and ending September 30, 2019, pursuant to the provisions of Section 190.008(2)(a), Florida Statutes; and

WHEREAS, the Board now desires to revise the annual budget for the fiscal year beginning October 1, 2018 and ending September 30, 2019; and

WHEREAS, Section 190.008(2)(a), Florida Statutes, requires that the District Board by passage of the Annual Appropriation Resolution shall adopt a budget for the each fiscal year and appropriate such sums of money as the Board deems necessary to defray all expenditures of the District during the ensuing fiscal year; and

WHEREAS, the District Manager has prepared a Proposed Budget, whereby the Proposed Budget projects the cash receipts and disbursements anticipated during a given time period, including reserves for contingencies for emergency or other unanticipated expenditures during the fiscal year.

NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF SUPERVISORS OF THE BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT;

Section 1.	Budget

a.	That the Board of Supervisors has reviewed the District Manager’s Proposed	
Budgets, a copy of which is on file with the office of the District Manager and	
at the District’s Records Office, and hereby approves certain amendments	
thereto, as shown in Section 2 below.	
b.	That the District Manager’s Proposed Budgets, attached hereto as Exhibit	
	“A,”	are	hereby adopted in accordance with the provisions of Section	
	190.008(2)(a), Florida	Statutes, and incorporated herein by	reference;	
	provided, however, that the comparative figures contained in the adopted	
	budget may be subsequently revised as deemed necessary by the District	
	Manager to reflect actual revenues and expenditures for fiscal year 2018-	
	2019.				

That the adopted budget shall be maintained in the office of the District Manager and at the District’s Records Office and identified as “The Revised Budget for the Blackburn Creek Community Development District for the Fiscal Year Beginning October 1, 2018 and Ending September 30, 2019, as adopted by the Board of Supervisors on November 13, 2019.

Section 2.	Appropriations

There is hereby appropriated out of the revenues of the Blackburn Creek Community Development District, for the fiscal year beginning October 1, 2018, and ending September 30, 2019, the sum of money to be raised by the levy of assessments and otherwise, which sum is deemed by the Board of Supervisors to be necessary to defray all expenditures of the District during said budget year, to be divided and appropriated in the following fashion:

TOTAL GENERAL FUND	$ 	

TOTAL ALL FUNDS	$ 	

Section 3.	Supplemental Appropriations

The Board may authorize by resolution, supplemental appropriations or revenue changes for any lawful purpose from funds on hand or estimated to be received within the fiscal year as follows:

Board may authorize a transfer of the unexpended balance or portion thereof of any appropriation item.

Board may authorize an appropriation from the unappropriated balance of any fund.

Board may increase any revenue or income budget amount to reflect receipt of any additional unbudgeted monies and make the corresponding change to appropriations or the unappropriated balance.

The District Manager and Treasurer shall have the power within a given fund to authorize the transfer of any unexpected balance of any appropriation item or any portion thereof, provided such transfers do not exceed Ten Thousand ($10,000) Dollars or have the effect of causing more than 10% of the total appropriation of a given program or project to be transferred previously approved transfers included. Such transfer shall not have the effect of causing a more than $10,000 or 10% increase, previously approved transfers included, to the original budget appropriation for the receiving program. Transfers within a program or project may be approved by the Board of Supervisors. The District Manager or Treasurer must establish administrative procedures which require information on the request forms proving that such transfer requests comply with this section.

Introduced, considered favorably, and adopted this 13th day of November, 2019.

ATTEST:	BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT	

Secretary	By:	 Its: 		

Blackburn Creek CDD
FY 2019 Adopted Budget (proposed revised)

Year To Date

FY 2019
		Actual	FY 2019
Adopted Budget			Variance	Adopted Budget
(proposed	
revised)	

Revenues												
On-Roll Assessments	$	72,015.36		$	123,955.00	$	(51,939.64)	$	72,015.36	
Off-Roll Assessments		10,560.73			-			10,560.73			10,560.73	
Other Income & Other Financing Sources		49.00			-			49.00			49.00	
Cash Carryforward		-			-			-			41,329.91	
Net Revenues	$	82,625.09		$	123,955.00	$	(41,329.91)	$	123,955.00	
General & Administrative Expenses												
Supervisor Fees	$	10,200.00		$	12,000.00	$	(1,800.00)	$	10,200.00	
Public Officials' Insurance		2,364.00			2,600.00			(236.00)			2,364.00	
Trustee Services		9,743.55			8,750.00			993.55			9,743.55	
Management		24,999.96			25,000.00			(0.04)			25,000.00	
Engineering		1,318.97			10,000.00			(8,681.03)			3,807.44	
Dissemination Agent		12,500.00			6,000.00			6,500.00			12,500.00	
District Counsel		15,042.50			20,000.00			(4,957.50)			20,000.00	
Assessment Administration		7,500.00			7,500.00			-			7,500.00	
Audit		4,500.00			5,500.00			(1,000.00)			5,500.00	
Arbitrage Calculation		500.00			1,000.00			(500.00)			500.00	
Travel and Per Diem		33.06			-			33.06			33.06	
Telephone		167.42			150.00			17.42			167.42	
Postage & Shipping		421.08			500.00			(78.92)			421.08	
Copies		61.95			200.00			(138.05)			61.95	
Legal Advertising		2,874.89			1,500.00			1,374.89			2,874.89	
Bank Fees		-			150.00			(150.00)			150.00	
Miscellaneous		-			2,400.00			(2,400.00)			2,400.00	
Office Supplies		191.11			200.00			(8.89)			191.11	
Web Site Maintenance		2,000.00			1,500.00			500.00			2,000.00	
Dues, Licenses, and Fees		175.00			250.00			(75.00)			175.00	
Stormwater Management		-			10,000.00			(10,000.00)			10,000.00	
General Insurance		3,414.00			3,755.00			(341.00)			3,414.00	
General Repair & Maintenance		-			5,000.00			(5,000.00)			5,000.00	
Total General & Administrative Expenses	$	98,007.49		$	123,955.00	$	(25,947.51)	$	124,003.50	

Total Expenses	
  $	98,007.49		
   $		
123,955.00	
   $	(25,947.51)	 $	124,003.50	
Income (Loss) from Operations	$	(15,382.40)		$	-		$	(15,382.40)		$	(48.50)	
Other Income (Expense)												
Interest Income	$	48.50	$	-	$	48.50	$	48.50	
Total Other Income (Expense)	$	48.50	 	
$	-	$	48.50	$	48.50	
Net Income (Loss)	$	(15,333.90)		$	-		$	(15,333.90)		$	-	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Payment Authorizations 94 -- 98

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorizations 94-98

No. 94	PFM Group	$22,599.07	
No. 95	PFM Group	$2,208.33	
No.96	DEO	$175.00	
No.97	Fishkind & Associates Supervisor Fees	$806.71	
No.98	Vogler Ashton	$395.00	

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 94
9/27/2019

Item
No .

Payee

Invoice	General
No.	Fund

r:

1	PFM Group Consulting
Reimbursables: Aug. 2019

OE-EXP-00428	$	99.07	FY 2019

Tax Roll Preparation and Submission

OE-TR-00003	$ 22,500.00
--
TOTAL	$    22,599.07

99.07
22,500.00

ir 020

RECEIVED SEP 3 0 2019

pfm

Date	Invoice Number September 19, 2019	OE-EXP-00428
Payment Terms		Due Date Upon Receipt	September 19, 2019

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:
Via ACH !preferred):

RE:	August 2019 Fedex - $94.57 August 2019 Postage - $4.50

Total Amount Due

RECEIVED SEP 2 5 2019

�

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

Federal Tax ID: 81-1642478

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

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Pa_ge
2 of 5

 	Invoice Number	
 	6-715-34484	

Account Number
 	0191-4396-1	

FedEx Express Shipment Detail By Payor Type (Original)

The Earned Discount for this ship date has been calculated based on a revenue threshold of$ 236655.67 Fuel Surcharge - FedEx has applied a fuel surcharge of 7.50% to this shipment.
Distance Based Pricing, Zone 2 Package sent from: 32926 zip code

Automation	INET	.Slru!lr	Recipient		
Tracking ID	775965206367	Venessa Ripoll	Ryan Hoppe		
Service Type	FedEx Priority Overnight	Blackburn Creek COD	1777 Main Street		
Package Type	FedEx Envelope	12051 Corporate Blvd	SARASOTA FL 34236 US		
Zone	02	ORLANDO FL 32817 US			
Packages	1				
Rated Weight	N/A	Transportation Charge		24.40	
Delivered	Aug 14, 201909:37	Discount		-2.20	
Svc Area	A4	Earned Discount		-5.86	
Signed by	S.JOHNSON	Automation Bonus Discount		-2.44	
FedEx Use	000000000/186/_	Fuel Surcharge		1.04	
		Total Charge	USO	$14.94	

The Earned Discount for this ship date has been calculated based on a revenue threshold of$ 236655.67 Fuel Surcharge - FedEx has applied a fuel surcharge of 7.50% to this shipment.
Distance Based Pricing, Zone 5

Automation	INET	.Slru!lr	Recipient		
Tracking ID
Service Type Package Type	775971515917
FedEx Standard Overnight FedEx Envelope	Kari Fox
PFM Financial Advisors LLC 116 Jefferson Street South	Adam Torres
S&P Global Ratings 55 Water Street		
Zone	05	HUNTSVILLE AL 35801 US	NEW YORK CITY NY 10041 US		
Packages	1				
Rated Weight	N/A	Transportation Charge		37.76	
Delivered	Aug 14, 2019 09:58	Discount		-3.40	
Svc Area	Al	Earned Discount		-16.04	
Signed by	J.ARMSTRONG	Automation Bonus Discount		-3.78	
FedEx Use	000000000/233/_	Fuel Surcharge		1.09	
		Total Charge	USO	$15.63	

FedEx® Billing Online
FedEx Billing Online allows you to efficiently manage and pay your FedEx invoices online. It's free, easy and secure. FedEx Billing Online helps you streamline your billing process. With all your FedEx shipping information available in one secure online location, you never have to worry about misplacing a paper invoice or sifting through reams of paper to find information for past shipments. Go to fedex.com to sign up today!

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treeA   	
Account Number
0191-4396-1

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 236,962.29

Tracking ID Service Type Zone Packages

775788252660
Ppd, Domestic 06
1

S.mdfil Amanda Lane PFM
12051 Corporate Blvd.

Recipient
LOCKBOX SERVICES-12-2657
U.S. BANK, N.A.-CDD 1200 ENERGY PARK DR

Transportation Charge Earned Discount Performance Pricing
Fuel Surcharge	

9.68
-1.06
-0.59
0.56

Rated Weight Delivered

1 lbs
Jul 23, 2019

ORLANDO FL 32817

EP-MN OlLB
SAINT PAUL MN 55108-5101

Total Charge	USO	$8.59/5

l.1

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 237,144.98. Net Charge represents minimum package charge for this parcel. As a result, full discounts may not apply.
Net charge represents minimum package charge for this parcel.

Tracking ID Service Type

775799055086
Ppd, Domestic

S..eruler
Alan Mishlove

Bec.iJllfil!l
CARLENE DESPARD

Transportation Charge
Fuel Surcharge	

7.85
0.55

Zone Packages Rated Weight Delivered

02
1
1 lbs
Jul 23, 2019

Public Financial Management 12051 Corporate Blvd
ORLANDO FL 32817

AMERIS BANK
1259 W GRANADA BLVD ORMOND BEACH FL 32174-594299

Total Charge	USO	$8.40

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 237,144.98. Net Charge represents minimum package charge for this parcel. As a result, full discounts may not apply.
Net charge represents minimum package charge for this parcel.

Tracking ID	775809987492	hruler	Recipient	Transportation Charge
Service Type	Ppd, Domestic	Alan Mishlove	CARLENE DESPARD		 Fuel Surcharge		 Zone	02	Public Financial Management	AMERIS BANK		Total Charge	USO
Packages	1	12051 Corporate Blvd	1259 W GRANADA BLVD
Rated Weight	1 lbs	ORLANDO FL 32817	ORMOND BEACH FL 32174-594299
Delivered	Jul 25, 2019

7.85
0.55
$8,40

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 237,144.98. Net Charge represents minimum package charge for this parcel. As a result , full discounts may not apply.
Net charge represents minimum package charge for this parcel.

Tracking 10	775815962954		Recipient	Transportation Charge	8.23	
Service Type	Ppd, Domestic	Amanda Lane	Local Government Audits /342	Performance Pricing	-0.38	
Zone	03	PFM	Auditor General	Fuel Surcharge	0.55	
Packages
Rated Weight	1
1 lbs	12051 Corporate Blvd.
ORLANDO FL 32817	111 West Madison Street
Claude Pepper Bldg, Rm 401	Total Charge	USO	$8.40	
Delivered	Jul 26, 2019		TALLAHASSEE FL 32399			
Prepaid Subtotal	USO	$42.19	
Total FedEx Ground	USO	$42.19	

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 	Invoice Number	
 	6-712-76954	

Account Number
 	6339-4889-5	

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FedEx Ground Shipment Summary By Payor Type

08/09	1	1	9.68	0.60	-1.06	9.22	
08/14	2	5	16.98	1.06	-1.86	16.18	
					Ground-Prepaid Subtotal	$25.40	

TOTAL THIS INVOICE	USO	$39.90

FedEx Ground Prepaid Detail (Original)

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 236,251.95

Tracking ID	775949145788	Sender	Recipient	Transportation Charge	9.68	
Service Type	Ppd, Domestic	Amanda Lane	LOCKBOX SERVICES-12-2657	Earned Discount	-1.06	
Zone	06	PFM - Orlando East	U.S. BANK, N.A.- COD	Fuel Surcharge	0.60	

$96.22

Packages	1	12051 Corporate Blvd	1200 ENERGY PARK DR	Total Charge	USD
Actual Weight	0.2 lbs	Orlando FL 32817	EP-MN OlLB
Rated Weight	1 lbs	SAINT PAUL MN 55108-5101
Delivered	Aug 13, 2019	\

. .. .. .. . ..

FedEx® Billing Online
FedEx Billing Online allows you to efficiently manage and pay your FedEx invoices online. It's free, easy and secure. FedEx Billing Online helps you streamline your billing process. With all your FedEx shipping information available in one secure online location, you never have to worry about misplacing a paper invoice or sifting through reams of paper to find information for past shipments. Go to fedex.com to sign up today!

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Invoice Number	"-	Invoice Date	'\.	Account Number	"\		
6-707-40585	I	Aua 15 2019	I	0191-4396-1	I		

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Page 2 of 3

08/02
08/06

2

2

17.91
8.23

1.11
0.55

-2.03
-0.38

FedEx Ground Shipment Summary By Payor Type

  Ground-Prep_aid	

TOTAL THIS INVOICE	USO	$25.39

FedEx Ground Prepaid Detail (Original)

The Earned Discount for this ship date has been calculated based on a revenue threshold of USD 236,110.45
Tracking ID	775906142889	Slndn	Recipient	Transportation Charge	9.68
Service Type	Ppd, Domestic	Amanda Lane	LOCKBOX SERVICES-12-2657	Earned Discount	-1.06

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Zone	06		PFM	U.S. BANK, N.A.- CDD	Performance Pricing	-0.59 12051 Corporate Blvd.	1200 ENERGY PARK DR	Fuel Surcharge		0.56

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ORLANDO FL 32817	EP-MN OlLB	Total Charge	USO	1	$8.59/t-j
SAINT PAUL MN 55108-5101

The Earned Discount for this ship date has been calculated based on a revenue threshold of USD 236,110.45. Net Charge represents minimum package charge for this parcel. As a result, full discounts may not apply.
Net charge represents minimum package charge for this parcel.
Tracking ID	775898996010	Slnl!!r	Recipient	Transportation Charge	8.23
Service Type	Ppd, Domestic	Amanda Lane	Local Government Audits/342	Performance Pricing	-0.38

Packages	1	12051 Corporate Blvd.	111 West Madison Street	Total Charge	USO	
Rated Weight	1 lbs	ORLANDO FL 32817	Claude Pepper Building, Room 401			
Delivered	Aug 05, 2019		TALLAHASSEE FL 32399			

Zone	03	PFM	Auditor General	Fuel Surcharge

$80..5450

FedEx® Billing Online
FedEx Billing Online allows you to efficiently manage and pay your FedEx invoices online. It's free, easy and secure. FedEx Billing Online helps you streamline your billing process. With all your FedEx shipping information available in one secure online location, you never have to worry about misplacing a paper invoice or sifting through reams of paper to find information for past shipments. Go to fedex.com to sign up today!

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 	Invoice Number	
 	6-721-82901	

Page
2 of 3

Account Number
 	6339-4889-5	

FedEx Ground Shipment Summary By Payor Type

08/16
08/20

9.68
8.23

0.60
0.51

-1.06
-0.91
Ground-Prep d Subtotal

9.22
7.83
$17.05

FedEx Ground Miscellaneous Char9_es

TOTAL THIS INVOICE	USO	$31.55

FedEx Ground Prepaid Detail (Original)

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 236,655.67
Tracking ID	776002219710	Sender	Recipient	Transportation Charge	9.68
Service Type	Ppd, Domestic	Amanda Lane	LOCKBOX SERVICES -12-2657	Earned Discount	-1.06

Packages	1	12051 Corporate Blvd	1200 ENERGY PARK DR	Total Charge		
Rated Weight	1 lbs	Orlando FL 32817	EP-MN-01LB			

Zone	06	PFM - Orlando East	U.S. BANK, N.A.- COD	Fuel Surcharge	0.60

USD

J ,3 l

Delivered	Aug 20, 2019	SAINT PAUL MN 55108-5101	\

.	$91/c;

FedEx® Billing Online
FedEx Billing Online allows you to efficiently manage and pay your FedEx invoices online. It's free, easy and secure. FedEx Billing Online helps you streamline your billing process. With all your FedEx shipping information available in one secure online location, you never have to worry about misplacing a paper invoice or sifting through reams of paper to find information for past shipments. Go to fedex.com to sign up today!

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Account Num-ber -
0191-4396-1

The Earned Discount for this ship date has been calculated based on a revenue threshold of S 236110.45 Fuel Surcharge - FedEx has applied a fuel surcharge of 7.50% to this shipment
Distance Based Pricing , Zone 2
FedEx has audited this shipment for correct packages, weight, and service. Any changes made are reflected in the invoice amount. We calculated your charges based on a dimensional weight of 20.0 lbs, 19 in x 13 in x 11 in, using a dimensional factor of 139.

Automation	INET	Se!llw	Recipient		
Tracking IO	775903228488	Melissa Erazo	Bryan T. Havir		
Service Type	FedEx Priority Overnight	Public Financial Management	8230 Old York Rd		
Package Type	Customer Packaging	1735 Market St	ELKINS PARK PA 19027 US		
Zone	02	PHILADELPHIA PA 19103 US			
Packages	1				
Actual Weight	17.0 lbs, 7.7 kgs	Transportation Charge		61.13	
Rated Weight	20.0 lbs, 9.1 kgs	Discount		-5.50	
Delivered	Aug 05, 2019 08:55	Earned Discount		-27.51	
Svc Area	Al	Automation Bonus Discount		-6.11	
Signed by	J.PHIPPS	Fuel Surcharge		1.65	
FedEx Use	000000000/1486/_	Total Charge	USO	$23.66	

Fuel Surcharge - FedEx has applied a fuel surcharge of 7.50% to this shipment. Distance Based Pricing, Zone 2
Package Delivered to Recipient Address - Release Authorized

Automation	INET	Se!llw	Recipient		
Tracking ID
Service Type Package Type
Zone	788907703494
FedEx First Overnight FedEx Envelope
02	Blackburn Creek CDD
Public Financial Management 12051 Corporate Blvd ORLANDO FL 32817 US	Pete Williams
5439 Bold Venture Pl
WESLEY CHAPEL FL 33544 US		
Packages	1				
Rated Weight	N/A	Transportation Charge		54.40	
Delivered	Aug 06, 2019 09:05	Fuel Surcharge		4.41	
Svc Area	A5	Residential Delivery		4.40	
Signed by	see above	Courier Picku e		0.00	
FedEx Use		000000000/3/02		Total Charge	USO	$63.21	
			USO	$173.08	

The Earned Discount for this ship date has been calculated based on a revenue threshold of$ 236110.45 Fuel Surcharge - FedEx has applied a fuel surcharge of 7.50% to this shipment.
Distance Based Pricing, Zone 3

Automation
Tracking ID	SSFO
788799244485	.Sewllt
Ciara Meyers	Recipient
Sarah K. Sanders		
Service Type	FedEx Priority Overnight	Public Financial Management	State Of Connecticut		
Package Type	Customer Packaging	1735 Market Street	55 Elm Street		
Zone	03	PHILADELPHIA PA 19103 US	HARTFORD CT 06106 US		
Packages	1				
Rated Weight	19.0 lbs, 8.6 kgs	Transportation Charge		86.36	
Delivered	Jul 31, 2019 09:07	Discount		-7.77	
Svc Area	Al	Earned Discount		-38.86	
Signed by	J.LESTER	Automation Bonus Discount		-8.64	
FedEx Use	000000000/1508/_	Fuel Surcharge		2.33	
		Total Cha!:9.e	USO	$33.42	
			Third Party Subtotal	USO	$33.42	
			Total FedEx Express	USO	$206.50	

\QCL	t), U;

r'\	Cre,e l

FuEx ®

I	Invoice Number	'\
6-101-4o5s5	1

Invoice Date  '\ CAccount Number	Pa_g_e
I	Aug 15, 2019	I	0191-4396-1	3 of 3

The Earned Discount for this ship date has been calculated based on a revenue threshold of USO 236,251.95. Net Charge represents minimum package charge for this parcel. As a result, full discounts may not apply.
Net charge represents minimum package charge for this parcel.

Tracking ID	775912011209	.Stndlr	Recipient	Transportation Charge	8.23	
Service Type	Ppd, Domestic	Amanda Lane	Local Government Audits/342	Performance Pricing	-0.38	
Zone	03	PFM	Auditor General	    Fuel Surcharge		0.55	
Packages Rated Weight Delivered	1
1 lbs
Aug 07, 2019	12051 Corporate Blvd.
ORLANDO FL 32817	111 West Madison Street
Claude Pepper Building, Room 401 TALLAHASSEE FL 32399	Total Charge	USO	$8.40	
Prepaid Subtotal	USO	$25.39	
Total FedEx Ground	USO	$25.39	

pitney bowes0

Account Summary Report

Date Range: August 1, 2019 to August 31, 2019
Meter Group: All Meters
Meter 1WOO - 1376538 OLD at ORLANDO, FL
 Meter 4W00 - 0347354 at ORLANDO, FL	

Meter Details
Lll!mll!n

I	-...,.,..me  Isertal Nymba[ l P l!P 41PNot Nymb@r I

ORLANDO, FL

4W00 - 0347354

0347354	24978470

ORLANDO, FL	I WOO - 1376538 OLD 1376538	24978470

Account Summary
Aaount	Sub AIX:oiint
Blackburn Creek COD

Pieces	I	T otal Cha

$4.500

Grand Total	$4.500

pfm
BilJTtf:	Gompa11y Address:

RECEIVED SEP 2 4 2019

1735 Market Street

Blackburn Creek COD
o PFM Group Consulting District Accounting Department

43rd Floor Philadelphia, PA 19103
+1 (215) 567-6100

rlando, FL 32817

12051 Corporate Blvd	Federal Tax ID: 81-1642478
United States of America

Remittance Options:

_,____.....,  � _____ ________

-�----------.....................................

_,,_

.____,

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

RE:	Preparation and Submission for FY2020 Tax Roll

Total Amount Due	$22,500.00

of	1

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 95
10/4/2019

Item
No.

Payee

Invoice	General
No.	Fund

1	PFM Group Consulting DM Fee: Sep. 2019 Website Fee: Sep. 2019

DM-09-2019-0006	$	2,083.33	FY 2019
DM-09-2019-0007	$	125.00	FY 2019
-
TOTAL	i 2,208.33 
2,208.33	I	FY 2019

1J;;)

RECEIVED OCT O 6 2019

pfm

Upon Receipt	September24 , 2019

Blackburn Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd Orlando, FL32817 United States of America

RECEIVED SEP 3 0 2019

1735 Market Street
43 rd Floor Philadelphia, PA19103
+1 (215 )567-6100

Federal Tax ID:81-1642478

@'i���'811111*'$�...

PFM Group Consulting LLC PO Box65126
Baltimore, MD21264-5126 United States of America

RE:	District Management- September, 2019

Total Amount Due	$2,083 33

1	of	1

pfm

Blackburn Creek COD
c/o PFM Group Consulting District Accounting Department
12051 Corporate Blvd Orlando, FL32817 United States of America

,m��

Remittance Options:

RECEIVED SEP 3 0 2019

1735 Market Street
43 rd Floor Philadelphia, PA19103
+1 (215 )567-6100

Federal Tax ID:81-1642478

PFM Group Consulting LLC PO Box65126
Baltimore, MD21264-5126 United States of America

RE:	Website Fee- September, 2019

Total Amount Due

1	of	1

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 96
10/11/2019

Item
No.

Payee	Invoice
No.

General
Fund

Fiscal
Year

1	Department of Economic Opportunity
FY 2019/2020 Special District Fee	74534	$	175.00	

 	TOTAL	$	175.00 

1/.

175.00

RECE\VEO OCl \ 2 2019

Florlda Department of Economic Opportunity, Special District Accountability Program
FY 2019/2020 Special District Fee Invoice and Update Form
Required by Sections 189.064 and 189.018, Florida Statutes, and Chapter 73C-24, Florida Administrative Code

Invoice No.: 74534			Date Invoiced: 10/01/2019	
Annual Fee: $175.00	Late Fee: $0.00	Received: _1_0.00	Total Due, Postmarked by 12/02/2019: $175.0g	

STEP 1: Review the following information, make changes directly on the form, and sign and date:
Special District's Name, Registered Agent's Name, and Registered Office Address:

Blackburn Creek Community Development District
Dr. Hank Fishkind
12051 Corporate Boulevard
Orlando, Fl 32817

D

· ··········

.......

FLORIDA DS.PARTMENT of
£CONOMtC OPPORTUNITY

Telephone:
Fax:
Email:
Status:
Governing Body:
Website Address:
County(ies):
Function(s):
Boundary Map on File:
Creation Document on FIie:
Date Established:
Creation Method:
Local Governing Authority:
Creation Document(s):
Statutory Authority:

(407) 302 325e- '=l z.,3 - s	tJo
(407) 2 a2 Tt3- stto I
  r,ltf@fisl,kit,d.eom	L A-/J E A ef	.{?"" . l>t'Yl
Independent Elected
blackburncreekcdd.com Sarasota
Community Development 12/16/2011
12/16/2011
11/09/2010
Local Ordinance Sarasota County
County Ordinance 2010-070
Chapter 190, Florida Statutes

Authority to Issue Bonds:
Revenue Source(s):
Most Recent Update:

Yes Assessments 10/14/2018

ENTERED	OCT 162019

I do hereby certify that the information above (changes noted if necessary) is accurate and complete as of this date. Registered Agent's Signature:	 		Date	I D-1 LI - I Gj
STEP 2: Pay the annual fee or certify eligibility for the zero fee:
	Pay the Annual Fee: Pay the annual fee online by following the instructions at www.Floridajobs.org/SpecialDistrictFee or by check payable to the Department of Economic Opportunity.
Or, Certify Eligibility for the Zero Fee:  By initialing each of the following items, I, the above signed registered agent, do hereby certify that to the best of my knowledge and belief, ALL of the following statements contained herein and on any attachments hereto are true, correct, complete, and made in good faith as of this date. I understand that any information I give may be verified.

1. 	

2.  
3.  

This special district and its Certified Public Accountant determined the special district is not a component unit of a local general-purpose government.
This special district is in compliance with the reporting requirements of the Department of Financial Services.
This special district reported $3,000 or less in annual revenues to the Department of Financial Services on its Fiscal Year 2017/2018 Annual Financial Report (if created since then, attach an income statement verifying $3,000 or less in revenues).

Department Use Only: Approved:  

Denied:   

Reason: 	_

STEP 3: Make a copy of this form for your records.
STEP 4: Mail this form and payment (if paying by check) to the Department of Economic Opportunity, Bureau of Budget Management, 107 E. Madison Street, MSC 120, Tallahassee, FL 32399-4124. Direct any questions to (850) 717-8430.
RECEIVED OCT O 3 2019

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 97
10/18/2019

Item	Payee	Invoice	General	Fiscal
No.	No.	Fund	Year

 	

F¥2oi!'l

' F, t'.20®,

_'!!: ·i=n o20

-,

Fishkind & Associates

Conference Calls	24622	$	6.71

FY 2019

Supervisor  Fees -10/09/2019 Meeting	I
Dale Weidemiller	-	$	200.00
Pete Williams	-	$	200.00
John Blakley	-	$	200.00
Kevin Johnson	-	$	200.00
-
TOTAL	$ 	806.71 

6.71	FY 2019

800.00	

Chairman I Vice Chairman

RECEIVED OCT 1 8 2019

..	""

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

FISHKIND
& ASSOCIATES

Blackburn Creek COD 12051 Corporate Blvd.
Orlando, FL 32817

File: BlackburnCreekDM
DM

RECEIVED OCT 1 5 2019

Invoice

10/15/2019

Invoice #: 124622

Blackburn Creek COD

Services:	Amount
Conference Calls	6.71

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

Balance Due	$6.71

1• nvo1• ce
INVOICE NUMBER INVOICE DATE ACCOUNT NO, DUE DATE
TAXID
AMOUNT DUE

PAGE 4
28442160
09/26/2019
85735742
10/26/2019
58-2421656

   BILLING REF# 1	
BtLUNG REF#4				
BILLING REF# 2	BILLING REF# 3		
CONF. NO	COST CENTER	CONF. DATE	CONF. TITLE/ NAME/ ANI	TIME	SERVICE	ACCESS TYPE	PERSONS	UNITS	RATE	CHARGE	TAX	CALL TOTAL	
	. "	)8/29/2019	19546548547	6:26PM • 8:45PM	GLOBALMEn@ AUDIO	,ou FREE	1	139	o.oo/MIN	0.00	p.00	

1).00	
	--;J_d)J. )I \	)8/29/2019	13865270621	6:34PM • 8:02PM	GlOBALMEET® AUDIO	TOLL FREE	1	88	o . o o/M 1N	0.00	p.oo		
		P8/29/2019	14072053629	6: 38PM • 8: 45PM	GLOBAlMEET©	AUDIO	-	OLLfRH	-	1	127	0.00/MIN	0.00	p.oo		
124713997		'	\ x{)		P9/11/2019	19417131116-	12: 10 PM • 12:28PM	GLOBA i.MEET( A VOIO	Oll FREE	=	1	1 8	o . oo/ MIN	0.00	t>.oo	0 .71
p.oo	
	-  - r'il.vVn·O-1V	p9/lt/2019	19413281111	12 ·10 PM • 12:35PM	GLOBAi.MEET® AUDIO	OlL FREE	1	'? 5	0.00/MIN	0.00	t,.oo		
	'r)V"'	P9/11/2019	12158456540	12:12PM • 12:30PM	IGL09ALMH :r @ AUDIO	OLL fRH	l	18	0 .00 / MIN	0.00	[1.00		
124713997			P9/ll/2019	15164106075	12 :4 7PM • 1:14PM	GLOBAlMEET@AUDIO	OLL FREE	1	27	o.oo/MIN	0.00	p,oo	

p.oo	
			P9/1t/20t9	19417131116	12:S)PM • 2:01PM	GLOBALMEU© Auo,o	OlL FREE	1	68	o.oo/MIN	0.00	p.00		
	.J.;;;4-!!.	;;;.	p9/11I2019	19413281111	12:54PM • 2:01PM	GLOBAlMEET® AUDIO	Oll FREE	I	67	o.oo/MIN	0.00	b.oo		
	-		P9/tt/2019	n158456540	12: 56PM	2:01PM	GL08AlME£T@ AUDIO	Oll FREE	1	65	o . oo/ MIN	0.00	i,.oo		
			P9/ll/2019	194,720,605	12: 59PM • 1:35PM	GL08ALMEET@ AUDIO	Oll FREE	1	36	o.oo/M1N	0.00	p.oo		
		09/11/2019	19417488080	12 : 59PM • 1:! 4PM	GLOBAlME£T® AUDIO	OLL FRH	t	15	O.OD/MIN	0.00	p.o o		
			P9/11/2019	18132233919	1:04PM • 2:03P M	GlOBAlMEET© AUDIO	OLL fRH	1	59	o.oo/MIN	0.00	o.oo		
	L	P9/ll/2019	18139651268	1: 22PM - 2:06PM	GtOBAlMEET@ AUDIO	Oll FREE	l	44	o.oo/MtN	0.00	1).00		
124713997

I
ti		09/lJ/2019	18132239400	10:5 8AM • I 1: 41AM	GLOBAlMEET® AuOIO	Olt FREE	I	43	o.oo/MtN	0.00	o.oo	

0.00	
		09/13/2019	1214651S358	10:58AM • 11 :H AM	GL08AI.MHT© AUDIO	OlL fREE	1	43	o.oo/MIN	0.00	0.00		
		09/13/2019	12158456540	10: 59AM • 11:41AM	GLOBAlMEET© AUDIO	OLL FREE	1	42	o.oo/MIN	0.00	o.oo		
124713997			-"y	,,	09/24/2019	16094180384	10:57AM • 12: 23PM	GLOBAi.MEET(!) AUDIO	OlL FREE	1	86	o .oo/ MIN	0.00	o.oo	

0.00	
	Ji	09/24/2019	19413599000	10:59AM • 12:29PM	GLOOAI.MEET@ AUDIO	OlL FREE	t	90	o.oo/MIN	0.00	,.oo		
	'\V--	D9/24/2019	19789473433	11 : 46 AM · 12 :0 7PM	Gl08AlMHT@ AUDIO	,OLL FREE	1	21	o.oo/MtN	0.00	0.00		

USD$577.17

MODERATOR

40323156-Vivian Carvalho (continued)	LOCATION

TOTAL PRE•TAX	0,00	TOTAL USF/OTHER	0,00	TOTAL STATE TAX/OTHER	o.oo	TOTAL MODERATOR CHARGES	USl>So.oo

Blackburn Creek COMMUNITY DEVELOPMENT DISTRICT

Date of Meeting: October 9, 2019

($200.00 per Supervisor per Meeting)

Board Members:	Present	Absent	Fee	

Dale Weidemiller			Jt ;;;.oo.oo	
Pete Williams	V	:ii,;J.oo,, oa
John Blakley	-	-1h9-60	60

Kevin Johnson	d/;Q.cm.oo

Vacant

 	 	
Total:	$	-	Oi)

! J(J.a1el£a el2

Approved For Payment:

Chairman / Secretary

October 9, 2019
Date

RECEIVED OCT 1 7 2019

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 98

10/25/2019

Item	Payee	Invoice	General	Fiscal	
No.		No.	Fund	Year	

1	
Vogler Ashton				
	General Legal 09/01/2019 - 09/30/2019	4947	$	118.50		
	General Legal 10/01/2019 - 10/15/2019	4947	$	276.50		
					
		TOTAL	$	395.00		
			
118.50	

 	FY 2019	
			276.50	➔t  t4•2@)	

cf?

�
Chairman I Vice Chairman

RECEIVED OCT 2 8 2019

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

	Page 1	
Blackburn Creek Community Development District		10/22/2019	
c/o Neal Communities of Southwest	Account No	1-33006	
Florida, LLC	Statement No	4947	

Sarasota FL 34240
us
Attn District Manager

S"lackburn Creek COD District Counsel

RECEIVED OCT 2 2 2019

For Legal Services Rendered September 1, 2019, through October 15, 2019 (45-day billing cycle)

Previous Balance	$237.00

Fees

	Hours		
09/04/2019				
KA	Review draft agenda and file for any agenda items	0.20	79 00	
09/25/2019				
KA	Review draft agenda	0.10	39.50	
10/03/2019				
KA	Review agenda and documents: Review ADA services agreement	0.40	158.00	
10/08/2019
KA	
Review final revised Agenda Packet	
-0-.3-·0	-1-1-8.50	

For Current Services Rendered	1 .00	395.00

Timekeeper Kimberly Ashton

Total Current Work

Recap,tulatlon

Hours 1.00

F3at	Total
$395.00	$395.00

395 00

Pa}'.:m_  l)1§.

10/21/2019	Payment	-237 00

Balance Due	$395.00

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Payment Authorization No. 99
11/1/2019

Item No.

Payee

Invoice	General	Fiscal
No.	Fund	Year

PFM Group Consulting OM Fee: October 2019 Website Fee: October 2019

DM-10-2019-0010	$	2,083.33
DM-10-2019-0011	$	125.00
-

--FY 2019

TOTAL	$    2,208.33 

 IL	
Secretary I Assistant Secretary

2,208.33

RECEIVED NOV O 4 2019

pfm

Date		Invoice Number October 29, 2019	DM-10-2019-0010
Payment Terms		Due Date Upon Receipt	October 29, 2019

Bill To:

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

Remittance Options:
Via ACH rorefen:edl:	�

RE:	District Management Fee: October 2019

Total Amount Due

RECEIVED OCT 3 0 2019

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

Federal Tax ID: 81-1642478

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

$2,083.33

1	of	1

pfm

Date		Invoice Number October 29, 2019	DM-10-2019-0011
Payment Terms		Due Date Upon Receipt	October 29, 2019

Bill To:

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

RECEIVED OCT 3 0 2019

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 - October 2019

Total Amount Due

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

1	of	1

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2018-113 – 2018-114

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2018-113 — 2018-114

2018-113	Ferguson Waterworks	$1,538.68	
2018-114	Forsberg Construction, Inc.	$80,563.80	

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

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 20I3 (the "Master Indenture"), as amended and supplemented by the Third Supplemental Trust lndenture from the District to the Trustee, dated as of March I, 2018 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2018-113

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

Amount Payable:	$1,538.68

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 the construction of Grand Palm, Phase 2B East. PO# 190301; 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 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

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

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

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or 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 2018 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding 2018 Capital Improvement Plan segment and portion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the report of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as  such report shall have been amended or modified on the date hereof.
Consulting Engineer ½

Grand Palm Phase 2B East
Ferguson Waterworks Invoice Summary

 	Invoice #	Invoice Amount	
 	1432196	$1,538.68	
$1,538.68

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

Please contact with Questions: 800-456-1488

SE? 1 6 2019	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1439882	$1,538.68	42174	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 PH2B EAST
C/O FORSBERG CONSTRUCTION PO#190301
PUNTA GORDA, FL 33950

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190301 - 12" GV

SALESMAN

TAE

JOB NAME

GRAND PALM PH2B EAST

INVOICE DATE

09/09/19

BATCH
10
81658

ORDERED

1

SHIPPED

1

ITEM NUMBER

1461SW

DESCRIPTION
Source Order#: 1423661
2PC SC Cl VLV BX 19-22 WTR

UNIT PRICE

95.000

UM	AMOUNT
EA ,V

95.00

2 SSLCE12AP
1	1 AFC2612DLAFMM

12 PVC WDG REST 'ONELOK WIA
12 DIMJ RW OL SS STEM VLV UA

INVOICE SUB-TOTAL

83.720
1276.237

EA Yv
EA

167.44
1276.24

1538.68

LEAD LAWWI RNING: IT IS ILLE1 AL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I DR OTHER APPLI( ABLE LAW INPOTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH 'NP INTHE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI  APPLICATIONS.   UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTIO.N

Thank you for your business

TERMS:	CASH ON DEMAND	ORIGINAL INVOICE

TOTAL DUE	$1,538.68

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.

PURCHASE ORDER No.	 	19030/	

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.forsbergconstruction.com

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

Job No.: I 9-03

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 28 East

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

Quantity	Unit	Description	Unit Price	Total Price	
						
I	LS	Pip, e  Valves, Fittings and Appurtenances in accordance	$	105,836 .55		$	105,836.55	
		with Exhibit "A" (paqes 1-3)				

						

						

						

						
		Prices are aood for duration of the project.				
						
		Project Duration: April 15, 20 19 - April 15, 2020				
Total Project Subtotal	s	105,836 .5 5	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax@ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	10,5 836.55	

Attention: Tyler Evenson

Vendor Phone: _:9_4..:...1.:-...-=--62=-.4.:..-.-3=-...4:.....9.:4.....:..__    _   _
VendorFax:	941-627-3519

_ _  _  _  _ _

X

.	�W	Eu-1.,._ r""-

ent {signatur e)

Date

Authorized Agent (signature)

Ferguson Waterworks	Blackburn Creek COD

'-I fj-1/ lo/
Date

Authorized j\ ent (printed/typed) Page 		of	2

! IMPORTANT!
*SEESPECIAL PROVISIONS ABOVE
ADDITIONAL TERMSANO CONDITIONS ON P/JGE 2

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

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. All items supplied without prior approval. that do not meet Project requirements, will 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 will be required to hold over until thefollowing work day to be unloaded. Purchaser will not beresponsible 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, sha ll have the right to procure said materials elsewhere without further responsibility to Vendor.

Quantities are approximate and subject to proje ct requirements.

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

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

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

I 1. Neither party will change, after, nor subst itut e any part of this Purchase Order without consent of the opposite party. All changes so agreed to shall be initialed and dated by authorized agents of both parties.

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

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

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

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

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

I 7. In the event any of these terms are declared to be unenforceable by a court of competent jurisdiction, then Purchaser and Vendor intend for the remaining terms and conditions to remain in full force and effect.

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

Page

2  of	2	Ferguson /nitia		Blackburn Creek COD lntita-l -

FERGUSON®
WATERWORKS

FEI-PT. CHARLOTTE WW 1705 18305 PAULSON DRIVE

pellverTo: GREGG
from:	Tyler A Evenson omments:

PORT CHARLOTTE, FL 33954-0000

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

14:59:57 APR 12 2019	Page 1 of 3

FEI-PORT CHARLOTTE #1705
Price Quotation Phone: 941-624-3494
Fax: 941-627-3519

Bid No:	B249276	Cust Phone: 941-637-8500
Bid Date:	04/12/19	Terms:	2% 10TH NET 25TH
Quoted By: TAE

Customer:	BLACKBURN CREEK COMMUNITY	Ship To:

BLACKBURN CREEK COMMUNITY GRAND PALM

GRAND	PALM	PH2BEAST	PH2BEAST
C/O FORSBERG CONSTRUCTION	C/O FORSBERG CONSTRUCTION
PUNTA GORDA, FL 33950	PUNTA GORDA, FL 33950

Cust PO#:	Job Name:	GRAND PALM PH2BEAST

Item	Description	Quantity	Net Price	UM	Total
WASTEWATER •
======================-===		
-  8"  PVC GRAV SVVR-		
SDR26HWSPX14	8X14 SDR26 HW PVC GJ SWR PIPE	1582	3.980	FT	6296.36	
PD3105G4737	3X1000 UG DET SWR GREE	2	28.000	EA	56 .00	
SUBTOTAL				6352.36	
- DBL SWR SRV (43} -					
MUL067248	8X6 PVC HW SWR GXGXG WYE	43	47.530	EA	2043 .79	
MUL067376	6 PVC HW SWR GXS 45 ELL	129	13.471	EA	1737.76	
MUL067326	6 PVC HW SWR GXG 45 ELL	43	18.245	EA	784.54	
MUL067277	6 PVC HW SWR GXG DBL WYE	43	68.265	EA	2935.40	
MUL040952	6 PVC SVVR HUB FEM CO ADPT	43	11.726	EA	504.22	
MUL040958	6 PVC SVVR REC THRO CO PLUG	43	8.951	EA	384 .89	
MUL043988	6 PVC SWR GSKT CAP	129	6.930	EA	893 .97	
SDR26HWSPU14	6X14 SDR26 HW PVC GJ SWR PIPE	1806	2.220	FT	4009.32	
CYPSKPX	2X4X8 YELL PINE STUD	43	3.000	EA	1 29.00	
PD3105G4737	3X1000 UG DET SWR GREE	2	28.000	EA	56 . 00	
SUBTOTAL				13478.89	

TOTAL WASTEWATER 	19831.25

DR18BPX PD3105652737 C1230BHS500 SPWPC8

* WATER MAIN•
=========-================
8" PVC WTR MAIN -

2120	6.701	FT	14 206.12	
3	28.000	EA	84.00	
5	89.000	EA	445.00	
35	50.050	EA	1751.75	
			16486.87	

8 C900 DR18 PVC GJ BLUE PIPE
3X1000 UG DET WTR BLUE
12GA 30MM 500 FT COP TRCR WIRE BLUE
8 SIGMA BELL REST F/ C900 •PVLOK
SUBTOTAL

8" GATE VLV ASSM (2)-

Sd FERGUSON
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax:941-627-3519

Page 2 of 3

14:59:57 APR 12 2019
Reference No: B249276

Item	Description	Quantity	Net Price	UM	Total

AFC2608DLAFMM	
8 DI MJ RWOL SS STEM VLV UA	
2		
647.000	
EA	
1294.00	
SSLCESAP	8 PVC WDG REST •ONELOK W/A	4		46.150	EA	184.60	
I461SW	2PC SC Cl VLV BX 19-22 WTR	2		95.000	EA	190.00	
RBGVTMX	3 BRSGATE VLV ID- 8	2		13.000	EA	26.00	
	SUBTOTAL					1694.60	
	-12" WATER MAIN·						
DR18BP12	12 C900 OR18 PVC GJ BLUE PIPE	720		
13.650	FT	
9828.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1		28 .000	EA	28.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2		89 .000	EA	178.00	
SPWPC12	12 SIGMA BELL REST F/ C900 •PVLOK	15		106.140	EA	1592.10	
	SUBTOTAL					11626.10	
	-12" FITTINGS·						
MJTLA12	12 MJ C153 TEE UA	1		242.940	EA	242.94	
MJSP12	12 MJ C153 SLD PLUG	1		84.680	EA	84.68	
MJ4LA12	12 MJ C153 45 BEND UA	3		141.090	EA	423.27	
MJ2LA12	12 MJ C153 22-1/2 BEND UA	4		130 . 565	EA	522.26	
SSLCE12AP	12 PVC WDG REST *ONELOK W/A	17		83.720	EA	1423.24	
IMJBGP12	12 MJ C153 BLT GSKT PK UGLAND	1		22 .000	EA	22.00	
	SUBTOTAL					2718.39	
PED11B1450	14X50 DIPS DR11HOPE PIPE BL STRIPE	250		4420 .000	C	11050.00	
C1245BEHS500	12GA 45MM 500 FT COP TRCR WJRE BLUE	1		148 .000	EA	148.00	
SP-J230141230	14 SS INS F/ HOPE DIPS SDR11	2		182.400	EA	364.80	
	SUBTOTAL					11562.80	
MJRLA1412	14X12 MJ C153 RED UA	2		186.735	EA	373.47	
SSLCE14AP	14 PVC WDGREST *ONELOK W/A	2		154.300	EA	308.60	
SSLCE12AP	12 PVC WDG REST •ONELOK W/A	2		83.720	EA	167.44	
	SUBTOTAL					849.51	

	- TIE INTO EXIST (2) •		
FBLSLAX	8X12 MJ C110LONG SLV UA	2	112.090	EA	

224.18
SSLCE8AP	8 PVCWDG REST *ONELOK W/A	4	46.150	EA	184.60	
	SUBTOTAL				408.78	

FBLSLA12	12X12 MJ C110 LONG SLV UA	2	279.660	EA	
SSLCE12AP	12 PVC WDG REST *ONELOK W/A	4	83 .720	EA	

559.32

SUBTOTAL

- 12' GATE VLV ASSM (2) -				894.20	
12 DI MJ RW OL SS STEM VLV UA	2	1276 .237	EA	2552.47	
12 PVC WDG REST *ONELOK W/A	4	83.720	EA	334.88	
2PC SC Ct VLV BX 19-22 WTR	2	95.000	EA	190.00	
3 BRS GATE VLV 10 - 12	2	13.000	EA	26.00	
SUBTOTAL				3103.35	
- FIRE HYO ASSM (3) •					
8X6 MJ C153 SWVL TEE UA	3	122.790	EA	
368.37	
8 PVC WDG REST *ONELOK W/A	6	46.160	EA	276.96	
6 MJ C153 BLT GSKT PK UGLAND	3	12.700	EA	38.10	
6 DI MJRWOl SS STEM VLV LJA	3	406 . 555	EA	1219.67	
2PC SC Cl VLV BX 19-22 WTR	3	95.000	EA	285.00	
3 BRS GATE VLV ID · 6	3	13 .000	EA	39.00	
6 C900 DR18 PVC GJ BLUE PIPE	40	3.860	FT	154.40	

334.88

AFC26120LAFMM SSLCE12AP I461SW RBGVTM12

MJSTLAXU SSLCE8AP IMJBGPU AFC2606DLAFMM
1461SW
RBGVTMU DR18BPU

FERGUSON
WATERWORKS

14:59:57 APR 12 2019
Reference No: B249276

Item	Description

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Quantity	Net Price	UM	Total

Page 3 of3

SSLCE6.AP
AFCB84BLAOLP

F202B962CC4 FFB10004NL

6 PVC WbG REST •oNELOK W/A
/4 VO B848 HYO 4'0 OL UA
SUBTOTAL

SINGLE SHORT (42) -

8X1 CC DBL STRP BRZ SOL DI/AC LF 1 CCX CTS PJ BALL CORP

6	34.040	204.24
3	1425.000	EA	4275.00
6660.74
42	102.610    EA	4309.62
42	50.240   EA	2110.08

PEC9BG300	•EXc 1X300 CTS OR9 HOPE BLUE PIPE	900	40.000	C	360.00	
PEC9BG100	*EXC 1X100 CTS DR9 HOPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	42	87.340	EA	3668 .28	
FINSERT52	1 CTS PET/ HOPE OR9 INS STFNR	84	1.260	EA	105.84	
CYPSKPX	2X4X8 YELL PINE STUD	42	3.000	EA	126.00	
CWA03111812	11X18X12 BX W/ Cl RDR LID SUD	42	68.000	EA	2856.00	
	SUBTOTAL				13781.82	
	- SINGLE LONG (44) -					
F202B962CC4	8X1 CC DBL STRP BRZ SOL DI/AC	44	102.610	EA	4514.84	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	44	50.240	EA	2210.56	
PEC9BG300	•EXC 1X300 CTS DR9 HDPE BLUE PIPE	2400	40.000	C	960.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	5	89.000	EA	445 .00	
P03105B52737	3X1000 UG DET WTR BLUE	3	28.000	EA	84.00	
FBA43444VVNL	LF 1 CTS X MTR ANG BV	44	87.340	EA	3842.96	
FINSERT52	1 CTS PET / HOPE DR9 INS STFNR	88	1.260	EA	110.88	
CYPSKPX	2X4X8 YELL PINE STUD	44	3.000	EA	132.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	44	68.000	EA	2992 .00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	1320	0.550	FT	726.00	
	SUBTOTAL				16018.24	
Net Total:	$105836.65	
Tax:	$0.00	
Freight:	$0.00	
Total:	$105836.65	

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 IMMEOIATELY FOR ASSISTANCE WITH DBE/MBE/WBE/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 Buye'rs acceptance of Seller's terms and conditions, which are incorporatedby reference and found either following this document, or
on the web at https://Www.ferguson.com/content/website-info/terms--osfale Govt Buyers: All Items are open market 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:

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 patt of a public work. [Copy of Certificate of Entitlement is attached].

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

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

CERTIFICATE OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 190301 from Ferguson Waterworks (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2B fu!fil.,

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.:

/1.ou nust initial each of the following requirements.
The attached Purchase Order is issued directly to the vendor supplying the tangible personal pr  ty thCeontractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.

§_

Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from public funds.
Governmental Entity will take title to the tangible personal property from the vendor at the time of p  a  e orof delivery by the vendor.
Governmental Entity assumes the risk of damage or loss at the time of purchase or delivery by the
vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does notqualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

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

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

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

Its: _	_	G,,=-'-"//, A.;;..:..t_;;c -	==-- -	-	-	DATE: l	cf/J-51/5

Federal Employer Identification Number	'

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

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

Blackburn Creek Community Development District
FORM OF REQUISITION FOR 2018 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 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 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);

Requisition Number:

Name of Payee:

Amount Payable:

2018-114

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

$80,563.80

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, ifapplicable):

Grand Palm, Phase 2B East Application No. 5 (See attached Invoice). This Application for Payment is approved based on a site and observation ofwork.

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

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

Blackburn Creek Community Development District

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

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

B		- 
Authonzed Officer

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

If this requisition is for a disbursement from  other than Costs oflssuance,  or for payment of capitalized interest, the undersigned Consulting Engineer here by 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 specificat ions for the corresponding 2018 Capital Improvement Plan seg ment an d po1tion of the 2018 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the repott of the Cons ultin g Engineer attached as an Exhibit to the Third Supplemental 1ndenture, as such report shall have been amended or modified on the date hereof.

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 28 East (COD Portion)

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

NTP DATE
ContractTim SUBSTANTIA FINAL

CONTRACTO	.

e
L

R	5

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

Forsberg Construction, Inc. 645 Charlotte Street
Punta Gorda, FL 33950	
FOR WORK COMPLETED FROM	9/1/2019	TO	9/30/2019	

CONTRACT PAYMENT SUMMARY

Original Contract Amount (CHANGE ORDER #8) Change Orders:	1,197,472.00	
Change Order Summary		
Number	Date Approved	Additive	Deductive		
		.			
		.			
		.			
		.			
Subtota ls	.	.		
Net Change Order Subtotal (Additive less Deductive)	.	
Current Contract Amount (Original Amount+ CO's)	I,197,472.00	

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

64%
5%	1,080,700.00
310,298.12
770,401.88
38,520.09	97%

71%
5,%	I, 165,50 4.00
310,298.12
855,205.88
42,760.29		
Net Earned (Total earned minus retainage)		731,881.78 /		812,445.58	812,445.58	
Total Previous Estimates					731,881.78	
AMOUNT DUE THIS PERIOD					80,563.80	

CERTIFICATION OF CONTRACTOR
The undersigned Contractor hereby swears under penalty of perjury that ( I ) all previous progress payments received from the Owner on acco unt 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 incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interestsand encumbrances; and (3) all Work covered by this Applicationfor Payment is in accordance with the Contract Documents and not defective as that term is defined in the Contract Documents.

Ashly Westre	Forsberg Construction, Inc.
Notary Public, State of Florida	645 Charlotte Street
My Commission expires August 23, 2020	Punta Gorda, Florida 33950
Sworn and subscribed to me this	Phone (941) 637-8500
2nd day ofOctober AD 2019		Fax (941) 639-1073 (STAMP I SEAL)	
Paymen t of the above AMOUNT DUE T HIS APPLICATION is recommended.

Engineer Owner

DATE

10J1/ l't	
/ [ Oct Z6J

Project:	Grand  Palm Phase  2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	91112019
Engineer:	Kimley.Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	9/3012019	

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

2	910	30"RCP	348 i LF	84.00	29,232.00	348.0	29,232.00	0.00	.	348.00	29,232.00	100.00%	
3	910	l36"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	O.OOi	.	177.00	26,727.00	100.00%	
5	910	34"x53"RCP	i	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	o.oo·	.	3.001	10,200.00 "	100.00%	
7	910	Type "F" Inlet 36" x 48 11 (inside size)	2	EA	4,200.00	8,400.00  I	2.0	8,400.00	O.OOj	.	2.00'	8,400.00 i	100.00%	
8	910	T""e "F" Inlet 42" x 6011 (inside size)	i 	2	EA	6,900.00	13,800.00 ;	2.0	13,800.00	0.001	-	2.001	13,800.00 i	100.00%	
9	910	Tvne "M" Inlet 36" x 48 11 (inside size)	2	EA	4,200.00	8,400.00 i	2.0	8,400.00	0.00	-	2.00t	8,400.00 I	100.00%	
10	910	Type "M" Inlet 42" x 60" (inside size)	4	EA	6,900.00	27,600.00  i	4.0	27,600.00	0.00	.-	4.00	27,600.00 i	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" Bared 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	JOO.DO	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 cJeanout	.	EA	450.00	.	0.0	-	0.00	.	0.00	.	100.00%	
20	910	6" Underdrain plug	.	EA	50.00	-	o.o	.	0.00	.	0.00	.	100.00%	
21	910	Modified Type "F' curb	3,230	LF	10.80	34,884.00	0.0	-	3230.00	34,884.00	3230.00	34,884.00	100.00%	
22	910	Type "M" curb, includes all transitions	4,550	LF	10.80	49,140.00	0.0	.	I 4550.00	49,140.00	4550.00	49,140.00	100.00¾	
23

1	910

960	Curb ramp	1 i EA	780.0!

5,600.00	22,400.00	4.0	22,400.00	0.00	-	4.00	22,400.00	100.00	
					
		Manholes 0' - 6'	4; EA		
2	960	Manholes 6' • 8'	4' EA	6,200.00	24,800.00	4.0	24,800.00	0.00	.	4.00	24,800.00	100.00¾	
3	960	Manholes 8' • I0'	I	EA	7,000.00	7,000.00	1.0	7,000.00	0.00	.	1.00	7,000.00	100.00¾	
4	960 !8" PVC (SDR 26) Gravitv Sewer 0' • 6'	230	LF	34.00	7,820.00	230.0	7,820.00	o.oo:	.	230.00	7,820.00 '	100.00¾	
5	960	8" PVC (SDR 26) Gravity Sewer 6' • 8'	680	LF i	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'	70.00	46,690.00	667.0	46,690.00	0.00i	-	667.00i	46,690.00  I	100.00¾	
7	960	Double sewer service	43	EA i	1,500.00	64,500.00	43.0	64,500.00	0.00	.	43.00	64,500.00	100.00¾	
8	960	Connection to existing gravity sewer	'	2	EA	6,600.00	13,200.00	2.0	13,200.00	0.00	.
·•-	•I2°.00	13,200.00	100.00%	
9	960	Testing of g,avity sewer	I	1,577	LF:	4.00	6,308.00	0.0	.	0.00	-	0.00%	
											
2,120	LF	28.00	59,360.00	21Z0.0	59,360.00	0.00	•	2120.00	59,360.00	100.00%	
2	I 1010	12" PVC DR-18, C900 Water Main	720	LF	44.00 I	31,680.00	720.0	31,680.00 I	0.00	.	720.00	31,680.00	100.00%	
3	1010	14" SDRl1 Directinnal Drill	250	LF	220.00'	55,000.00	250.0	55,000.00 i	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	1211 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	.
o.oo:	.	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		42.00	42,000.00 ,	100.00%	

-

Project:	Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	9/112019	
Engineer:	JGmley-Horn and Associates, Inc.	Punta Gordai FL 33950	To:	9/30/2019	

PREVIOUS WORK

WORK THlS PERIOD

WORK TO DATE

ITEM NO.
.. 8

CODES
1010

DESCRIPTION OF WORK
ISin\;le water service (Lon )
ITie-in to existing Water Main
!Pressure testing of main
bacte ologica
11	..
Florida Trench Safety Act

UNIT

CONTRACT

QUAN  JNIT
441  EA I
4	EA I
3;090 I LF

PRICE

TOTAL

QTY

VALUE

QTY

VALUE

 	

1,200.00 I 	52,800.00 '	44,0! 	52,800.00 	0.00	.	44.00' 	52,800.00 '

QTY	VALUE

2,500.00 i	10,000.00

 	0.00,	- 

2.10·1.. 	6,489.00	0.01

.. 	2.0!	5,000.00 

PERCENT COMPLETE
%
..   00
50.0-0%-

...

-

0.00

-

    2.00	5,000.00

0.00

-

'

0.00%

··.h,
!I _;,. I

3,090
' f - ',.\ %

LF

1.90 i	 5,871.00 

'',,,;;i it t

.,

i;· ,.

o.o,

! 	,:1 tE

 	- 
:, ; ;· ,.r ii!l'/1

 0.00!	-	o.ooj·	-	0.00%

..

'

1 LS

'

100.00i

100.00 '

l.O!

100.00

0.001

-

•..

_;iiili
1.001
1.00•

..

." ;,; : -

'"

100.00 ,	100.00%

2
4
5
6

53,020.00  ! -	 	1.0	53,020.00 - - . 0.001

-

53,020.00 I	100.00%

'

''

'

 	25,600.00   I	
8,300.00 I so,000.00 I
1,197.472.00

1.0	25,600.00 	0.00[   

0.0,
1.0!

-
50,000.oo I
I 080,700.00

.. . -

.-- .

 	1:001	25,600.00  I 	100.00%

O.OOj
0.00[

-

- .. I
I
I

o.ooi
1.001

-.   ': 	0.00%

84,804.00

50,000.00 i	100.00%
1,165,504.00	97.33%

Summary of Work Classitications

9	1010	
lO	1010	

I	

1260	

910	Material Price Increases for 2019	IILS	.?.3,020.00	
260	Construction stakeout	liL§	 	   25,600.00-	
260	Record drawings/ As-Built Survey	'	l;LS	I	8,300.00	
510	Mobilization	:	JiLS	I	50,000.00	
	TOTAL			

PHASE3C		
DRAINAGE	$	540,974.00	$	456,170.00	$	84,804.00	$	540,974.00	100.00%	
SANITARY SEWER	$	228,078.00	$	221,770.00	$	.	$	221,770.00	97.23%	
WATER DISTRIBUTION	$	291,400.00	$	274,040.00	$	-	$	274,040.00	94.04%	
MISCELLANEOUS	$	137,020.00	$	128,720.00	$	-	$	128,720.00	93.94%	
TOTAL	
$ 1,197,472.00	
$ 1,080,700.00	
$	84,804.00	$  1,165,504.00	97.33%	

Project:   Grand Palm Phase 2B East (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from;	9/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL  33950	To:	9/3012019	

ITEM NO.	
DESCRIPTION OFWORK	

QUAN	

'INIT	MATERIAL UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK IBIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
	I.a DRAINAGE (excludes FDOT final nine insN ction) I					I		I	I	
1	24"RCP		221	LF	24.78	5,476.38	221.00	5,476.38		0.00:	.	221.00	5,476.38 '	100.00%	
2	30" RCP	I	348	LF	I	35.13	12,225.24	348.00	12,225.24		0.001	.	348.00	12,225.24	100.00%	
3	36" RCP	1,211	LF I	48.73	59,012.03	1211.00	59,012.03		0.001	.	'	1211.00	59,012.03	100.00%	
4	42" RCP	177	LF		62.92 I	11,136.84		177.00	11,136.84	0.00	-	177.00	11,136.84	100.00%	
5	34"x53"RCP	475	LF		106.41 :	50,544.75		475.00	50,544.75 :	0.00		.	'	475.00	50,544.75	100.00%	
6	iGrated Swale Inlet	3	EA		2,369.40.	7,108.20	3.00	7,108.20 i	0.00	.	3.00	7,108.20	100.00%	
7	Type "F" Inlet 36" x 48" (inside size)	2, EA	1,943.04	3,886.08	2.00	3,886.08 I	0.00	.	2.00.'	3,886.08	100.00o/o	
8	:Tvne "F" Inlet 42" x 60" (inside size)	2 'EA	1,943.04	3,886.08	2.00	3,886.08	0.00	.	2.001	3,886.08	100.00%	
9	T'\IT'le "M" Inlet 36" x 43« (inside size)	2	'EA	1,986.40	3,972.80		2.00	3,972.80	0.00	.	2.00	3,972.80 ,	100.00%	
JO	Type "M" Inlet 42" x 60" (inside size)	4	EA	1,986.40	7,945.60		4.00	7,945.60	0.00	.	4.00	7,945.60,	100.00%	
11	30" Flared End Section	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	3	EA	1,562.00	4,686.00		3.oo·	4,686.00	0.00	.	3.00	4,686.00 I	100.00%	
13	42" Flared End Section	I	EA	1,809.50	1,809.50	1.00	1,809.50	0.00	.	1.00	1,809.50	100.00%	
14	34"x53" Flared End Section	2	EA	1,962.10	3,924.20	2.00	3,924.20	0.00	.	2.00	3,924.20	100.00%	
15	Small Control Structure		3	EA	2,339.89	7,019.67	3.00	7,019.67	0.00	-	3.00	7,019.67	100.00%	
16	Construct Swale		360	LF	.	.	360.00	.	0.00	.	360.00	.	100.00%	
17	Rio-Rao for Bubbler Structures		23	SY	.	.	23.00	.		0.00	-	23.00	.	100.00%	
18	611  Roadside underdrain	-	LF	.	-	0.00	-	'	0.00		-	i	0.00	-	100.00%	
19	Underdrain cleanout	.	EA	.	-	0.00	.	0.00	.	0.00	.	100.00%	
20	6" Underdrain olug	.	EA		.	.	;	0.00		.	'	0.00	.	0.00	.	100.00%	
21	Modified TvnP "F" curb	3,230	LF		.	'	.	0.00	-	3230.00	.	3230.00i	.	100.00%	
22	T,me "M" curb, includes all transitions	4,550	LF	.	.	0.00	.	4550.00	.	4550.00'	.	!	100,00%	
23	Curb ramo		Ii	EA	.	-	0.00	-	1.00	.	1.00		.		100,00%	
	'.J.b	SANITARY SEWER	i								:	
I	Manholes 01       6'
-		4;	EA	1,577.15	6,308.60	4.00	6,308.60	0.00	.	4.00	6,308.60 :	100.00%	
2	!Manholes 6'   81		4'	EA	1,782.43	7,129.72		4.00	7,129.72	0.00	.	4.00	7,129.72  ,	100.00%	
3	Manholes 8' - 10'	Ii EA	1,791.22	1,791.22		1.00	1,791.22	0.00	.	1.00	1,791.22	100.00"/4	
4	8' PVC (SDR 26) Gravitv Sewer 0' • 6'	230 i LF	3.97	913.10		230.00	913.10	0.00	.	230.00	913.10	100.00"/4	
5	8" PVC (SDR 26) Gravity Sewer 6' - 8'	680	LF	3.97	2,699,60	680.00	2,699.60	0.00	.	680.00	2,699.60	100.00"/4	
6	8' PVC (SDR 26) Gravity Sewer 8' - 10'	667	LF	3.97	2,647.99	667.00	2,647.99		o.oo'	.	'	667.00	2,647.99	100.00"/4	
7	Double sewer service	43	EA	313.46	13,478.78	43.00	13,478.78	0.00		.	'
43.00	13,478,78	100.00"/o	
8	Connection to existing gravity sewer	2	EA	.	.	2.00	.	0,00		-	2.00	.	0.00"/,	
9	Testina of gravity sewer	1,577	LF '	-	.	0.00		-	!	0,00	.	0.00	.	0.00o/,	
	Le WATERDISTRIBUTION	'			''						
I	8" PVCDR-18, C900 Water Main	2,120	LF	7.78	16,493.60	2120.00	16,493,60 '	0.00	.	2120.00·	16,493.60	100.00o/o	
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" SDRII Directional Drill	250	LF	49.65	12,412.50	250.00	12,412.50	0.00	.	250.00	12,412.50	100.00%	
4	811 Gate valve and valve box	2 i EA	847.30	1,694.60	2.00	1,694.60	0.00	.	2.00	1,694,60	100.00%	
5	12" Gate valve and valve box	2 I EA	1,551.68	3,103.36	2.00	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	0.00		.	3.00	6,860.73	100.00o/o	

10/2/l019	Page 1 of2	Material Purchased by CDD

Project:   Grand Palm Phase 2B East (CDD Portion}	Forsberg Construction, Inc.	Pay Request No.	5	
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	9/1/2019	
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	9/30/2019	

..

ITEM NO.
7
8
9

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

QUAN
42
44
4

MATERIAL UNIT PRICE
328.14
364.05
325.75

PURCHASE ORDER TOTAL
13,781.88
16,018.20
1,303.00

PREVIOUS WORK

WORK nns PERIOD

WORK TO DATE

fJNTT EA I EA
EA

QTY
42.00
44.00
4.00

VALUE

QTY

VALUE

QTY

PERCENT COMPLETE
%

I
I

13,781.88, 	O.OOi 

-

I

16,018.20
1,303.00

o.oo:

o.oo,

.

.

I 	44.00 

42.001 -

VALUE
     13,781.88 
    16,018.20 I 1,303.00

100.00%

1_00.00%

•·---

';

4.001

100.00%
6,847.96 ! 	I00.00%

(I) EA

3,532.04

(3,532.04)!
292,734.08   I

-1.00 -
$

3,532.o4 I
292,734.08  I

0.00

$

-

$

-

,_1.00,-
$

3,532.04 I
292,734.08

3,i29.37 ,

1oq:
100.00% I00.00%

Summary

Ferguson Waterworks
Cast Systems County Materials 6% State Sales Tax

$	98,901.78
$	45,918.60
$	147,913.70
$	17,564.04

$	98,901.78
$	45,918.60
$	147,913.70
$	17,564.04

$
$
$
$

-
-

TOTAL

$	310,298.12

$	310,298.12

$

-
-

-

$	98,901.78
$	45,918.60
$	147,913.70
$	17,564.04

100.00%
100.00%
100.00%
100.00%

$	310,298.12	100.00%

(I)	EA	6,847.96	(6,847.96 I	-1.00 •	6,847.96	o.oo:	.	!	-1.00,'-	
(I)	EA	3,129.37	(3,129.37)1	-1.00 -	3,129.37	0.00	.	I	-1.001-	

10/21:2019	Pagel ofl	Material Purchased by CDD

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratification of Requisitions 2019-36 -- 2019-52

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Ratifications of Requisitions 2019-36 -- 2019-52

2019-36	Ferguson Waterworks	$89,222.30	
2019-37	Forsberg Construction, Inc	$159,895.94	
2019-38	Ferguson Waterworks	$3,660.42	
2019-39	Ferguson Waterworks	$13,452.57	
2019-40	Forsberg Waterworks	$180,646.37	
2019-41	Ferguson Waterworks	$288.00	
2019-42	Cast Systems, LLC	$2,815.28	
2019-43	Ferguson Waterworks	$7,673.37	
2019-44	Cast Systems LLC	$12,500.48	
2019-45	Country Materials Corp	$10,991.92	
2019-46	Country Materials Corp	$1,562.00	
2019-47	Cast Systems LLC	$3,761.39	
2019-48	Ferguson Waterworks	$484.00	
2019-49	Country Materials	$11,144.86	
2019-50	Kimley Horn	$6,152.08	
2019-51	Ferguson Waterworks	$9,430.00	
2019-52	County Materials Corp	$27,448.40	

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 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-36

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

$89,222.30

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 lB(a) Application No. 1 (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 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in co1111ection 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 Accow1t 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

Autho'edOfficer	:

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

wJk.w..

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby certifies that this disbursement is for a Cost of the 2019 Capital Improvement Plan, which Cost does not exceed the amount specified for the category of improvement as set forth on Exhibit D to the Third Supplemental Indenture, and is consistent with: (i) the applicable acquisition or construction contract; (ii) the plans and specifications for the corresponding2019 Capita l 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 repo1t shall  have been amended or modified on the date hereof.

Consulting Engineer

...

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase lBa (COD Portion)

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

NTPDATE
Contract Tim SUBSTANTIA FINAL

CONTRACTO	.

e L

R	1

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	8/1/2019	TO	8/31/2019	

CONTRACT PAYMENT SUMMARY

Original Contract Amount (CHANGE ORDER #6)
Change Orders:	755,053.00	
Change Order Summary		
Number	Date Anoroved	Additive	Deductive		
		-			
		-			
		-			
		-			
Subtotals	-	-		
Net Change Order Subtotal (Additive less Deductive)	-	
Current Contract Amount (Original Amount + CO's)	755,053.00	
	Previous Status	Current Status		
Value of Work in Place
Value of Material Purchased by Owner Tota l Earned(% & $)
Retainage (% & $)	

0%
5%	-
-
-
-	15%

12%
5%	116,735.00
22,8 1 6.79
93,9 18.21
4,695.91		
Net Earned (Total earned minus retainage)		-		89,222.30	89,222.30	
Total Previous Estimates					-	
AMOUNT DUE THIS PERIOD					89,222.30	

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 app lied by the undersignedto discharge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered O through O 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, secur ity 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.

Notary Public, State of Florida

My Commission expires Auglt&'..;itJ"l(J'N).V..,...,l"'rl"Y'V'""' 'VV'V'I
Sworn and subscribed to me 5th day of September AD 20

(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.

SIGNATURE	DATE

Engineer Owner

Project:	Grand Palm Phase lBa (COD Portion)	Forsberg Construction, Inc.	Pay Request No.	1	
Owner:	Blackburn Creek COD	645 Charlotte Street	For work from:	8/1/2019	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

TAL

1,760.00

7
8
9
IO 11
15
16
17

I

1
I
I I I

I

PREVIOUS WORK	WORK TillS PERIOD	WORK TO DATE	PERCENT
COMPLETE

2		910	24" RCP	I		611 i	LF1	65.00	39,715.00	0.0	-	403.00		
3		910	30" RCP	I		173	LF	84.00	14,532.00	0.0	-	0.00	-	0.00'	-	0.00%1	
																
4		910	36" RCP		472	LF !	116.00	54,752.00	0.0	-	60.00	6,960.00	60.00i	6,960.00 '	12.71%I	
5		910	Grated Swale Inlet		I	EA	3,400.00	3,400.00	0.0	-	0.00	-	0.001	-	i	0.00%	
																
6	I		910	Type "M" Inlet 36" x 48" (inside size)		5	EA	4,200.00	21,000.00	0.0	-	i	3.00	12,600.00	3.00•	12,600.00 '	60.00%	

QTY	VALUE		QTY	VALUE	QTY	VALUE 0.0		-		32.00

910	Type "M" Inlet 42" x 60" (inside size)	2	EA	6,900.00	13,800.00	0.0	-	i	0.00	-	0.00	-	0.00%	
													
910	24"FlaredEndSection	2	EA	4,100.00	8,200.00	0.0	-	2.00	8,200.00	2.00I	8,200.00 i	100.00%	
910	30" Flared End Section	I	EA	4,500.00	4,500.00	0.0	-	0.00	-	0.00	-	0.00%	
910	36"FlaredEndSection	3	EA	5,800.00	17,400.00	0.0	-	1.00	5,800.00	1.00	5,800.00	33.33%	
910	Small Control Strocture	I	EA	5,600.00	5,600.00	0.0	-	0.00	-	0.00	-	0.00%	
910	Modified Type "F" curb (Islands)	220	LF	16.20	3,564.00	0.0	-	i	0.00	-	0.00	-	0.00%	
													
910	Type "M" curb, includes all transitions	4,420	LF	10.80	47,736.00	0.0	-	0.00	-	0.00	-	0.00%	
910	Curb ramp	4	EA	780.00	3,120.00	0.0	-	0.00					

'

960	Manholes 0' - 6'	4	EA	5,600.00	22,400.00	0.0	-	0.00	-	0.00	-	0.00%
2	I	960	Manholes 6' - 8'	4	EA	6,200.00	24,800.00	0.0	-	0.00	-	0.00	-	0.00%
3	960	Manholes 10' - 12'	2    EA	7,800.00	15,600.00	0.0	-	0.00	-	0.00	-	0.00%
4	960	8" PVC (SDR 26) Gravity Sewer 0' - 6'	788	LF	34.00	26,792.00	0.0	-	0.00	-	0.00	-	0.00%
5	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	553	LF	52.00	28,756.00	0.0	-	0.00!	-	0.00	-	0.00%
6	960	8" PVC (SDR 26) Gravity Sewer 8' - 10'	280	LF	70.00	19,600.00	0.0	-	0.001	-	0.00	-	0.00%
7	960	7,,'   ~ ,-~	., ~	-,	-	382	LF	87.00	33,234.00	0.0	-	0.00	-	0.00	-	0.00%
8	960	Single Sewer Service	4	LF	1,500.00 '	6,000.00	0.0	-	0.00	-	1	0.001	-	I	0.00%
9	960	Double sewer service	26    EA	1,500.00 I	39,000.00	0.0,	-	0.00	-	'	0.00,	-	0.00%

IO	960	Connection to existing gravity sewer	I	EA	6,600.00	6,600.00	0.0	-	0.00	-	I	0.001	-	!	0.00%
11	960	Open Cut Restoration and MOT	I	LS	11,300.00	11,300.00	0.0	-	0.00
12	960	Testing of gravity sewer	2,003	LF	4.00	8,012.00	0.0	-	0.00

1010	4"PVCDR-18,C900WaterMain	520 I   LF	24.00	12,480.00	0.0	-	0.00	-	0.00	-	0.00%
2	1010	8" PVC DR-18, C900 Water Main	1,960 i LF	28.00	54,880.00	0.0	-	0.00	-	0.00	-	O:iJOo/,
3	1010	4" Gate valve and valve box	2 ,  EA	1,500.00	3,000.00	0.0	-	0.00	-	0.00	-	0.00%
4	1010	8" Gate valve and valve box	4 i        EA	2,000.00	8,000.00	0.0	-	0.00	-	0.00	-	0.00%
5	1010	8"x8" Tapping Sleeve and Valve	2 ! EA	7,800.00	15,600.00	0.0	-	0.00	-	0.00	-	0.00%
6	1010	Blowoff Assembly	I	EA	1,200.00	1,200.00	0.0	-	0.00	-	0.00	-	0.00%
7	1010	HG-2 Automatic Flushing Device	I	EA	7,400.00	7,400.00	0.0	-	0.00	-	0.00	-	0.00%
8	I      1010	Fire Hydrant Assembly	2    EA	6,000.00	12,000.00	0.0	-	0.00	-	0.00	-	0.00%
9	i      1010	Single water service (Short)	34	EA	1,000.00	34,000.00	0.0	-	0.00I	-	0.00	-	0.00%
IO	1010	Singlewaterservice(Long)	22	EA	1,200.00	26,400.00	0.0	-	0.00'	-	1	0.00,	-	'	0.00%
11	i  1010	Tie-in to existing Water Main	2    EA	2,500.00	5,000.00	0.0	-	0.00	-	0.00[	-	0.00%
12	1010	Pressuretestingofmain	2,480	LF	2.10	5,208.00	0.0i	-	0.00	-	0.00i	-	i	0.00%
13	I      1010	Chlorination and bacteriological	2,480	LF	1.90	4,712.00	0.0!	-	0.00	-	0.00i	-	i	0.00%

Project: Owner: Engineer:

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

UNIT

Forsberg Construction, Inc.

								

645 Charlotte Street Punta Gorda, FL 33950

PREVIOUS WORK

VALUE

CONTRACT

WORK THIS PERIOD

Pay Request No. For work from: To:

WORK TO DATE

1
8/1/2019
8/31/2019

PERCENT COMPLETE

	LS	'	100.00	100.00	0.0i		100.00	1.00	100.00%	
	260	Construction stakeout	I	LS		25,600.00	25,600.00	0.0i	 	0.20	5,WOO 1	0.20	20.00%	
4	260	Record dr-;;wings / As-Built Survey	I	LS		8,300.00	8,300.00 _	0.0i	0.00		 	0.00		 	0.00%	
5	510	Mobilization	I   LS	50,000.00	50,000.00	0.0I 	1.00
 	TOTAL		755,053.00
Summary of Work Classifications	50,000.00 I
116,735.00	LOO!	50,000.00	100.00%1
 	  116,735.00	15.46%	

			

PHASE JC		
DRAINAGE	$	239,079.00	$	$	61,515.00	$	61,515.00	25.73%1	
SANITARY SEWER	$	242,094.00	$	$	$	0.00%
WATER DISTRIBUTION	$	189,880.00	$	$	$	0.00%
MISCELLANEOUS	$	84,000.00	$	$	55,220.00	$	55,220.00	65.74%1
TOTAL	$	755,053.00	$	$	116,735.00	$	116,735.00	15.46%	

PRICE

TOTAL

_QTY

VALUE

_Q_TY	VALUE	%

 	

	

						

Project:    Grand Palm Phase !Ba (CDD Portion)	Forsberg C nstruction, Inc.	Pay Request No.	1
Owner:    Blackburn Creek CDD	645 Chai-lotte Street	For work from:	8/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL  33950	To:	8/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

k™IT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
l  I.a    DRAINAGE (excludes FDOT final pipe insoection)i						.		
1	118" RCP	32	LF			16.05	513.60	0.00	-	32.00	513.60	32.00i	513.60	100.00%	
2	124" RCP	611	LF '	24.65	15,061.15	0.00	.	403.00	9,933.95	403.00	9,933.95	65.96%	
3	30" RCP	173	LF	35.33		6,I 12.09 I	0.00	-	0.00	-	0.00	-	0.00%	
4	36" RCP			472	i LF			48.53:	22,906.16 .	0.00	-	60.00	2,911.80	60.00	2,'.)l 1.80 .	12.71%	
5	Grated Swale Inlet	I 'EA		650.54 •	650.54 ;	0.00	.	0.00	.	0.00	.	I	0.00%	
6	Tvne "M" Inlet 36" x 48" (inside size)	5 • EA		1,526.64 :	7,633.20 ;	0.00	-	3.00	4,579.92	3.00	4,579.92 I	60.00%	
7	Type "M" Inlet 42" x 60" (inside size)			2	i EA		1,526.64	3,053.28	0.00	-	0.00	-	0.00	.	0.00%	
8	24" Flared End Section	2 I EA	1,012.00	2,024.00	0.00		.	'	2.00	2,024.00	2.00	2,024.00 1	100.00%	
9	30" Flared End Section	1 I EA	1,315.40	1,315.40	0.00		.		0.00	.	0.00	.	0.00%	
10	36" Flared End Section	3	EA	1,562.00	4,686.00	0.00		.		1.00	1,562.00 '	1.00	1,562.00	33.33%	
11	Small Control Structure	1	EA	1,847.74	1,847.74	0.00		-		0.00	.	0.00	.	0.00%	
	Lb SANITARY SEWER												
I	Manholes 0'. 6'	4	EA	1,537.21	6,148.84	0.00	-	0.00	-	0.00	-	0.00%	
2	Manholes 6' - 8'	i	4	EA	1,754.51	7,018.04	0.00	-	0.00	-	0.00	-	0.00%	
3	Manholes  10' - 12'	'		2	EA	2,249.77	4,499.54	0.00	.	0.00	-	0.00	-	0.00%	
4	8" PVC (SDR 26) Gravity Sewer 0' - 6'		788	LF	4.06	3,199.28		0.00!	-	0.00	.	0.001	.	0.00%	
5	8" PVC (SDR 26) Gravity Sewer 6' - 8'		553	LF		!	4.06	2,245.18		0.00,	.	0.00	-	o.oo:	-	0.00%	
6	8" PVC (SDR 26) Gravity Sewer 8' - 10'	280	LF			4.06	1,136.80	0.00	-	0.00	..-	0.00i	-	0.00%	
7	18" PVC (SDR 26) Gravity Sewer 10' - 12'		382	LF			4.06	1,550.92	0.00	-	0.00	-	0.00	-	i	0.00%	
8	iSingle Sewer Service	4	LF			273.52	1,094.08	0.00	-	0.00	-		0.00 1	-	I	0.00%	
9	!Double sewer service	26	EA	314.29	8,171.54	0.00	-	0.00	-	0.00	-	I	0.00%	
	Le WATER DISTRIBUTION											
I	4" PVC DR-18, C900 Water Main	520	LF	3.19	1,658.80	0.00	-	0.00	-	0.00	-	0.00%	
2	8" PVC DR-18, C900 Water Main	1,960	LF	9.30	18,228.00	0.00	-	0.00	-	0.00	-	0.00%	
3	4" Gate valve and valve box	2	EA	484.41	968.82	0.00	-	0.00	-	0.00	-	0.00%	
4	8" Gate valve and valve box	4	EA		847.30 I	3,389.20	0.00	-	0.00	-	!	0.00	-	0.00%	
5	8"x8" Tapping Sleeve and Valve	2	EA	1,770.06	'	3,540.12	0.00		-		0.00	-	0.00	-	0.00%	
8	Fire Hydrant Assembly			2	EA		2,274.03	4,548.06	0.00		-		0.00	-	0.00	-	0.00%	
9	Single water service (Short)			34	EA		319.96	10,878.64	0.00		-		0.00	-	I	0.00	-	0.00%	
10	Single water service (Long)			22	EA		365.73		8,046.06	0.00	-	0.00	--	0.00	-	0.00%	
11		2	EA	107.80			0.00	-	0.00	-	0.00	-	0.00%	
	Tie-in to existing Water Main					215.60								
TOTAL	$	152,340.68	$	-	$	21,525.27	$	21,525.27	14.13%	

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

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

$	-
$	-
$	-
$	-			

$	-
$	4,579.92
$	16,945.35
$	1,291.52		

$	-
$	4,579.92
$	16,945.35
$	1,291.52	

0.00%
14.85%
32.20%
14.13%	

'

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

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

ITNIT	MATERIAL
UNIT PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK THIS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETE
%	
	TOTAL				$	161,481.12	$	-	$	22,816.79	$	22,816.79	14.13%	

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

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the 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 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:

2019-37

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

Amount Payable:	$159,895.94

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 2A(e) 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 incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has  not  previously been paid].

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

Blackburn Creek Community Development District

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

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

Attached hereto are originals of the invoice(s) from the  vendor of the  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 ofissuance, or for payment of cap italized 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 lrnprovement 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 E xh ibit to the Third Supplemental lndenture, as such report shall have been amended or modified on the date hereof

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase 2Ae (CDD Portion)

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

NTPDATE
Contract Time SUBSTANTIAL FINAL

CONTRACTOR	5

November 26, 2018
330 Days
October 22, 2019
November 19, 2019

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

CONTRACTPAYMENTSUMMARY

Original Co ntract Amount Change Orders:	1,615,661.00	
Change Order Summarv		
Number	Date Annroved	Additive	Deductive		
		-			
		-			
		-			
		-			
Subtota ls	-	.		
Net Change Order Subtotal (Additive less Deductive)	-	
Current Contract Amount (Original Amount+ CO's)	1,615,661.00	

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

58%
5%	1,282,177.00
344,865. 18
937,311.82
46,865.59	91%	1,469,593.00
363,969.66
68%	1,105,623.34
5%	55,281.17		
Net Earned (Total earned minus retainage)		890,446.23	J,050,342. 17	1,050,342.17	
Total Previous Estimates				890,446.23	
AMOUNT DUE THIS PERIOD				159,895 .94	

CERTIFICATION  OF CONTRACTOR
The undersigned Contractor hereby swears under penalty of perjury that (I) all previous progress payments received from the Owner on account of Work performed under the Contract referred to above have been applied by the undersigned to discharge in full all obligations of undersigned incurred in connection with Work covered by prior Applications for Payment numbered I through 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 interestsand 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.

CONTRACTOR

Ashly Wester
Notary Public, State of Florida

My Commission expires Aug;	Y	JA.N 'Y"Y'.t"w'V V' V"	._,..._,.__,,.,.,
Sworn and subscribed to me t 5th day of September AD 201

(STAMP / SEAL)

onstruction, Inc.
645 Charlotte Street
Punta Gorda, Florida 33950 Phone (941) 637-8500
Fax (941) 639-1073

Payment of the above AMOUNT DUE THIS APPLICATION  is recommended.

SIGNATURE	DATE

Engineer Owner

Project:	Grand Palm Phase 2Ae (CDD Portion)	Forsberg,Construction, Inc.	Pay Request No.	5	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	8/1/2019	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

PERCENT COMPLETE

i

	I	
	960	Manholes O' - 6'	6	EA	5,600.00	33,600.00	6.0	33,600.00	0.00		6.00:	33,600.00 I	100.00%	
2	960	Manholes 6' - 8'	7	EA	6,200.00	43,400.00	7.0	43,400.00	0.00		7.00'	43,400.00 .	100.00%	
3	960	Manholes 8' - IO'	3	EA	7,000.00	21,000.00	3.0	21,000.00	0.00		3.ool	21,000.0Q_ I	100.00%	
4	960	Manholes IO' - 12'	I	EA	7,800.00	7,800.00	1.0	7,800.00	0.00		1.00'	7,800.00 !	100.00%	
5	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%	
6	960	8" PVC (SDR 26) Gravity Sewer 0' - 6'	1,135	LF	34.00	38,590.00	1135.0	38,590.00	0.00		1135.00'	38,590.00 I	100.00%	
7	!	960	8" PVC (SDR 26) Gravity Sewer 6' - 8'	1,328	LF	52.00	69,056.00	1328.0	69,056.00	0.00		1328.00	69,056.00	100.00%	
8	'	960	8" PVC (SDR 26) Gravity Sewer 8' - IO'	603	LF	70.00	42,210.00	603.0	42,210.00	0.00		603.00	42,210.00	100.00%	

	
I1,330.00	
206.0	
11,330.00	
0.00	
206.00	
11,330.00	
2		910	24"RCP	481	LF	65.00	31,265.00	481.0	31,265.00	0.00		481.00	31,265.00	100.00%	
3		910	l30" RCP	427	LF	84.00	35,868.00	427.0	35,868.00	0.00		427.00	35,868.00	100.00%	
4	910	36"RCP	1,023	LF	I16.00	118,668.00	1023.0	118,668.00	I	0.00		1023.00	118,668.00	100.00%	
5	
I	910	42" RCP	571	LF	151.00	86,221.00	571.0	86,221.00	0.00		571.00	86,221.00	100.00%	
6		910	48"RCP	447	LF	226.00	101,022.00
13,600.00	447.0	101,022.00	0.00		447.00	101,022.00	100.00%	
7	
i	910	Grated Swale Inlet	4	EA	3,400.00		
4.0	13,600.00	0.00		
4.00	13,600.00	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)	6	EA	4,200.00	25,200.00	6.0	25,200.00	0.00		6.001	25,200.00	100.00%	
10		910	Type "M" Inlet 42" x 60" (inside size)	8	EA	6,900.00	55,200.00	8.0	55,200.00	0.00		8.00i	55,200.00	100.00%	
11		910	30" Flared End Section	2	EA	4,500.00	9,000.00	2.0	9,000.00	0.00		2.001	9,000.00	100.00%	
12	910	36" Flared End Section	4	EA	5,800.00	23,200.00	4.0	23,200.00	0.00		4.00!	23,200.00 '	100.00%	
13	910	42" Flared End Section	3	EA	6,600.00	19,800.00	3.0	19,800.00	0.00		3.00,	19,800.00	100.00%	
14	910	48" Flared End Section	3	EA	9,200.00	27,600.00	3.0	27,600.00	0.00		3.oo!	27,600.00	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	70	SY	100.00	7,000.00	0.0	70.00	7,000.00	10.001	7,000.00	100.00%	
20	910	Modified Type "F" curb	320	LF	10.80	3,456.00	0.0	-··~	0.00		o.oo:		0.00%	
21	910		8,400	LF	10.80		
0.0	0.00			0.00%	
		Type "M" curb				90,720.00				o.oo:		
22	910	Curb ramp	7	EA	780.00	5,460.00	0.0	0.00		0.001	0.00%	

9			960	8" PVC (SDR 26) Gravity Sewer 10' - 12'	387	LF	87.00	33,669.00	387.0	33,669.00	0.00		387.00	33,669.00	100.00%	
10			960	8" PVC (SDR 26) Gravity Sewer 12' - 14'	344	LF	101.00	34,744.00	344.ol	34,744.00	0.00		344.00	34,744.00	100.00%	
I1			960	8" PVC (SDR 26) Gravity Sewer 14' - 16'	271	LF	130.00	35,230.00	211.01	35,230.00	0.00		271.00	35,230.00	100.00%	
12	'			960	Single sewer service	IO	EA	1,500.00	15,000.00	9.0'	13,500.00	1.00	1,500.00	10.00	15,000.00	100.00%	
13	I

1	!
2
3
4
5	960
960

1010
JOJO
1010
1010
1010	Double sewer service
Connection to existing gravity sewer Testing of gravity sewer

8" PVC DR-18, C900 Water Main
8" Gate valve and valve box Fire Hydrant Assembly Single water service (Short) Single water service (Long)	54
3
4,068

4,840
10
5
76
42	EA EA LF

LF EA EA EA EA	1,500.00
6,600.00
4.00

28.00
2,000.00
6,000.00
1,000.00
1,200.00	81,000.00
19,800.00
16,272.00

135,520.00
20,000.00
30,000.00
76,000.00
50,400.00	39.0i
3.0t
0.0i

4388.0
9.0
5.0
0.0
0.0	58,500.00
19,800.00

122,864.00
18,000.00
30,000.00	15.00
0.00
0.00

452.00! LOOI
I	0.00
76.00
42.00	22,500.00

76,000.00
50,400.00 I	54.00
3.00

5.00
76.00
42.00	81,000.00
19,800.00

30,000.00
76,000.00
50,400.00	100.00%
100.00%

100.00%
100.00%
100.00%	

,

9/S/2019	Page 1 of2	Schedule of Values

Project:	Grand Palm Phase 2Ae (COD Portion)	Forsberg Construction, Inc.	Pay Request No.	5	
Owner:	Blackburn Creek CDD	645 Charlotte Street	For work from:	8/1/2019	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

PREVIOUS WORK	WORK THIS PERIOD	WORK TO DATE	PERCENT
ITEM
NO.		
CODES	DESCRIPTION
OFWORK	
QUAN >TN!T	UNIT
PRICE	CONTRACT
TOTAL	
QTY	
VALUE	
QTY	
VALUE	
QTY	
VALUE	COMPLETE
%	
6	I		JOJO	Tie-intoexistingWaterMain	2 EA:	2,500.00	5,000.00	I.QI	2,500.00 ·	o.oo,		-	I.00i	2,500.00 I	50.00%	
7	I   JOJO	Pressure••d;ncrofmain	4,840	LF  i	2.10	J0,164.00	0.01	-	o.ooi	-	0.001	-	I	0.00%
8	I    !OW	Chforinationand	· ·	·	4,840.  LF	196.	•	o:o!	-	0.00	-	0.00	-	0.00%

;lL2i  l1","ill11ilillll!i\li!llll'i'.I	.	"""	'" ,,,:,	:/·	'.' ...,,·

·.	·· .-,:': ...'··

..' "' ..

-}	260	Construction stakeout	I   LS	25,600.00!	25,600.00  I	0.41	J0,240.00 r-·	 		15,360.00 I	1.00	25,600.00  '	J00.00%

1	'     1260    :Florida Trench Safety Act  ------+-	I  11 .S	100.00	100.00  !	1.01	100.00  I	0.00	-	:	1.001	J00.00,	100.00%
0.60
4	260	,Record drawings/ As-Built Survey	.	_ _	I   LS	8,300.00 I	8,300.00 1--	0.o:	-  .  i	0.00	....:	0.00	-	0.00%
5	5JO	IMobilization/ General Conditions	I   LS     I	50,000.00I	50,000.00	1.0'	50,000.00 I	0.00	-	!	1.00	50,000.00	J00.00%
TOTAL	1,615 661.00	1,282,177.00	187,416.00	1,469-,93.00	90.96%

PHASE3C		
DRAINAGE	$	683,0JO.00	$	576,374.00	$	7,000.00	$	583,374.00	85.41%	
SANITARY SEWER	$	512,371.00	$	472,099.00	$	24,000.00	$	496,099.00	96.82%	
WATERDISTRIBUTION	$	336,280.00	$	173,364.00	$	141,056.00	$	314,420.00	93.50%	
MISCELLANEOUS	$	84,000.00	$	60,340.00	$	15,360.00	$	75,700.00	90.12%	
TOTAL	$ 1,615,661.00	$ 1,282,177.00	$	187,416.00	$ 1,469,593,00	90.96%	

-Summary of  Work Classihcations

Summary of Accounting Codes

260	$	33,900.00	$	J0,240.00	$	15,360.00	$	25,600.00	75.52%	
5JO	$	50,000.00	$	50,000.00	$	-	$	50,000.00	J00.00%	
9JO	$	683,010.00	$	576,374.00	$	7,000.00	$	583,374.00	85.41%	
960	$	512,371.00	$	472,099.00	$	24,000.00	$	496,099.00	96.82%	
1010	$	336,280.00	$	173,364.00	$	141,056.00	$	314,420.00	93.50%	
1260	$	100.00	$	100.00	$	-	$	100.00	J00.00%	

TOTAL	
$ 1,615,661.00	
$ 1,282,177.00	
$	187,416.00	
$ 1,469,593.00	
90.96%	

Project:     Grand Palm Phase 2Ae (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	5
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	8/1/2019
Engineer: Kimley-Horn and Associates, Inc.	Punta Gorda, FL  33950	To:	8/31/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

ITNJT	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		
1	18" RCP	206	LF		16.21	3,339.26		206.00	3,339.26	0.00	-		206.001	3,339.26		100.00%	
2	24" RCP	481	LF	i	24.81	11,933.61		481.00	11,933.61	0.00	-		481.00,	11,933.61		100.00%	
3	30" RCP	427	LF	35.14	15,004.78		427.00	15,004.78	0.00	-		427.00i	15,004.78		100.00%	
4	36" RCP	1,023	LF	48.58	49,697.34		1023.00	49,697.34	0.00	-		1023.00	49,697.34		100.00%	
5	42" RCP		571	LF		61.06	34,865.26		571.00	34,865.26	0.00	-		571.00'	34,865.26		100.00%	
6	48" RCP		447	LF		76.65	34,262.55 !	447.00	34,262.55		o.oo,	-	447.00		34,262.55		100.00%	
7	Grated Swale Inlet		4	EA		566.55	2,266.20 '	4.00	2,266.20	0.001	-	4.00	2,266.20	100.00%	
8	Tvne "F" Inlet 36" x 48" (inside size)		2	EA	-	-	2.00	-	0.00	-	2.00	-	100.00%	
9	Type "M" Inlet 36" x 48" (inside size)		6	EA	1,858.67	11,152.02		6.00	11,152.02		0.00'	-	6.00	11,152.02  '	100.00%	
10	Tvne "M" Inlet 42" x 60" (inside size)	8	EA	1,858.67	14,869.36		8.00	14,869.36 i	0.00;	-	8.00	14,869.36	
11	30" Flared End Section	2	EA	1,315.40	2,630.80		2.00	2,630.80 i	0.00!	-	i	2.00	2,630.80		
12	36" Flared End Section	4	EA	1,562.00	6,248.00		4.00	6,248.00 .	0.00	-	4.00	6,248.00	100.00%	
13	42" Flared End Section	3	EA	1,809.50	5,428.50		3.00	5,428.50 :	0.00	-	3.00	5,428.50	100.00%	
14	48" Flared End Section	3	EA	2,292.10	6,876.30		3.00	6,876.30 '	0.00	-		3.00	6,876.30	100.00%	
15	Medium Control Structure	I	EA	3,292.71	3,292.71		1.00	3,292.71 !	0.00	-		1.00	3,292.71	100.00%	
16	Rio-Rao for Bubbler Structures	70	SY	-	-	0.00	-	70.00	-	70.00	-	0.00%	
20	Modified Type "F" curb	!	320	LF	-	-	0.00	-	0.00	-	0.00	-	0.00%	
21	Ts.me "M" curb		8,400	LF	-	-		O.OO!	-	0.00	-	0.00	-	0.00%	
22	Curbramo		7	EA	-	-	0.00	-	0.00	-		0.00	-	0.00%	
	Lb SANITARY SEWER						'		
I	!Manholes 01       6'
-	6	EA		1,557.74	9,346.44	6.00	9,346.44	0.00	-		6.00,	9,346.44		100.00%	
2	Manholes 6' - 8'	7	EA		1,731.29	12,119.03	7.00	12,119.03	0.00	-		7.00i	12,119.03		100.00%	
3	.Manholes 8' - 10'	3	EA		2,181.24	6,543.72	3.00	6,543.72	0.00	-	3.00	6,543.72	100.00%	
4	IManholes 10' - 12'	I	EA	2,507.88	2,507.88	1.00	2,507.88	0.00	-	1.00	2,507.88 !	100.00%	
5	!Manholes 14' - 16'	2	EA	2,748.81	5,497.62	2.00	5,497.62	0.00	-	2.00	5,497.62  '	100.00%	
6	8" PVC (SDR 26) Gravity Sewer O' - 6'	1,135	LF	4.15	4,710.25	1135.00	4,710.25		0.00,	-	1135.00	4,710.25  '	100.00%	
7	8" PVC (SDR 26) Gravity Sewer 6' - 8'	1,328	LF	4.15	5,511.20  '	1328.00	5,511.20	0.00	-	1328.00		5,511.20	
1	100.00%	
8	8" PVC (SDR 26) Gravity Sewer 8' - IO'	603	LF	4.15	2,502.45 i	603.00	2,502.45		0.00!	-	603.00	2,502.45	100.00%	
9	8" PVC (SDR 26) Gravity Sewer 10' - 12'	387	LF		4.15	1,606.05 i	387.00	1,606.05		0.001	-	!	387.00	1,606.05	100.00%	
10	8" PVC (SDR 26) Gravity Sewer 12' - 14'	344	LF		4.15	1,427.60,	344.00	1,427.60	0.00		-	I	344.00	1,427.60	100.00%	
11	8" PVC (SDR26) Gravity Sewer 14' - 16'	271 ! LF	4.15	1,124.65	271.00		1,124.65	

1	0.00	-	271.00	1,124.65	100.00%	
12	Single sewer service	10 ! EA	300.87	3,008.70	9.00	2,707.83	1.00	300.87	10.00	3,008.70	100.00%	
13	Double sewer service		54	1 EA	313.73	16,941.42	39.00	12,235.47	15.00	4,705.95	54.00	16,941.42	100.00%	
14	Connection to existing gravity sewer	3	EA	-	-	3.00	-	0.00	-	3.00	-	0.00%	
15	Testing of gravity sewer	4,068	LF	-	-	0.00	-	0.00	-		o.oo·	-		0.00%	
	Le WATER DISTRIBUTION										
I	8" PVC DR-18, C900 Water Main	I	4,840	LF	8.18	39,591.20	4388.00	35,893.84	452.00	3,697.36	4840.00	39,591.20  ;	100.00%	
2	8" Gate valve and valve box	'	10	EA	I	905.56	9,055.60	9.00	8,150.04	1.00	905.56	-	10.00	9,055.60	100.00%	
3	Fire Hydrant Assembly	i	5	EA	

1	2,297.19	11,485.95	5.00	11,485.95	0.00	-	5.00	11,485.95	100.00%	
4	Single water service (Short)	76	EA	i	322.25	24,491.00	0.00	-	76.oo:	24,491.00	76.00	24,491.00	100.00%	

Project:	Grand Palm Phase 2Ae (CDD Portion)	Forsberg Const uction, Inc.	Pay Request No.	5	
Owner:	Blackburn Creek COD	645 Charlotte Street	For work from:	8/1/2019	
Engineer:	Kimley-Horn and Associates, Inc.	Punta Gorda, FL 33950	To:	8/31/2019	

MATERIAL	PURCHASE

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

PERCENT

 	5	ingle water service (Long)
6	!Ti . in to existing Water Main
 	: Ferguson Adj tment
: ounty Materials Adjustment ..
TOTAL

42  I EA
2·1 EA (1),  EA
(1)1 EA

374.23
107.80 ll,7_76,61 20,126.49 ,

-    . 15,111.66 I
215.60  !
(11)76.61)L
(20,126,49);
343,367.61 I

0.00
1.00
0.00
0.00'

-- 		-	 107.80
-
325,344.51 I

42. ¼--_15,717.66 ! 	42.00	15,717.66  I 	100.00%
1.00,

--- -

I

$

$

-1.00:-
-1.'ooT--
$

107.80 , 11,116.61 I 20,126.49 I 18,023.10 I

2.00
-1.00 -
-1.00 -

$

215:i;o  •
11,776.61  i
20,126.49  I
343,367.61  i

100.00%
100.00%
100.00%

100.00%

Summary

ITEM	DESCRIPTION			UNIT	ORDER							COMPLETE	
NO.	OF WORK	QUAN	UNIT	PRICE	TOTAL	QTY	VALUE	QTY	VALUE	QTY	VALUE	%	

Ferguson Waterworks	$	125,612.72	$	87,463.13	$	38,149.59	$	125,612.72	100.00%	
Cast Systems	$	67,594.98	$	67,594.98	$	-	$	67,594.98	100.00%	
County Materials	$	150,159.91	$	170,286.40	-$	20,126.49	$	150,159.91	100.00%	
6% State Sales Tax	$	20,602.06	$	19,520.67	$	1,081.39	$	20,602.06	100.00%	
TOTAL	$	363,969.66	$	344,865.18	$	19,104.48	$	363,969.66	100.00%	

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 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:

2019-38

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

Amount Payable:	$3,660.42

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 lB(a). Purchase Order# 180601; 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 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 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 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 ofissuance, 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 (ill) 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.

tJ	

Consulting Engineer	�

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 1B(a)

    Invoice #	Amount	
    1441318	$3,660.42	
Sub-Total	$3,660.42

FERGUSON®
WATERWORKS
17323 JEAN STREET
FT  MYERS, FL 33967-9998	SEP 2 5 2019

Pleas e contact with Questions: 800-456-1488

    INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1441318	$3,660.42	41951	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 PH1BA
C/0 FORSBERG CONSTRUCTION INC PO#180601
PUNTA GORDA, FL 33950

BLACKBURNCREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC 645 CHARLOTTE ST

SHIP WHSE.
1705	SELL
WHSE.
1705	TAX CODE

FLE	CUSTOMER ORDER NUMBER

180601	SALESMAN

TAE	JOB NAME

PH1BA SOURCE	INVOICE DATE

0 9/ 1 8/ 19	BATCH
10
8 1712	
ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT
So u rce O rde r#: 141 5 136
2	2    I4 61 SW	2PC SC C l VLV B X 19-22 WTR	95.000	EA  .V	190.00
4	4   SSLCE8AP	8 PVC WDG REST *ONELOK W/A	46.150	EA ,v	184 .60
1	1   PSD3105B52	3X1000 UG DET WTR BLUE	28.000	EA  ,V	28.0 0
2	2   AFC2608DLAFTM	8 DI MJ RW OL SS TAPN VLV LIA	827.400	EA   V	1654.80
2	2     J4320900X8	8X8 SS TAPN SLV 8.60-9.05	788.510	EA  Jr 	1677 .02
2	2   RBGVTMX	3 BRS GATE VLV ID - 8	13.000	EA  ,V	26.00
2	0   IBRLFBKG	LF 2X1 BRS BUSH	EA	,0 00
2	0   MJTPXK	8X2 MJ C153 TAP PLUG	EA	0.00
INVOICE SUB-TOTAL	3660.42

L E A D LAW WA NIN G: IT IS ILLE <6AL TO IN S TAL L PR ODL C TS TH AT ARE NO T "LEA D FREE" IN ACCO RD AN CE W ITH
US FE DE RAL < R O TH E R APP L IC ABLE LAW IN POTA BLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH *NP IN THE DE SC RIPTI ON ARE NO T L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLE A P P LICA TIO N S. U YER IS SOLELY RESF ONSIBLE FOR PRODU CT SELECTION.

Thank you for your business		
TERMS:	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE	$3,660.42	
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/content/website-info/terms-of-sale, incorporated by reference. Seller may convert checks to ACH.

rul Ln/"'\.)t: Ul Ut:I l'JU.	/80601

Blackburn Creek Community Development District
c/o
Forsberg Co nstructi on, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (94 l) 637-8500	Fax, (941) 639-1073
Und erground Utility License liCUC0557 l6
Visit Us at \\Ww.forsl>c rgconstructio n.com

Ven dor: Ferguson Waterworks Addr ess: 18305 Paulson Drive
 Port Charlott e, FL 33954	

Job No.: 18-06

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

Project Addr ess: Obervat ion 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 I 0tll of 2ndMonth Vendor Phon e: 941-624-3494		 	

Quantity	Unit

Description

..

Unit Price

Total Price 	

---

    j

[

I

LS

1Pipe, Valves.Fittin gs and Appurtenanc;e in a ccordance
with Exhibit "A" (pages 1-3)

$

-

68,883.70

$

68,883.70

..	 	

----·

--

-

-

-

-·-

..

-

----

-

---
--
.--

--·	-	-
-	-

--

--

----·

-- .
-----·

I. -

-

--

I

--·

Pricesare good for duration of the project.

---

-----	--·
Project Durat ion: Janu ary 1, 2019 - January I, 2020

I
 L-    ....	

--- --

I 	

---

Total Project Subtotal	s
Sales Tax @ 6 %

----

Discre tio nary Tax @_1.0    %   on

- - --

I st $5,000.00
TOTAL

$

68,883.70
tax exempt tax exempt
68,883.70

A tten tion : _!t   ier  Evenson	 		Vendor Fax: 94 1-627-35 19

Ferg uson  W at er w orks    	 Vendor name	··

_  X-	-F-  -	---'-- -	   J	I	I _J  ---	

Blackburn Creek COD

"-:----'  	-	-	-	:f	,l_,}_fL   

Auth	ze   t\g nt (signature)	Date

Authorized

r  nrde/	};	-	-

 		 A1e !  	

Authori	ze  d  Agent (sig n;i ture)	D a t e
! IMPORTANT!

SEESPECIAL PROVISIONS ABOV E.

Page	of	2	ADDITIONAL TERMS ANO CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
All material sha ll be as spec ified and warranted in accordance to the Project sp ecifications, pl ans and addencla.
Material sh all be within accepted standards for workmanship and quality, and sha ll be satisfactory to me et approval of the Owner, Owner's representative and Purchaser.

When requestedby Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete se t of shop draw ings for Purchaser's r eview and approval. All items suppli ed without prior approval, that do not meet Project requiremen ts,will be returned to Vendor, by Vendor, at no charge to Purcl1aser.

Tim e is of tl1e essen ce.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Venclor sh all notify Purchaser 24 hours in advance of arrival to j obsite to confirm delivery.

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

Shou ld the Vendor fail to provide materialas scheduled by Purchaser and Vendor, the Purchaser, up on 3 day written notice to Vendor, shall have the right to procure said materials elsewh ere without further responsibility to Vendor.

Quan titi esare approximate and subject to proj ect requirements.

Vendor agrees to accept without charge to Purchaser, all extra, n on-specialty materials in good concli tion which rem ain a er completion of work and will issue full credit for same.

Vendor shall sign ancl return Purchase Order within IO days of Purchase Or der date. Purchas er w ill return an executed Purchase Order to Vendor.

I 0.		To in sure prompt paymen t, Purchase Order number must appear on all invoicesand copies of signed delivery slips attached.

I I.	Neither party will change, alter, nor sub stitu te any part of this Purchase Order without consent of tile opposit e party. All changes so agreed to sh all be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaserw ith ou t receipt of a properly sign ed and acceptable Pur chase Order.

Sh ipm ent of any materials. be for e signin g this Purchase Order, will be considered an acceptance of this Pur chaseOrder.

If V e nd or fails to properly execu te and return Purchase Order within IO days, Purchaser may consid e r offer rejected.

1 5. This agr eement sh all be governed by the laws of th e State of Florida with venue in Charlo tte Coun ty, Florida.

.	The authorized agent sign in g this Purchas e Orde r for the Vendor must be duly authori zed to do so on b ehalf of the Vendor or on behalf of any such disclosed prin cipal.

In the event any of theseterms are declared to be unenforceable by a court of competent j urisdi ction, then Purch aser and Vendor intend for the remaining terms and conditions to rem ain in full force and effect.

This Purchase Order is the only binding contract between Purchaser and Vendor for this proj ect and the work described. This Purchase Order replaces arr previous contracts and  agreements, whether  written or  verbal, regarding this project. No other document will supersedethe requirements of this Purchase Order u nless signed by an authorized agent of each parly subsequen t to the date of this Purchase Order.

Page   2  of	2	Ferguson Initi al	Blackburn Creek COD ln ti tal	-

OeliverTo:
rom:	• Tyler A Evenson Comments:

FERGUSON

8		FEI-PT.CHARLOTTE WW 1705 18305 PAULSON DRIVE

WATERWORKS

PORT CHARLOTTE, FL 33954-0000

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

12 :30 :10 FEB 25 2019	Page 1 of 4

FEI-PORT CHARLOTTE #1705

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

XHI	'

B i d No:
Bid Date:
Quoted By:	B247136
02/25/19
TAE	Cust Phone:
Terms:	941-637-8500
NET 10TH PROX	
Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY	
	GRAND PALM PHASE 18a		GRAND PALM PHASE 18a	
	645 CHARLOTTE ST
PUNTA GORDA, FL 33950		645 CHARLOTTE ST
PUNTA GORDA, FL 33950	

Cust PO#:	180601	Job Name:	GRAND PALM PH 1Ba

Item		Description	Quantity	Net Price	UM	Total 'SEWER•
=====-=====-----===-----=
- 8 " PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2030	3.980    FT	8079.40
PD3105G4737	3X1000 UGDET SWR GREE	2	28.000   EA	56.00
SUBTOTAL	8135.40
- SINGLE SWR SRV (4)·
MUL067248	8X6 PVC HW SWR GXGXG 'NYE	4	47.530    EA	190.12
MUL067376	6 PVC HW SWR GXS 45 ELL	12	13.470   EA	161.64
MUL067326	6 PVC HW SWR GXG 45 ELL	4	18.240    EA	72.96
SDR26HWSPU14	6X14 SDR26 HWPVC GJ SWR PIPE	168	2.220    FT 	372.96
MUL067206	6 PVC HW SWR GXGXG 'NYE	4	36.570    EA	146.28
MUL040952	6 PVC SWR HUB FEM CO ADPT	4	11.720   EA	46.88
MUL040958	6 PVC SWR REC THRO CO PLUG	4	8.950    EA	35.80
CYPSKPX	2X4X8 YELL PINE STUD	4	3.000    EA	12.00
MUL043988	6 PVC SWR GSKT CAP	8	6.930    EA	55.44
SUBTOTAL	1094.08
- DBL SWR SRV (26) -

8X6 PVC HW SWR GXGXG 'NYE	26	47.530	EA	1235.78	
6 PVC HW SWR GXS 45 ELL	78	13.470	EA	1050.66	
6 PVC HW SWR GXG 45 ELL	26	18.240	EA	474.24	
6 PVC HW SWR GXG DBL WYE	26	68.260	EA	1774.76	
6 PVC SWR HUB FEM CO ADPT	26	11.720	EA	304.72	
6 PVC SWR REC THRO CO PLUG	26	8.950	EA	232.70	
6 PVC SWR GSKT CAP	78	6.930	EA	540.54	
6X14 SDR26 HW PVC GJ SWR PIPE	1092	2.220	FT	2424.24	
2X4X8 YELL PINE STUD	26	3.000	EA	78.00	
3X1000 UG DET SWR GREE	2	28.000	EA	56.00	
SUBTOTAL				8171.64	

MUL067248 MUL067376 MUL067326 MUL067277 MUL040952 MUL040958 MUL043988 SDR26HWSPU14 CYPSKPX PD3105G4737
TOTAL SANITARYSEWER	17401.12

1$ FERGUSON"

Page 2 of 4
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
Fax: 941-627-3519

12:30:10 FEB 25 2019
Reference No; B247136

Item	Description	Quantity	Not Price	UM	Total	
	
WATER MAIN•					
	=== =========== g=========					
	4" PVC WATER MAIN·					
DR18BPP	4 C900 DR18 PVC GJ BLUE PIPE	540	2.080	FT	1123.20	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
G1230BHS600	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00	
SPWPG4	4 SIGMA BELL REST F/ G900 'PVLOK	8	29.700	EA	237.60	
	SUBTOTAL				1477.80	
	-FITTINGS-					
MJ4LAP	4 MJ G153 45 BEND UA	2	29.240	EA	58.48	
SSLCE4AP	4 PVC WDG REST "ONELOK W/A	4	29.990	EA	119.96	
	SUBTOTAL				178.44	
	
4" GATE VLV ASSM (2) -					
AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV UA	2	318.430	EA	638.86	
SSLCE4AP	4 PVC WDG REST 'ONELOK W/A	4	29.990	EA	119.98	
1481SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMP	3 BRS GATE VLV ID- 4	2	13.000	EA	26.00	
	SUBTOTAL				972.82	
	
- 8" PVC WTR MAIN -					
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	2000	6.700	FT	13400.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	58.00	
C1230BHS500	12GA 30MM 500 FT COP TRGR WIRE BLUE	4	89.000	EA	358.00	

8 SIGMA BELL REST F/ COOO "PVLOK	42	60.050	EA	2102.10	
SUBTOTAL				15914.10	

SPWPC8

8" FITTINGS -

MJ2LAX	8 MJ C163 22-112 BEND UA	8	88.900	EA	413.40	
MJTLAX	8 MJ C163 TEE UA	1	127.850	EA	127.65	
MJRLAXP	8X4 MJ C153 RED UA	1	46.400	EA	48.40	
SSLCE8AP	8 PVC WDG REST "ONELOK W/A	28	46.150	EA	1292.20	

MJ4LAX	8 MJ C153 45 BEND UA	6	68.700   EA	412.20
SSLGE4AP	4 PVC WDG REST 'ONELOK W/A	1	29.990    EA	29.99

- 8" GATE VLV ASSM (4) -

8 DI MJ RW OL SS STEM VLV UA	
4	

647.000	

EA	

2588.00	
8 PVC WDG REST •ONELOK WIA	8	46.160	EA	369.20	
2PG SC GI VLV BX 19-22 WTR	4	95.000	EA	380.00	
3BRSGATEVLVID-8	4	13.000	EA	52.00	
SUBTOTAL				3389.20	
- FIRE HYD ASSM (2) -					
8X6 MJ G153 SWVL TEE UA	2	122.790	EA	245.58	
8 PVC WDG REST 'ONELOK WIA	4	46.150	EA	184.60	
6 PVC WDG REST 'ONELOK WIA	4	34.040	EA	138.16	
6 MJ C153 BLT GSKT PK UGLAND	2	12.700	EA	25.40	
6 DI MJ RW Ol SS STEM VLV UA	2	406.555	EA	813.11	
2PC SC Ci VLV BX 19-22 WTR	2	95.000	EA	190.00	

SUBTOTAL	2321.84
AFC2608DLAFMM SSLGE8AP 1461SW RBGVTMX

MJSTLAXU SSLGE8AF SSLCE6AP IMJBGPU AFC26060LAFMM
1461SW RBGVTMU DR18BPU

3 BRS GATE VLV ID-6	2	13.000	EA	
6 C900 DR18 PVC GJ BLUE PIPE	20	3.860	FT	

26.00
77.20

� FERGUSON®
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Page 3 of4

12:30:10 FEB 25 2019
Reference No: B247136

Item
AFCB84BlAOlP	Description
5-114 Vo B848 HYO 4'0 ol UA	Quantity	Net Price
------ms:ooo	UM
""EA""	Total

2850.00	
	SUBTOTAL				4548.05	
	SINGLE SHORT (34) •					
FS90404	4X1 CC BRS SDL C900	9	72.200	EA	849.80	
FS90804	ax1 cc BRS SDL C900	25	102.610	EA	2565.25	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	34	50.240	EA	1708.16	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	600	40.000	C	240.00	
PEC9BG100	"EXC 1X100 CTS ORS HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	34	87.340	EA	2969.56	
FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	68	1.260	EA	85.68	
CYPSKPX	2X4X8 YELL PINE STUD	34	3.000	EA	102.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	34	68.000	EA	2312.00	
	SUBTOTAL				10878.45	
	SINGLE LONG (22) •					
FS90404	4X1 CC BRS SOL C900	6	72.200	EA	433.20	
FS90804	ax, cc BRS SOL C900	16	102.610	EA	1841.76	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	22	50.240	EA	1105.28	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1200	40.000	C	480.00	
PEC9BG100	"EXC 1X100 CTS DR9 HDPE BLUE PIPE	100	40.000	C	40.00	
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	22	87.340	EA	1921.48	
FINSERT52	1 CT$ PET/ HOPE DR9 INS STFNR	44	1.260	EA	55.44	
CYPSKPX	2X4X8 YELL PINE STUD	22	3.000	EA	66.00	
CWA03111812	11X18X12 BX W/CIRDR LID SUD	22	68.000	EA	1498.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	880	0.550	FT	484.00	
	SUBTOTAL				8046.16	
FBLSLAX	BX12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST 'ONELOK WIA	2	48.150	EA	92.30	
	SUBTOTAL				216.60	
	8X8 HOTTAP (2) •					
J4320900X8	8X8 SS TAPN SLV 8.60-9.05	2	788.610	EA	1577.02	
AFC2608DLAFTM	8 DI MJ RWOLSS TAPNVLV UA	2	827.400	EA	1654.80	
1461SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMX	3 BRS GATE VLV ID- 8	2	13.000	EA	26.00	
SSLCE8AP	8 PVC WDG REST "ONELOK WIA	2	46.150	EA	92.30	
	SUBTOTAL				3540.12	
NetTotal:	$68883.70	
Tax:	$0.00	
Freight:	$0.00	
Total:	$68883.70	

Florida Admin Rule 12A-I.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 COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

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

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

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

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

CERTI FICATE OF ENTITLEMEN T
The und ersigned authorized representative of the Blackburn Creek Community Development District, a local unit of specia l purpose government (hereinafter "Go vernme ntal Entity"), Florida Consum er's Ce r ti ficate of Exe mpt io n Num ber 85-8015773053C-0.affir ms that the tangible personal property pur chased pu,·s uan t to Purchase Order Number 180601 from Ferguson Wa terw or ks (Vendor) on or after 2 /22/19 (date) will be incorporated into or become a part of a public facility as par t of a public works contr act pursuant to contract# n.li!. with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Pur chase Ord er meets the following exe mpt ion requirements conta ined in Section 21 2.08( 6). F.S., a nd Rule 12A-l.094, F.A.C.:

You 11111st initial each oft he folfowi11g requirements.

The attached Purchase Order is iss ued directly to the vendor supplyin g the  tangible  personal  pro )Crty the Contractor will use in the identified public works.
The vendo r"s invoice will be issued directly to Governmental Entity.
. Payment of the vendor"s inv oice will be made directly by Governmental Entity to the vend o r from pub ic fund s.
-	Governmental Entity will take title to the tangible personal property from the vendor at the time of pth-cl1ase or of delive1y by the vendor.
A	. 5. Government al Entity assumes the risk of damage or loss at the time of purchase or delivery by the

Go vernment al Entity affirm s that if the tangible personal property identified in the attached Pur chase Ord er does not qualify for the exemption provided in Section 212. 08 (6 ), F.S. and Rule 12 A-1. 0 9 4 , F.A.C.. Governme ntal Entity will be subject to the tax, interest, and penalties due on the tangible personal p roperty purchased. If th e  Florida Department of Revenue deter mines  that the tangible  personal property pur chased
tax-exempt by issu ing this Ce rtifi cate does not qualify for the exemption,Governmenta l Entity will be liable for any tax, penalty, and interest determined to be clue.

I unders tand that if I fraudulently issue th is certificate to evade the payment of sa les 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.

U nder the penalties of perjury. I declare that I hav e read the foregoing Ce rtifi cate of Entitlement and the
facts stated in it are true.

Q	

Blackbu rn Creek Communit y Development District, a local uni t of special pur pose government By:

Federal Empl oyer Identification Numb er: -   --   -   -   -   - -  -	=	­

You must attach a copy of the Pu rc hase Order to this Certificate of Ent itle ment.

Do not send to the Florida Depar tment of Revenue. This Certificate of Entitlement mus t be retain ed in the
vendor's and the cont ractor's books and records.

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

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture· from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 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 1, 2018 (the Master Indenture as amended and supplemented is hereinafter refeiTed 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:

2019-39

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

Amount Payable:	$13,452.57

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 materials for construction of Grand Palm, Phase 2Ad. PO # 190401; See attached for invoice detail.

The undersigned hereby certifies that [obligations h1 the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2018 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2018 Capital Improvement Plan and represents a Cost of the 2018 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

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

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

If this requisition is for a disbursement from other than the Costs of Issuance Account or for payment of capitalized interest, there shall be attached a resolution of the Governing Body of the District approving this requisition or 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

< -

AutorizedOffice	

By:. :------' =----------
�

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

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

Consulting Engineer --- / .,

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #	Amount	
    1439891	$13,452.57 
Sub-Total	$13,452.57

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

Please contact with Questions: 800-456-1488

SEP 1 6 2019	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1439891	$13,452.57	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.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 - VLV / HYD

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

09/09/19

BATCH
10
81658

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM
Source Order#: 1423817

AMOUNT

1	1   I461SW	2PC SC Cl VLV BX 19-22 WTR	95.000	EA •"	95.00
7	7    I461SW	2PC SC Cl VLV BX 19-22 WTR	95,000	EA ,v-	665.00
4	4    I461SW	2PC SC Cl  VLV BX 19-22 WTR	95.000	EA   t1/	380 . 00

V

4	4    IMJBGPU	6  MJ C153 BLT GSKT PK UGLAND	12.700	EA  •
1	1   AFC2606DLAFMM	6 DI MJ RW OL SS STEM VLV LIA	406.550	EA  \

50.80
406.55

4	4     AFC2606DLAFMM	6  DI  MJ RW OL SS STEM VLV LIA	406.555	EAv t;:	1626 . 22

4	4   AFCB84BLAOLP	5-1/4 VO 8848 HYO 4'0 OL UA	1425.000	EA ,

5700.00

7	7    AFC2608DLAFMM	8 DI MJ RW OL SS STEM VLV LIA	647.000	EA  lV	4529.00
INVOICE SUB-TOTAL	13452.57

LEAD LAW WA NING: IT IS ILLEC AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL OR OTHER APPLI( ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH •NP IN THE DESCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLE APPLICATIONS. UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	CASH ON DEMAND	ORIGINAL INVOICE

TOTAL DUE	$13,452.67

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/content/website-info/terms-of-sale,incorporated by reference. Seller may convert checks to ACH.

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, 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 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:

2019-40

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

Amount Payable:	$180,646.37

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 lB(a) Application No. 2 (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 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that  has  not  previously been paid].

The undersigned hereby further ce1iifies 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

�	

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 20 I9 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 amendedor modified on the date hereof

CONTRACTOR'S APPLICATION FOR PAYMENT

PROJECT	Grand Palm Phase IBa (CDD Portion)

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

NTP DATE
Contract Time SUBSTANTIAL FINAL

CONTRACTOR	2

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	9/1/2019	TO	9/30/2019	

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

12%
5%	116,735.00
22,816.79
93,918.21
4,695.91	49%

38%
5%	371,571.00
87,498.72
284,072.28
14,203.61		
Net Earned (Total earned minus retainage) Total Previous Estimates
AMOUNT DUE THIS PERIOD		89,222.30		269,868.67	269,868.67
89,222.30
180,646.37	

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

Notary Public, State of Florida
My Commission expires August 23, 2020 Sworn and subscribed to me!hi 2nd day of October AD 2019

(STAMP/ SEAL)

Forsberg Construction, Inc. 645 Charlolle Street

Punta Gorda, Florida 33950 Phone(941)637-8500
Fax (941) 639- I073

Payment of the above AMOUNT DUE THIS APPLICATION is recommend ed.

Engineer Owner

DATE

 	roh.l1'1	
tb0,± l o1�

Project:
Owner.
Engineer:	Gnmd Palm Phase IBa (CDD Portion)
Blackburn Creek CDD
Kimley•Horn and Associates, Inc.				Forsberg Construction, Inc.
645 Charlotte Street Pnnta Gorda, FL 33950		Pay Request No.
For work from:
To:	2
9/112019
9/3012019	
						PREVIOUS WORK	WORK nns PERIOD	WORK TO DATE	PERCENT COMPLETE	

1,760.00	1,760.00
2	910	24" RCP	611 ,  LF	65.00	39,715.00	403.0	208.00	13,520.00	39,715.00
3	910	30"RCP	173 i  LF	84.00	14,532.00	0.0	173.00	14,532.00	173.00	14,532.00	100.00%
4	910     '36"RCP	472    LF 1	116.00	54,752.00	60.0	6,960.00	412.00	47,792.00	472.00	54,752.00	100.00%
5	910	Grated Swale Inlet	I	EA'	3,400.00	3,400.00	0.0	1.00	3,400.00	1.00	3,400.00	100.00%
6	910	Type "M0   Inlet 36" x 48" (inside size)	5    EA	4,200.00	21,000.00	3.0	12,600.00	2.001	8,400.00	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 i	o.o	2.00	13,800.00 '	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	I	EA	4,500.00	4,500.00	O.Oi	1.00	4,soo.oo I	LOO	4,500.00	100.00%
10	910	36" Flared End Sectioo	3   EA	5,800.00	17,400.00	LO	5,800.00	2.00	11,600.00	3.00	17,400.00	100.00%
11	910	Small Control Structure	EA	5,600.00	5,600.00	0.0	1.00	5,600.00	LOO	5,600.00	100.00%
15	910	ModifiedT    e "F" curb (Islands)	220	LF	16.20	0.0	0.00	0.00	0.00%
910	Type "M" curb, includes all transitions	LF	0.0	0.00	0.00%
Curb ramp

2
3	960
4	960

Manholes 10' -12'
8" PVC (SDR26) Gravity Sewer0' -6'

2
788

EA i
LF

0.0
0.0

2.00	12,400.00
2.00	15,600.00
0.001

2.00	50.00'¼
2.00	100.00'¼
o.oo!	0.00%

5	960

8" PVC (SDR26) Gravity Sewer 6' - 8'	553	LF

28,756.00

0.0

260.00

13,520.00 i	260.00

13,520.00

47.02'¼

6	960
7	960

8" PVC (SDR26) Gravity Sewer 8' - JO'	280	LF
382	LF

70.00
87.00

19,600.00 i	0.0
33,234.00	0.0

280.00
382.00

19,600.00.	280.00
33,234.00	382.00

19,600.00
33,234.00

100.00%
100.00%

8	960
9	960
10	960
II	960

Single Sewer Service	4	LF
Double sewer service	26    EA
Connection to existing gravity sewer	EA
Opeo Cut Restoration and MOT	LS
Testing of gravity sewer

1,500.00
1,500.00
6,600.00

6,000.00
39,000.00
6,600.00
11,300.00
8,012.00

0.0
0.0
0.0

0.00
0.00
1.00
0.50

6,600.00
5,650.00

0.00
0.00
1.00	6,600.00
0.50	5,650.00

0.00%
0.00%
100.00%
50.00%

2	1010
3	1010
4	1010

4"PVCDR-18, C900 Water Main
8"PVCDR-18, C900 Water Main
4" Gate valve and valve box 8" Gate valve and valve box

4; EA

28.00
1,500.00
2,000.00

3,000.00
8,000.00

0.0
0.0
0.0

156.00
0.00
o.oo!

4,368.00

7.96%
0.00%
!	0.00(	0.00%

5	1010
6	1010
7	1010
8	1010
9	1010

8"x8" Tapping Sleeve and Valve
Blowoff Assembly
HG-2 Automatic Flushing Device Fire Hydrant Assembly
Single water service (Short)

2	EA I	7,800.00
I	EA:	1,200.00
I	EA'	7,400.00
2    EA	6,000.00
34    EA	1,000.00

15,600.00
1,200.00
7,400.00
12,000.00
34,000.00

0.0
0.0
0.0
0.0
o.o

2.00\	15,600.00 I	2.00,	15,600.00
0.00	0.00
0.00	0.00
0.00	0.00
0.00	0.00

100.00%
0.00%
0.00%
0.00%
0.00%

10	1010
II	1010
12	1010
13	1010

Single water service (Long) Tie-in to existing Water Main Pressure testing ofmain
Chlorination and bacteriolo cal

22    EA
2	EA
2,480	LF
2,480	LF

1,200.00 ,	26,400.00
2,500.00	5,000.00
2.10	5,208.00
1.90	4,712.00

0.0	0.00
0.0	0.00
0.0	0.00
0.0	o.oo:

0.00
0.00
0.00
0.00i

0.00%
0.00%
0.00%
0.00%

Project: Owner: Engineer:

Grand Palm Phase !Ba (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:

2
9/1/2019
9/30/2019

PREVIOUS WORK

WORK THIS PERIOD

WORK TO DATE

PERCENT COMPLETE

QTY

3
4
5

jF!orida Trench Safety Act
Construction stakeout
Record drawings / As-Built Survey
510 .Mobilization

25,600.00 !

100.00 I

5,120.00 i

..

0.00
0.20 	

s,iiooj

 		 	

 	

 	40.00%

1 !LS I 1LS

8,300.001
50 000.001

8,300.00I
50,000.00 ,

0.01
LOI

50,000.0.0

0.00
0.00

 	0.001	0.00%

LOO!

50,000.00

100.00"/o

TOTAL	755,053.00		116,735.00	254,836.00	371,571.00	49.21%	
	Summary of Work	assifications					
PHASE3C
DRAINAGE	
$	239,079.00	s	
61,515.00	
$	123,144.00	
$	184,659.00	
77.24%	
SANITARY SEWER	$	242,094.00	s		$	106,604.00	$	106,604.00	44.03%	
WATER DISTRIBUTION	$	189,880.00	$		$	19,968.00	$	19,968.00	10.52%	
MISCELLANEOUS	$	84,000.00	$	55,220.00	$	5,120.00	$	60,340.00	7l.83'½	
TOTAL	$	755,053.00	
$	116,735.00	$	254,836.00	$	371,571.00	49.21%	

Project:  Grand Palm Phase !Ba (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	2
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	9/1/2019
Engineer: Kimley-Horn and AssociateSt Inc.	Punta Gorda, FL 33950	To:	9/30/2019

ITEM
NO,

DESCRIPTION OF WORK

QUAN

MATERIAL UNIT
11N11	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 oioe ins=ction),
I	18" RCP	32    LF	16,0_5 !	513.60 !	32.00

513.60 !	0,00

I	I
.	32.001

 	..
513.60 i 	100.00%

2	24" RCP

611 l LF	24,65 :	15,061.15  '	403.00

9,933.95 :	208.00'	5,127.20	611.00i	15,06Ll5

100.00%

 	3	30" RCP	1-	173 'LF	'	35.33 ·	6,112.09 !	0,00

·- ..

.	173.00

6,112.0JJ 	173.001	6,Jl2.09 I	100.00%

36"RCP

'	472 LF

48.53 '	22,906.16

60.00

2,911.80

412.00

19,994.36  ·	472.001	22,906.16  .	100.0--0%

'Grated Swale Inlet

EA

650.54

650.54

0.00

.	1.00

650.54

1.001

650.54

100.00%

e	"M" Inlet 36" x 48" (inside size)	!	5 i EA

1,526.64

7,633.20

3.oo:	.:1,579,92

2.00	 	3,053,28 -

     5.00:	7,633.20	100.00%

TYPe "M" Inlet 42" x 6011  (inside size)	2  i EA.  !	1,526.64

3,053.28

0.00

...	.

2.00	3,053.28 -

2.00	3,053.28 i	toq

24" Flared End Section	2 I EA	1,012.00

2,024.00

2.00; 	2,024.00 	0.00! 

.	..

2.00

 		2,024.00 	100.00%

30" Flared End Section	1 i EA	1,315.40

...

1,315.40

..

-

      o.oo,	

1.00:

. -
1,315.40

1.00

1,315.40 :	100.00%

.

36" Flared End Section

...

3    EA	1,562.00

4,686.00

l.00i

1,562.00

2.00	3,124.00

...
3.00

4,686.00 !

Small Control Structure	I	EA

1,847.74 !

1,847.74

! ...	o.ool 		.

1.00....

-...

1,847.74 ' ...

1.00

l,_847,74

100.00%

---

100.00%

l.b SANITARY SEWER
I	Manholes 0' • 6'

4	EA

1,537.21 '

6,148.84 .	0.00

 	i 
.	-··-

 	...
-

0,00

0.00%

'

Manholes 6' • 8'	:'	4'   EA
Manholes 10' • 12'	'	2,   EA

1,754.51
2,249.77 ;

7,018.04
4,499.54

0.00
0.00

.

'

.-.	'

0.00'
2.00
2.QO

3,509.02 I'	2.00:
4,499.54	2.00

...

-
3,509.02
4,499.54

50,00%
100.00%

:8" PVC (SDR26) Gravity Sewer 0' • 6'

788 LF

i

3,199.28

0.00,

-	0,00	.

0.00;

-	0.00%

8" PVC (SDR 26) Gravity Sewer 6' • 8'
8" PVC (SDR 26) Gravity Sewer 8' - IO'

553 LF 280 i LF

4,06
4.06

2,245.18
1,136.80

o.oo:	-
0.00	.

260,00
280.00

1,055.60
1,136.80

260,00
280.00

1,055.60 :	47.02%
1,136.80 ;	100,00%

7	8" PVC (SDR 26) Gravitv Sewer 10' - 12'1	382 LF

4,06

1,550.92

O.OOi

-	382.00

1,550.92

382.00

... 1,550,92

100.00%

8	Sinele Sewer Service

4 I LF i

273.52

1,094.08

0.00 1

.	. ..

0.001

-	I	0.00

-	_0.00%

'

9	Double sewer service	26. EA	314.29
l.c WATER DISTRIBUTION

8,171.54

0.00

-
...   .

o.oo·	-

0.00

.....-
-·

0.00%

I	4" PVC DR-18, C900 Water Main	520 LF
8" PVC DR-18, C900 Water Main	1,960 LF
4" Gate valve and valve box	:

3.19 I	1,658.80 :
9.30 i	18,228.00.

0.00
0.00

o.oo:	0.00

-

-

-··-···-
.	156.00i	1,450,80 :	156,00 ·-

-
1,450.80

0.00%
7.96%

2    EA	484.41	968.82 .	0.00 -

-	0.00	- ...

o.oo:

-	0.00%

igu Gate valve and valve box	i	4;

EA I ..

847.30	3,389.20

o.oo

-	-·

0.00	.

o.oo·	.	i

0.00%

i8"x8" T'!!' ing Sleeve and Valve

2:   EA  i	1,770.06.	3,540.12

0.001

-	2.00 ...	3,540,12

2.00'	3,540.12 I	100.00%

 	8	:Fire Hydrant Assembly

I	2    EA	2,274.03  j	4,548.06

0.001

.	0.00

··--	.

0.00

.	'	0.00%

i Sin2le water service (Short)
lSini!:le water service (Long)
 	II	!Tie-in to existing Water Main

i	34	EA
22  i  EA
i	2       i  EA

319.96
365.73
107.80

10,878.64
8,046,06
215.60

o.oo:
0.00'
0.00'

-
-
.	..

0.00
0.00
o.oo:

.	0,00
-	0.00
.	0.00

.	0.00%
.	i	0.00%
 	-  I	-··   0.00%

TOTAL

Ferguson Waterworks
Cast Systems County Materials 6% State Sales Tax

i	$	152,340.68 I	$	21,525.27
Summary

$	68,871.10	$	-
$	30,851.18	$	4,579.92
$	52,618.40	$	16,945.35
$	9,140.44	$	1,291.52

$	61,020.69 i	$	82,545.96 I	54.19%

$	8,734.24	$	8,734.24	12.68%
$	16,613.40	$	21,193.32	68.70%
$	35,673.05	$	52,618.40	100.00%
$	3,661.24	$	4,952.76	54.19%

Project: Grand Palm Phase !Ba (CDD Portion)	Forsberg Construction, Inc.	Pay Request No.	2
Owner:    Blackburn Creek CDD	645 Charlotte Street	For work from:	911/2019
Engineer: KimleyMHorn and Associates, Inc.	Punta Gorda, FL 33950	To:	9/30/2019	

ITEM NO.	
DESCRIPTION OF WORK	

QUAN	

JNJT	MATERIAL
UNIT
PRICE	PURCHASE
ORDER TOTAL	PREVIOUS WORK

QTY	VALUE	WORK TillS PERIOD

QTY	VALUE	WORK TO DATE

QTY	VALUE	PERCENT COMPLETI
%	
	TOTAL				$	161,481.12	$	22,816.79	$	64,681.93	$	87,498.72	54.19%	

101212019	Page.2 of2	Material Purchased by CDD

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

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the 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);

Requisition Number:

Name of Payee:

Amount Payable:

2019-41

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

$288.00

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

Direct purchase of materials for construction of Grand Palm, Phase 2Ad. PO# 190401; See attached for invoice 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 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 whic h 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

AutorizedOfficer

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 Co nsult ing 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 fotth on Exhibit D to the Third Supplementa l 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 Capita l 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.

VJL.n

Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #	Amount	
    1423819	$288.00	
Sub-Total	$288.00

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

Please contact with Questions: 800-456-1488

OCT O 2 2019

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1423819	$288.00	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:

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH2AD
CIO FORSBERG CONSTRUCTION INC PO#190401
PUNTA GORDA, FL 33950

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 • 2X4'S

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

09/27/19

BATCH
10
81762

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	

./	27	
27	
CYPSKPX	Source Order#: 1423639
2X4X8 YELL PINE STUD	
3.000	
EA	
81.00	
/	41	41	CYPSKPX	2X4X8 YELL PINE STUD	3.000	EA	123.00	
/ 28	28	CYPSKPX	2X4X8 YELL PINE STUD	3.000	EA	84.00	
				INVOICE SUB-TOTAL		288.00	

LEAD LAW WPRNING : IT IS ILLE, AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL l ROTHER APPLI( VIBLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS 1/1 TH *NP IN THE DI SCRIPTION ARE NOT L D FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TE RMS:	CASH ON DEMAND	ORIGINAL INVOICE

TOTAL DUE	$288.00

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/content/website-info/terms-of-sale, incorporated by reference. Seller may convert checks to ACH.

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 REQIDSITION 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 Fourth Supplemental Trust Indenture from the District to the Trustee, dated as of February 1, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-42

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

$2,815.28

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, ifapplicable):

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

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set f01th above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

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

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

Blackburn Creek Community Development District

lf this requisition is for a disburseme nt from other than the Costs ofl ssuance 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 wiih respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Aut'Officer	:

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

If this requisition is for a disbursement from other than Costs ofl ssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereb y 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 Thi.rd Supplemental In denture , and is consistent with: (i) the applicable acquisition or construction co ntract; (ii) the plans and specifications for the corresponding 2019 Capital Improvement Plan seg ment and portion of the 2019 Capital Improvem ent Plan with respect to which such disbursement is being made; and (iii) the report of the Cons ult ing Engineer attached as an Exhibit to the Thi.rd Supplemental Indenture, as such report shall have been amended or modified on the date hereof

w
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #	Amount	
 	41107	$2,815.28	
Sub-Total	$2,815.28

t:A..«i'I'

SYS'f E)IS L,L,C,

OCT O 3 2019

CAST SY8TEM81 LLC
19400 PEACHLAND BLVD PORT CHARLOTTE, PL 331'8 Phone: (141) 821-3474
Fa>e: (141) a-aa1440

Invoice Number: 41107

IN Vl ll\ ,I

Cus	l 

Invoice Date:	10/3/2019

Contao:t

QLACKBURNCREEK COMMUNITY Ol!VE\.OPME!NT
12051 CORPORATij BLV0
ORLANDO,  Fl- 32817-14110

Ship to: GAANC PALM 2Ad
US 41 RIQHT ON RIV! R RO Ll!!FT ON HARNEY ST

ProJ1ot Man1u1r:	ANORBW

c u,tom,r IP: 8V.CK8URN CREE

8hlp Vl1:

PO:	190403
County: EXEMPT
81111Rtp:	ADAM ROWAN

Struoture10

(PHASE. 2Ad) TYPE MINI.BTW/USF# 111OM
--	..  .	.
(PHAH 2Ad) TYPSM!NI.ETW/USfl# 111OM

Ti Xllblt N0fl•TIJUlblt

Ticket Numbt n	41107	Dollvory Datt:	1O/J/201Q	Tt rmt :	Nl2T 30	
Job Numbe:r	14759	Load:		Dut Datt:	11/2/2018	

Amount
$1,407.94
$1,407.114

10.00
SU 1U II

--

a ub Total	SU 1U II
- --	-		- - -  -  -  -  . TIX		1 0,00

- -

lnvolot Total	SU 1U II
- -	-  -   -  -  --	- -'
LOIi   opo11lt 	10.00
lfwol0tt l 11l1not	H ,111U ll

PURCHASE ORDER No. 	/90403	

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

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

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

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

Attention: Adam Rowan 239-595-4664

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: Obervation Blvd off of Center Road

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

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

Cast Systems, LLC	Blackburn Creek COD

Vendor name

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

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

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

ADDITIONAL TERMS AND CONDITIONSON PAGE 2

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

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

Tlme is of the essence.

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

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

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

Quantities are approximate and subject to project requirements.

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

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

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

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

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

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

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

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

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

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

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

Page   2  of	2

Cast System· s lnitial  ackburnCreek COD In ti

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Its: 	 	

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

_	_	_	_	_	---'

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

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

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

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

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the tern1s of the Master Trust Indenture from the District to U.S. Bank National Association, Fo1t Lauderdale, Florida, as trustee (the "Trustee"), 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 I, 2019 (the Master Indenture as amended and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-43

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

Amount Payable:	$7,673.37

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

Direct purchase of material for construction of Grand Palm, Phase lB(a). Purchase Order# 180601; See attached for invoice information

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

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

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

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:--" ----:-;,'-----,--c--=:------

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

If this requisi tio n is for a disbursement from other than Costs oflssuance, or for payment of capitalized interest, the undersigned Consulting Engineer hereby ce1tifies that this disbursement is for a Cost of the 2019 Capital Imp rovement 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 applica ble 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.

-

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	Ferguson Waterworks Project:	Phase 1B(a)

    Invoice #	Amount	
    1439888	$7,673.37	
Sub-Total	$7,673.37

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

Please contact with Questions:  800-456-1488

SEP 1 6 2019	 	

INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE
 	1439888	$7,673.37	41951	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 PH1BA
C/O FORSBERG CONSTRUCTION INC PO#180601
PUNTA GORDA, FL 33950

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC 645 CHARLOTTE ST

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180601

SALESMAN

TAE

JOB NAME

PH1BA SOURCE

INVOICE DATE

09/09/19

BATCH
10
81658

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	

/	2	
2	
1461SW	Source Order#: 1415136
2PC SC Cl VLV BX 19-22 WTR	
/ 95.000	
EA	
190.00	
j"	4
2	1461SW
1461SW	2PC SC Cl VLV BX 19-22 WTR
2PC SC Cl VLV BX 19-22 WTR	95.000
95.000	EA
EA	380.00
190.00	
2	2	IMJBGPU	6 MJ C153 BLT GSKT PK LI GLAND	/	12.700	EA	25.40	
2	2	AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV LIA	318.430	EA	636.86	
2	2	AFC2606DLAFMM	6 DI MJ RWOL SS STEM VLV LIA	406.555	EA	813.11	
/ 4	4	AFC2608DLAFMM	8 DI MJ RWOL SS STEM VLV LIA	647.000	EA	2588.00	
/ 2	2	AFCB84BLAOLP	5-1/4 VO B84B HYO 4'0 OL LIA	1425.000	EA	2850.00	

..................,............*••······· .................•.....• ..•.•.••.....•..•..............

INVOICE SUB-TOTAL

7673.37

LEAD LAWW .RNING: IT IS ILLE AL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL 1DR OTHER APPLI( !ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS V', TH 'NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABL: APPLICATIONS . UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE	TOTAL DUE	$7,673.37
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.

rul Ln/"'\.)t: Ul Ut:I l'JU.	/80601

Blackburn Creek Community Development District
c/o
Forsberg Co nstructi on, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (94 l) 637-8500	Fax, (941) 639-1073
Und erground Utility License liCUC0557 l6
Visit Us at \\Ww.forsl>c rgconstructio n.com

Ven dor: Ferguson Waterworks Addr ess: 18305 Paulson Drive
 Port Charlott e, FL 33954	

Job No.: 18-06

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

Project Addr ess: Obervat ion 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 I 0tll of 2ndMonth Vendor Phon e: 941-624-3494		 	

Quantity	Unit

Description

..

Unit Price

Total Price 	

---

    j

[

I

LS

1Pipe, Valves.Fittin gs and Appurtenanc;e in a ccordance
with Exhibit "A" (pages 1-3)

$

-

68,883.70

$

68,883.70

..	 	

----·

--

-

-

-

-·-

..

-

----

-

---
--
.--

--·	-	-
-	-

--

--

----·

-- .
-----·

I. -

-

--

I

--·

Pricesare good for duration of the project.

---

-----	--·
Project Durat ion: Janu ary 1, 2019 - January I, 2020

I
 L-    ....	

--- --

I 	

---

Total Project Subtotal	s
Sales Tax @ 6 %

----

Discre tio nary Tax @_1.0    %   on

- - --

I st $5,000.00
TOTAL

$

68,883.70
tax exempt tax exempt
68,883.70

A tten tion : _!t   ier  Evenson	 		Vendor Fax: 94 1-627-35 19

Ferg uson  W at er w orks    	 Vendor name	··

_  X-	-F-  -	---'-- -	   J	I	I _J  ---	

Blackburn Creek COD

"-:----'  	-	-	-	:f	,l_,}_fL   

Auth	ze   t\g nt (signature)	Date

Authorized

r  nrde/	};	-	-

 		 A1e !  	

Authori	ze  d  Agent (sig n;i ture)	D a t e
! IMPORTANT!

SEESPECIAL PROVISIONS ABOV E.

Page	of	2	ADDITIONAL TERMS ANO CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
I.	All material sha ll be as spec ified and warranted in accordance to the Project sp ecifications, pl ans and addencla.
Material sh all be within accepted standards for workmanship and quality, and sha ll be satisfactory to me et approval of the Owner, Owner's representative and Purchaser.

When requestedby Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete se t of shop draw ings for Purchaser's r eview and approval. All items suppli ed without prior approval, that do not meet Project requiremen ts,will be returned to Vendor, by Vendor, at no charge to Purcl1aser.

Tim e is of tl1e essen ce.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Venclor sh all notify Purchaser 24 hours in advance of arrival to j obsite to confirm delivery.

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

Shou ld the Vendor fail to provide materialas scheduled by Purchaser and Vendor, the Purchaser, up on 3 day written notice to Vendor, shall have the right to procure said materials elsewh ere without further responsibility to Vendor.

Quan titi esare approximate and subject to proj ect requirements.

Vendor agrees to accept without charge to Purchaser, all extra, n on-specialty materials in good concli tion which rem ain a er completion of work and will issue full credit for same.

Vendor shall sign ancl return Purchase Order within IO days of Purchase Or der date. Purchas er w ill return an executed Purchase Order to Vendor.

I 0.		To in sure prompt paymen t, Purchase Order number must appear on all invoicesand copies of signed delivery slips attached.

I I.	Neither party will change, alter, nor sub stitu te any part of this Purchase Order without consent of tile opposit e party. All changes so agreed to sh all be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaserw ith ou t receipt of a properly sign ed and acceptable Pur chase Order.

Sh ipm ent of any materials. be for e signin g this Purchase Order, will be considered an acceptance of this Pur chaseOrder.

If V e nd or fails to properly execu te and return Purchase Order within IO days, Purchaser may consid e r offer rejected.

1 5. This agr eement sh all be governed by the laws of th e State of Florida with venue in Charlo tte Coun ty, Florida.

.	The authorized agent sign in g this Purchas e Orde r for the Vendor must be duly authori zed to do so on b ehalf of the Vendor or on behalf of any such disclosed prin cipal.

In the event any of theseterms are declared to be unenforceable by a court of competent j urisdi ction, then Purch aser and Vendor intend for the remaining terms and conditions to rem ain in full force and effect.

This Purchase Order is the only binding contract between Purchaser and Vendor for this proj ect and the work described. This Purchase Order replaces arr previous contracts and  agreements, whether  written or  verbal, regarding this project. No other document will supersedethe requirements of this Purchase Order u nless signed by an authorized agent of each parly subsequen t to the date of this Purchase Order.

Page   2  of	2	Ferguson Initi al	Blackburn Creek COD ln ti tal	-

OeliverTo:
rom:	• Tyler A Evenson Comments:

FERGUSON

8		FEI-PT.CHARLOTTE WW 1705 18305 PAULSON DRIVE

WATERWORKS

PORT CHARLOTTE, FL 33954-0000

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

12 :30 :10 FEB 25 2019	Page 1 of 4

FEI-PORT CHARLOTTE #1705

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

XHI	'

B i d No:
Bid Date:
Quoted By:	B247136
02/25/19
TAE	Cust Phone:
Terms:	941-637-8500
NET 10TH PROX	
Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY	
	GRAND PALM PHASE 18a		GRAND PALM PHASE 18a	
	645 CHARLOTTE ST
PUNTA GORDA, FL 33950		645 CHARLOTTE ST
PUNTA GORDA, FL 33950	

Cust PO#:	180601	Job Name:	GRAND PALM PH 1Ba

Item		Description	Quantity	Net Price	UM	Total 'SEWER•
=====-=====-----===-----=
- 8 " PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2030	3.980    FT	8079.40
PD3105G4737	3X1000 UGDET SWR GREE	2	28.000   EA	56.00
SUBTOTAL	8135.40
- SINGLE SWR SRV (4)·
MUL067248	8X6 PVC HW SWR GXGXG 'NYE	4	47.530    EA	190.12
MUL067376	6 PVC HW SWR GXS 45 ELL	12	13.470   EA	161.64
MUL067326	6 PVC HW SWR GXG 45 ELL	4	18.240    EA	72.96
SDR26HWSPU14	6X14 SDR26 HWPVC GJ SWR PIPE	168	2.220    FT 	372.96
MUL067206	6 PVC HW SWR GXGXG 'NYE	4	36.570    EA	146.28
MUL040952	6 PVC SWR HUB FEM CO ADPT	4	11.720   EA	46.88
MUL040958	6 PVC SWR REC THRO CO PLUG	4	8.950    EA	35.80
CYPSKPX	2X4X8 YELL PINE STUD	4	3.000    EA	12.00
MUL043988	6 PVC SWR GSKT CAP	8	6.930    EA	55.44
SUBTOTAL	1094.08
- DBL SWR SRV (26) -

8X6 PVC HW SWR GXGXG 'NYE	26	47.530	EA	1235.78	
6 PVC HW SWR GXS 45 ELL	78	13.470	EA	1050.66	
6 PVC HW SWR GXG 45 ELL	26	18.240	EA	474.24	
6 PVC HW SWR GXG DBL WYE	26	68.260	EA	1774.76	
6 PVC SWR HUB FEM CO ADPT	26	11.720	EA	304.72	
6 PVC SWR REC THRO CO PLUG	26	8.950	EA	232.70	
6 PVC SWR GSKT CAP	78	6.930	EA	540.54	
6X14 SDR26 HW PVC GJ SWR PIPE	1092	2.220	FT	2424.24	
2X4X8 YELL PINE STUD	26	3.000	EA	78.00	
3X1000 UG DET SWR GREE	2	28.000	EA	56.00	
SUBTOTAL				8171.64	

MUL067248 MUL067376 MUL067326 MUL067277 MUL040952 MUL040958 MUL043988 SDR26HWSPU14 CYPSKPX PD3105G4737
TOTAL SANITARYSEWER	17401.12

1$ FERGUSON"

Page 2 of 4
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
Fax: 941-627-3519

12:30:10 FEB 25 2019
Reference No; B247136

Item	Description	Quantity	Not Price	UM	Total	
	
WATER MAIN•					
	=== =========== g=========					
	4" PVC WATER MAIN·					
DR18BPP	4 C900 DR18 PVC GJ BLUE PIPE	540	2.080	FT	1123.20	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
G1230BHS600	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00	
SPWPG4	4 SIGMA BELL REST F/ G900 'PVLOK	8	29.700	EA	237.60	
	SUBTOTAL				1477.80	
	-FITTINGS-					
MJ4LAP	4 MJ G153 45 BEND UA	2	29.240	EA	58.48	
SSLCE4AP	4 PVC WDG REST "ONELOK W/A	4	29.990	EA	119.96	
	SUBTOTAL				178.44	
	
4" GATE VLV ASSM (2) -					
AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV UA	2	318.430	EA	638.86	
SSLCE4AP	4 PVC WDG REST 'ONELOK W/A	4	29.990	EA	119.98	
1481SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMP	3 BRS GATE VLV ID- 4	2	13.000	EA	26.00	
	SUBTOTAL				972.82	
	
- 8" PVC WTR MAIN -					
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	2000	6.700	FT	13400.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	58.00	
C1230BHS500	12GA 30MM 500 FT COP TRGR WIRE BLUE	4	89.000	EA	358.00	

8 SIGMA BELL REST F/ COOO "PVLOK	42	60.050	EA	2102.10	
SUBTOTAL				15914.10	

SPWPC8

8" FITTINGS -

MJ2LAX	8 MJ C163 22-112 BEND UA	8	88.900	EA	413.40	
MJTLAX	8 MJ C163 TEE UA	1	127.850	EA	127.65	
MJRLAXP	8X4 MJ C153 RED UA	1	46.400	EA	48.40	
SSLCE8AP	8 PVC WDG REST "ONELOK W/A	28	46.150	EA	1292.20	

MJ4LAX	8 MJ C153 45 BEND UA	6	68.700   EA	412.20
SSLGE4AP	4 PVC WDG REST 'ONELOK W/A	1	29.990    EA	29.99

- 8" GATE VLV ASSM (4) -

8 DI MJ RW OL SS STEM VLV UA	
4	

647.000	

EA	

2588.00	
8 PVC WDG REST •ONELOK WIA	8	46.160	EA	369.20	
2PG SC GI VLV BX 19-22 WTR	4	95.000	EA	380.00	
3BRSGATEVLVID-8	4	13.000	EA	52.00	
SUBTOTAL				3389.20	
- FIRE HYD ASSM (2) -					
8X6 MJ G153 SWVL TEE UA	2	122.790	EA	245.58	
8 PVC WDG REST 'ONELOK WIA	4	46.150	EA	184.60	
6 PVC WDG REST 'ONELOK WIA	4	34.040	EA	138.16	
6 MJ C153 BLT GSKT PK UGLAND	2	12.700	EA	25.40	
6 DI MJ RW Ol SS STEM VLV UA	2	406.555	EA	813.11	
2PC SC Ci VLV BX 19-22 WTR	2	95.000	EA	190.00	

SUBTOTAL	2321.84
AFC2608DLAFMM SSLGE8AP 1461SW RBGVTMX

MJSTLAXU SSLGE8AF SSLCE6AP IMJBGPU AFC26060LAFMM
1461SW RBGVTMU DR18BPU

3 BRS GATE VLV ID-6	2	13.000	EA	
6 C900 DR18 PVC GJ BLUE PIPE	20	3.860	FT	

26.00
77.20

� FERGUSON®
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Page 3 of4

12:30:10 FEB 25 2019
Reference No: B247136

Item
AFCB84BlAOlP	Description
5-114 Vo B848 HYO 4'0 ol UA	Quantity	Net Price
------ms:ooo	UM
""EA""	Total

2850.00	
	SUBTOTAL				4548.05	
	SINGLE SHORT (34) •					
FS90404	4X1 CC BRS SDL C900	9	72.200	EA	849.80	
FS90804	ax1 cc BRS SDL C900	25	102.610	EA	2565.25	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	34	50.240	EA	1708.16	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	600	40.000	C	240.00	
PEC9BG100	"EXC 1X100 CTS ORS HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	34	87.340	EA	2969.56	
FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	68	1.260	EA	85.68	
CYPSKPX	2X4X8 YELL PINE STUD	34	3.000	EA	102.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	34	68.000	EA	2312.00	
	SUBTOTAL				10878.45	
	SINGLE LONG (22) •					
FS90404	4X1 CC BRS SOL C900	6	72.200	EA	433.20	
FS90804	ax, cc BRS SOL C900	16	102.610	EA	1841.76	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	22	50.240	EA	1105.28	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1200	40.000	C	480.00	
PEC9BG100	"EXC 1X100 CTS DR9 HDPE BLUE PIPE	100	40.000	C	40.00	
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	22	87.340	EA	1921.48	
FINSERT52	1 CT$ PET/ HOPE DR9 INS STFNR	44	1.260	EA	55.44	
CYPSKPX	2X4X8 YELL PINE STUD	22	3.000	EA	66.00	
CWA03111812	11X18X12 BX W/CIRDR LID SUD	22	68.000	EA	1498.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	880	0.550	FT	484.00	
	SUBTOTAL				8046.16	
FBLSLAX	BX12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST 'ONELOK WIA	2	48.150	EA	92.30	
	SUBTOTAL				216.60	
	8X8 HOTTAP (2) •					
J4320900X8	8X8 SS TAPN SLV 8.60-9.05	2	788.610	EA	1577.02	
AFC2608DLAFTM	8 DI MJ RWOLSS TAPNVLV UA	2	827.400	EA	1654.80	
1461SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMX	3 BRS GATE VLV ID- 8	2	13.000	EA	26.00	
SSLCE8AP	8 PVC WDG REST "ONELOK WIA	2	46.150	EA	92.30	
	SUBTOTAL				3540.12	
NetTotal:	$68883.70	
Tax:	$0.00	
Freight:	$0.00	
Total:	$68883.70	

Florida Admin Rule 12A-I.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 COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

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

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

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

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

CERTI FICATE OF ENTITLEMEN T
The und ersigned authorized representative of the Blackburn Creek Community Development District, a local unit of specia l purpose government (hereinafter "Go vernme ntal Entity"), Florida Consum er's Ce r ti ficate of Exe mpt io n Num ber 85-8015773053C-0.affir ms that the tangible personal property pur chased pu,·s uan t to Purchase Order Number 180601 from Ferguson Wa terw or ks (Vendor) on or after 2 /22/19 (date) will be incorporated into or become a part of a public facility as par t of a public works contr act pursuant to contract# n.li!. with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Pur chase Ord er meets the following exe mpt ion requirements conta ined in Section 21 2.08( 6). F.S., a nd Rule 12A-l.094, F.A.C.:

You 11111st initial each oft he folfowi11g requirements.

The attached Purchase Order is iss ued directly to the vendor supplyin g the  tangible  personal  pro )Crty the Contractor will use in the identified public works.
The vendo r"s invoice will be issued directly to Governmental Entity.
. Payment of the vendor"s inv oice will be made directly by Governmental Entity to the vend o r from pub ic fund s.
-	Governmental Entity will take title to the tangible personal property from the vendor at the time of pth-cl1ase or of delive1y by the vendor.
A	. 5. Government al Entity assumes the risk of damage or loss at the time of purchase or delivery by the

Go vernment al Entity affirm s that if the tangible personal property identified in the attached Pur chase Ord er does not qualify for the exemption provided in Section 212. 08 (6 ), F.S. and Rule 12 A-1. 0 9 4 , F.A.C.. Governme ntal Entity will be subject to the tax, interest, and penalties due on the tangible personal p roperty purchased. If th e  Florida Department of Revenue deter mines  that the tangible  personal property pur chased
tax-exempt by issu ing this Ce rtifi cate does not qualify for the exemption,Governmenta l Entity will be liable for any tax, penalty, and interest determined to be clue.

I unders tand that if I fraudulently issue th is certificate to evade the payment of sa les 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.

U nder the penalties of perjury. I declare that I hav e read the foregoing Ce rtifi cate of Entitlement and the
facts stated in it are true.

Q	

Blackbu rn Creek Communit y Development District, a local uni t of special pur pose government By:

Federal Empl oyer Identification Numb er: -   --   -   -   -   - -  -	=	­

You must attach a copy of the Pu rc hase Order to this Certificate of Ent itle ment.

Do not send to the Florida Depar tment of Revenue. This Certificate of Entitlement mus t be retain ed in the
vendor's and the cont ractor's books and records.

Blackburn Creek Community Development District

FORM OF REQUISITION FOR 2019 CAPITAL IMPROVEMENT PLAN

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust  Indenture  from  the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March I, 20I 3 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust  Indenture  from  the  District  to  the Trustee, dated as of February 1, 2019 (the  Master  Indenture  as  amended  and  supplemented is hereinafter referred to as the  "Indenture")  (all  capitalized  terms  used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-44

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

$12,500.48

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

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

The undersigned hereby certifies that [obligations in the stated amount set forth above have been incurred by the District, that each disbnrsement set forth above is a proper charge against the Series 20I 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.

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 ce1tificate entitled to retain.

Blackburn Creek Community Development District

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:
Au10rizedOffice

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.

-g

,,J
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #		Amount	 40948	$6,904.94
 	40959	$5,595.54	
Sub-Total	$12,500.48

f AS'I,
SYS1'EIIS L,LC,

CAST 8Y8TEM8, LLC
11400 PEACHLAND Bl.VD PORT CHARI.OTTE, FL 33148 Phono1 (841) H G•S474
Fax: (141) H l •t« I

SEP 03 2019

Invoice Numbe:r 40948
PY	Invoice Datt:	8/30/2019
 	  -

Blll to:		BLACKBURNCREEK COMMUNTIY CEVl!LOPMt!NT 120G1 CORPOAATE BL.VD
ORLANDO, FL 32817-1480
Contact:

Cu1t0mer 10:	81.ACKOURN CRl:li

Ship Via:

Ship to: ORANO PALM 2Ad
US 41 RIGHf ONRIVl!lR RO L.Efi'l' ON HARNII Y ST

ProJtot M1n111or1   AN01'\l! W
PO:	180403
County: EXi MPf
81111Rep:	ACAMROWAN

Ticket Numbt r:	40i48
Job Number:	147H

/

Struoturt ID

Dollvt ry Dato:	8130/21011

l truoturoTypo

Torm1:
lll!O Di tt i

Nl!f 30
Q/H/20HI

- - -	- -  - -	---

Am-ou-nt

MHB,li,G,12 MHB•G·G•1 4 MH O•G-ti•06

(PHAS 2Ad) 40" I AMH W/U81'# HO ll8/10
(PHAH 2M) 40" OAMHWIU8fi# 170 01/10
. . ..	. .   .  .	.	.	..	. .	. ....
(rA!8   2Ad) 41"8AMH W/U8fi# 17010/1

12,177.11
.    .	.. . .    . .	.
'2 ,177.11
.. 2i ,aao,n

TIIKi!l:!1@
Nlln•TIIXl\DIO
Bub 'fOIAI	111,000 4

,o,oo

--	-  --	- ·-	- -	--
fill(

-

II WOIH Totll	l l!,QOU 4
-·   -  -	-   --	-   -   -·   -
l.t!H   t1p@11it	tlHlO
lnvuln ll iili flH	

C AS'I'
SYS'l'l )IS L,L,C,

SEP O 4 2019

CAST SYSTEMS, LLC 19400 PEACHLAND BLVD
PORT CHARLOTTE, FL 33948 Phone: (941) 625-3474
Fax: (941) 255-9448

Invoice Number: 40959
Invoice Date:	9/4/2019

IN VO IC[ 

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

Customer ID: BLACKBURN CREE

Ship Via:

Ship to: GRAND PALM 2Ad
US 41 RIGHTON RIVER RD LEFT ON HARNEY ST

Project Manager: ANDREW
PO:	190403
County: EXEMPT
Salet Rep:	ADAM ROWAN

Ticket Number:	40959	Delivery Date:	9/4/2019	Term, :	NET 30	
Job Number:	14769	Load:		Due Date:	10/4/2019	

Structure ID MH B-0-5-13 MH 8-5-5-08 MH B-5-5-10

Structure Type
(PHASE 2Ad) 48" SAMH W/USF# 170 08110
(PHASE 2Ad) 48" SAMH W/USF# 170 06108 (PHASE 2Ad) 48" SAMH W/USF# 170 00/08

Amount

/

-   -	-   .
$2,177.11
$1 .-8 34.15
$1,684.28/

Taxable Non-Taxable
Sub Total

$0.00
$5,595.54
$5,595.04

Tax	$0.00
lnvolot Totll	$M9o.54
l.t H Ot poalt	$0.00
Invoice Balanoe	$U  95.54

PURCHASE ORDER No. 	/90403	

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

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

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

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

Attention: Adam Rowan 239-595-4664

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: Obervation Blvd off of Center Road

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

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

Cast Systems, LLC	Blackburn Creek COD

Vendor name

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

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

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

ADDITIONAL TERMS AND CONDITIONSON PAGE 2

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

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

Tlme is of the essence.

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

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

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

Quantities are approximate and subject to project requirements.

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

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

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

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

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

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

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

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

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

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

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

Page   2  of	2

Cast System· s lnitial  ackburnCreek COD In ti

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Its: 	 	

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

_	_	_	_	_	---'

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

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

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

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

The undersigned, an Authorized Officer of Blackbum Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the tem1s 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 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 terms used herein shall have the meaning ascribed to such tenn in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-45

County Materials Corp.
P.O. Box435 Astatula, FL 34705

$10,991.92

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 lB(a).
Purchase Order # 180602; See attached for invoice information

The undersigned hereby ceitifies 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 20I 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.

The undersigned hereby further certifies that such reqmsit1011 contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

AutonzedOfficer	:

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

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

Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 1B(a)

    Invoice #		Amount	 18802-09	$3,829.04
18802-10	$3,611.92
    18802-11	$3,550.96	
Sub-Total	$10,991.92

COUNTY

SHIPPED	INVO IC E DATE	I	ORDER NO.	
08/27/19	08/27/19	I	148 802-09	
I	P.O. NO.		I	PAGE #	
44	I ct	18060 2		I 1 of 1	

. (866) 343 -8 488 Fax (352) 343-0471

SEP O 3 2019	INVOICE

M ATE R I A LS C O RPO RA T I O N
CUST #:	3275
Grand Palm Phase 1Ba
SHIP TO : Sarasota County

ASTATULA, FL 3 470 5-0 435

REMIT TO:
PO BOX 38
MARATHON, WI 54448 -00 38

Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRU CTION 645 CHARLOTTE STREET PUNTA GORDA FL 33950

LINE I
NO.	PRODUCT AND DESCRIPTION	I	SHIPPED	I
Q T Y.	Q T Y.
U/M	I	UNI T PRICE	I	AMOUNT (NET)	
5	230380s	32. 00	LF	34. 73 ..,.	111 1 . 36	
	30"	RCP CL3 SMALL BELL				
6	230s	4.00	EA	0.00	0. 00	
	30" RCCP GASKET SMALL BELL #839230				
7	236380s	/4 6. 00	LFT	48. 53 ./	27 17. 68	
	36" RCP CL3 SMALL BELL				
8	236s	7. 00	EA	0 . 00	0. 00	
	36 " RCCP GASKET SM ALL BELL #839236				
			Total	3829 . 04	
			Invoice Tot al	3829. 04	

COUNTY

MATERIALS CORPORATION

. (866) 343-8488 Fax (352) 343-0 471
ASTATULA, FL 3 470 5-0 435

REMIT TO: PO BOX 38

SEP O 3 2019	INVOICE

SHIPPED	INVOICE DA TE	I	ORDER NO.	
08 /28 /1 9	08/28 /19	I	14880 2-10	
I	P.O. NO.		I	PAGE#	
44	I ct	180602		I 1 of 1	

CUSH   :	3275	MARATHON, WI 54448 -0038
Grand Palm Phase 1Ba
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TD:

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION 645  CHARLOTTE  STREET PUNTA GORDA FL 33950

DESCRIPTION	I

NOE. 1	AND   DOOCT
5	230380s
30" RCP CL3 SMALL BELL
6	230s
30" RCCP GASKET SMALL BELL #839230

QTY .	QTY.

I	l

SfiJPPED	U/ M
VJ 04. 00	LF

00	EA

UNIT	, I
PRICE	A
34. 73"

0. 00

AMOUNT
(NET)
3611. 92 V

0. 00

Total  Invoice Total

3611. 92
3611. 92

� COUNTY.

(866) 343-84 88 Fax (352) 343-04 7 1
AS TATULA, FL 3470 5-0 435

SEP O 3 2019	IN VOICE

SHIPPED	INVOIC E DATE	I	OR D ER NO.	
08 /29/19	08/29/19	I	14880 2-11	
I	P.O. ND.		I	PAGE #	
44	l ct	180602		I 1 of 1	

M ATE RI A L S CO RPO RAT I O N

REMIT TO:
PO  BOX 38
CU ST  #:	3275	MARATHON, WI 54448 -0038
Grand Palm Phase ·1Ba
SHIP rn, Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BILL TO:

BLACKBURN  CREEK COD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORD A FL 33950

LNI   E
NO.	I	PRODUCT
AND DESCRIPTION	I		QTY . SHI PPED	I	
QTY.
U /M	I	UN IT PRICE	1	AMOUNT (NET)	
	218380s		152. 00	LFT	16. 05 V	2439.60	
	18" RCP CL3 SMALL BELL					
2	218ep		19. 00	EA	0.00	0.00	
	18"RCCP GASKET SMALL BELL					
5	230380s	./	32. 00	LF	34. 73	11 11. 36	
	30" RCP CL3 SMALL BELL					
6	230s		4.00	EA	0. 00	0 . 00	
	30" RCCP GASKET SM ALL BELL 11839230					
				Total	3550.96	
				Invoice Total	3550.96	

PURCHASE ORDER No. 	180602	

Blackburn Creek Community Development District
c/o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (941) 637-8500	Fax: (941) 639-1073
Und erground Utility License #CUC 055716
Visit Us at www.forsbcrgconstruction.com

Vendor: County Materials Corporation Address: P.O. Box 435
   Astatula, FL 34705	

Job No.:   18 -06-----
P.O. Date: February 21, 2019

Project Name: Grand Palm Phase I Ba

Project Address: Obervation Blvd off of Center Road

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

Payment Terms: _N:....:..::.e 3:t:..0:......::..da:::.yccs.._ 	_

Vendor Phone: _8_6_6'-·3_4_3_-8_4_8_8	_

Quantity	Unit		Description	Unit Price	Total Price	
							
32	+/-	LF	l8"RCP	s	16 . 0 5		s	5 13 . 60	
616	+/-	LF	24' RCP	$	24.45		$	15,061.20	
176	+/-	LF	30"RCP	s	34.73		s	6,112.48	
472	+/-	LF	36"RCP	s	48 . 53		$	22,906.16	
2	+/-	EA	24" Flared End Section	$	1,0 1 2.00		$	2,024.00	
I	+/-	EA	30" Flared End Section	$	1,315.40		$	1,315.40	
3	+/-	EA	36" Flared End Section	$	1,5 62.00		$	4,686 .00	

						
						
	I					
						
		Prices are qood for duration of the project.				
						
		Project Duration: January 2, 2019 - January 2, 2020				
Total Project Subtotal	$	52,618 .84	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ J .0 % on J st S5,000.00	tax exempt	
TOTAL	$	52,618 .84	

Attention : Johnny_ Smith 941-915-3671

Coun!}' Materials

't.

Venaorname
X '"-Ult	0 1 Q	i l 1- 3.;6 L

Vendor Fax: 352-343-0471

Blackburn Creek COD

Cha		C: 
3L1! L'f

Authorized Agent {signature)	CJ	Date
 	 		1haj	

/\Umonzea /\gent (signature)	Date
! IMPORTANT!

Authorized Agent 1printedftyped)
Page	I	of	2

�SEESPECIAL PROVISIONS ABOVE.
ADDITIONAL TERMS AND CONDITIONS ON PAGE 2

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

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

Time is of the essence.

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

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

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

Quantities are approximate and subject to project requirements.

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

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

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

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

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

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

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

I 5. This agreement shall be governed by the Jaws of the State of Florida with venue in Charlotte County, Florida.

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

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

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

Page   2  of	2	County Materials Initial	Blackburn Creek COD lntital	,........

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

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

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

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

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

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

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

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

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

CERTIFICATE OF ENTIT LEMEN T
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 180602 from County Materials (Vendor) on or after 2/21/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

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

You must initial each of the following requirements.
The attached Purchase Order is issued directly to the vendor supplying the tangible personal priper theContractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pubj½ u ds.
&l:f/4· Governmental Entity will take title to the tangible personal property from the vendor at the time of
pu ase orof delivery by the vendor.
5.	Governmenta l Entity assumes the risk of damage or loss at the time of purchase or delivery by the vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Cer tificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to bedue.

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

Under the penalties of perjury, 1 declare that I have read the foregoing Cer tifica te of Ent itle ment and the facts stated in it are true.

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

By: -=	-	 ----=    =-...i.-"":L:		 :

Its-:

-     -	 -' s-:::'-'-= ..::...::::::...,c-_ _ _ _ _ _ _ _

,,,

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

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

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

II

06?022 11/0C/H

FlORIDA

[£  01 sumer1s Certiflcate ci[ Exemption]
Issued Pursuant to Chapter 2121 Florida Siatutes

DR-14
R.10/15

I	85·8015773053C·O	11/30/2016	11/30/2021	COUNTY GOVERNMENT

Certllicata Number
This certifies that·

Effective Date	Expiration Da_te	ExemptiQn C tegory

BLACKBURN -CREEK COMMUNITY DEVELOPMENT DISTRICT
12051 CORPORATE BLVD
ORLANDO Fl 32817-1450

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

ll	Important Information for Exempt Organizations

DR-14
R.10/15

FLORIDA.

You m_ust provide an vendors . nd suppliers with an exemption certificate before maklng tax-exempt purchases. See Rule 12A-1.038, Florida Administrative Code (F:A.C.).

Your Consumer's Certificate of Exemption Is to be used solely by your organizationfor your organization's
cuslommy nonprofit activities.

Pmchases made by an Individual on behalf of the organization are taxable, even it the Individualwlll be reimbusred by the organization.

4,		This exemption applies only topurchases your organization makes. The sale or lease to others of tangible personal property, sleeping accommodations, or other real property Is taxable. Yot.- organization must register, and collect and remit sales and use tax on such taxable transactions. Note: Churches are exempt from this requirement except when they are the lessor of real property (Rule 12A-1.070, F.A.CJ.

It Is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no circumstancesshould this certificate be used for the personal benefit of any lndlvldual.  Violators will be liable for payment of the sales tax plus a penally of 200% of the tax,and may be subject to conviction of a third-degree felony. Any violation will require the revocation of this certificate,

If you have questions regarding your exernptlon certificate, please contact the Exemption Unit of Account Management at 800-352-367.1 From the available options, select KReglstratron of Taxes," then "Registration lnfonna ion,• and finally "Exemption Certificates and Nonprofit Entitles." The malllng address Is PO Box 6480, Tallahassee, FL 32314-6480.

RECEIVED f.JOV.1 11 2016

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 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:

2019-46

County Materials Corp.
P.O. Box435 Astatula, FL 34705

Amount Payable:	$1,562.00

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

Direct purchase of material for construction of Grand Palm, Phase lB(a). Pnrchase Order# 180602; See attached for invoice information

The undersigned hereby certifies that [obligations in the stated amow1t set forth above have been incurred by the District, that each disbursement set forth above is a proper charge against the Series 2019 Acquisition and Construction Account, that each disbursement set forth above was incurred in connection with the acquisition and/or construction of the 2019 Capital Improvement Plan and represents a Cost of the 2019 Capital Improvement Plan, and has not previously been paid] OR [the requisition is for Costs of Issuance payable from the Costs of Issuance Account that has not previously been paid].

The undersigned hereby further ce1tifies that there has not been filed with or served upon the District notice of any lien, right to lien, or attachment upon, or claim affecting the right to receive payment of, any of the moneys payable to the Payee set forth above, which has not been released or will not be released simultaneously with the payment hereof.

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

Blackburn Creek Community Development District

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By e?	

/

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 dis burse ment 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 fmprovement Plan segment and portion of the 2019 Capital Improvement Plan with respect to which such disbursement is being made; and (iii) the repo1t of the Consulting Engineer attached as an Exhibit to the Third Supplemental Indenture, as such report shall have been amended or modi fied on the date hereof.

f'

 w	C\	
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 1B(a)

    Invoice #	Amount	
   148802-12	$1,562.00	
Sub-Total	$1,562.00

SEP 1 6 2019	INVOICE

SHIPPED	
INVOICE DATE	I	ORDER NO.	
09/11 /19	09/11 /19	I	148802-12	
I	P.O. NO.		I	PAGE#	
44	I ct	180602		I 1 of 1	

(866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38
CUST ,,	3275	MARATHON, WI 54448-0038
Grand Palm Phase 1Ba
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION
BILL m	645 CHARLOTTE STREET
PUNTA GORDA FL 33950

LINE
NO.		PRODUCT
AND DESCRIPTION	I	QTY.
SHIPPED		I	QTY. I
VIM	UNIT PRICE	J,	AMOUNT
(NET)	
11	236889s	1.	00	EA	1562. oov

Total	1562.00	
	36" FLARED END SECTION GB SMALL BELL						
				Total		1562. 00	
				Invoice		1562. 00	

PURCHASE ORDER No. 	180602	

Blackburn Creek Community Development District
c/o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (941) 637-8500	Fax: (941) 639-1073
Und erground Utility License #CUC 055716
Visit Us at www.forsbcrgconstruction.com

Vendor: County Materials Corporation Address: P.O. Box 435
   Astatula, FL 34705	

Job No.:   18 -06-----
P.O. Date: February 21, 2019

Project Name: Grand Palm Phase I Ba

Project Address: Obervation Blvd off of Center Road

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

Payment Terms: _N:....:..::.e 3:t:..0:......::..da:::.yccs.._ 	_

Vendor Phone: _8_6_6'-·3_4_3_-8_4_8_8	_

Quantity	Unit		Description	Unit Price	Total Price	
							
32	+/-	LF	l8"RCP	s	16 . 0 5		s	5 13 . 60	
616	+/-	LF	24' RCP	$	24.45		$	15,061.20	
176	+/-	LF	30"RCP	s	34.73		s	6,112.48	
472	+/-	LF	36"RCP	s	48 . 53		$	22,906.16	
2	+/-	EA	24" Flared End Section	$	1,0 1 2.00		$	2,024.00	
I	+/-	EA	30" Flared End Section	$	1,315.40		$	1,315.40	
3	+/-	EA	36" Flared End Section	$	1,5 62.00		$	4,686 .00	

						
						
	I					
						
		Prices are qood for duration of the project.				
						
		Project Duration: January 2, 2019 - January 2, 2020				
Total Project Subtotal	$	52,618 .84	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ J .0 % on J st S5,000.00	tax exempt	
TOTAL	$	52,618 .84	

Attention : Johnny_ Smith 941-915-3671

Coun!}' Materials

't.

Venaorname
X '"-Ult	0 1 Q	i l 1- 3.;6 L

Vendor Fax: 352-343-0471

Blackburn Creek COD

Cha		C: 
3L1! L'f

Authorized Agent {signature)	CJ	Date
 	 		1haj	

/\Umonzea /\gent (signature)	Date
! IMPORTANT!

Authorized Agent 1printedftyped)
Page	I	of	2

�SEESPECIAL PROVISIONS ABOVE.
ADDITIONAL TERMS AND CONDITIONS ON PAGE 2

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

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

Time is of the essence.

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

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

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

Quantities are approximate and subject to project requirements.

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

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

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

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

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

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

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

I 5. This agreement shall be governed by the Jaws of the State of Florida with venue in Charlotte County, Florida.

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

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

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

Page   2  of	2	County Materials Initial	Blackburn Creek COD lntital	,........

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

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

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

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

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

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

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

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

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

CERTIFICATE OF ENTIT LEMEN T
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-8015773053C-0, affirms that the tangible personal property purchased pursuant to Purchase Order Number 180602 from County Materials (Vendor) on or after 2/21/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

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

You must initial each of the following requirements.
The attached Purchase Order is issued directly to the vendor supplying the tangible personal priper theContractor will use in the identified public works.
The vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from pubj½ u ds.
&l:f/4· Governmental Entity will take title to the tangible personal property from the vendor at the time of
pu ase orof delivery by the vendor.
Governmenta l Entity assumes the risk of damage or loss at the time of purchase or delivery by the vendor.

Governmental Entity affirms that if the tangible personal property identified in the attached Purchase Order does not qualify for the exemption provided in Section 212.08(6), F.S. and Rule 12A-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Cer tificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to bedue.

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

Under the penalties of perjury, 1 declare that I have read the foregoing Cer tifica te of Ent itle ment and the facts stated in it are true.

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

By: -=	-	 ----=    =-...i.-"":L:		 :

Its-:

-     -	 -' s-:::'-'-= ..::...::::::...,c-_ _ _ _ _ _ _ _

,,,

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

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

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

Blackburn Creek Community Development District
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 l, 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 terms used herein shall have the meaning ascribed to such te1m in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-47

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

$3,761.39

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

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

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

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

The undersigned hereby finther ce1tifies that such requts1t10n contains  no  item  representing payment on account of any retained percentage  which  the  District  is at  the date of such certificate entitled to retain.

Blackburn Creek Community Development District

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

B	--  7dofficer

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

If this requis ition is for a disbursement from other than Costs of Issuance, or for payment of capitalized interest, the undersig ned Co nsulting 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 Indentu re, as such report shall have been amended or modified on the date hereof.

C�on�sulting  Engineer

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #	Amount	
 	41010	$3,761.39	
Sub-Total	$3,761.39

CAS'I'
SYS'l'l )IS L,L,C,

CAST SYSTEMS, LLC 19400 PEACHLAND BLVD
PORT CHARLOTTE, FL 33948 Phone: (841) 820•3474
Fax: (941) 200-8«8

SEP 17 2019

Invoice Number: 41010
Invoice Date:	9/5/2019

INVOIC:F-

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

Customer ID: BLACKBURN CREE

Ship Via:

Ship to: GRAND PALM 2Ad
US 41 RIGHT ON RIVER RD LEFT ON HARNEY ST

Project Manager: ANDREW
PO:	190403
County: EXEMPT
Sal11 Rep:	ADAM ROWAN

Ticket Number:	41010	Delivery Date:	9/5/2019	Term,:	NET30	
Job Number:	14759	Load:		Due Date:	10/5/2019	

Structure ID MH B-5-5-06 MH B-5-5-09

Structure Type
(PHASE 2Ad) 48" SAMH W/USF# 170 08/10 (PHASE 2Ad) 48" SAMH W/USF# 170 00/06

Amount
.	-
$2,177.11
$1,084.28/

Taxable	$0.00

Non-Taxaleb	$3,761.39
Sub Total	$3,761.39
Tax	$0.00
Invoice Total	$3,761.39
-  - -	-
L.111Deposit	$0.00
Invoice Balance	$3,761.39

PURCHASE ORDER No. 	/90403	

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

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

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

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

Attention: Adam Rowan 239-595-4664

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: Obervation Blvd off of Center Road

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

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

Cast Systems, LLC	Blackburn Creek COD

Vendor name

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

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

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

ADDITIONAL TERMS AND CONDITIONSON PAGE 2

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

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

Tlme is of the essence.

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

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

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

Quantities are approximate and subject to project requirements.

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

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

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

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

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

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

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

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

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

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

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

Page   2  of	2

Cast System· s lnitial  ackburnCreek COD In ti

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Its: 	 	

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

_	_	_	_	_	---'

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

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

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

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

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master 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 terms used herein shall have the meaning ascribed to such term in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-48

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

$484.00

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

Direct purchase of material for construction of Grand Palm, Phase lB(a). Purchase Order# 180601; 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 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 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 hereo£

Blackburn Creek Community Development District
The undersigned hereb y 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 propetty acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:
Authortzed Officer

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

If this requisition is for a disb ursement from other than Costs oflssuance, 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 attac hed as an Exhibit to the Third Supplemental Indentur e, 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 1B(a)

    Invoice #	Amount	
    1444073	$484.00	
Sub-Total	$484.00

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

Please contact with Questions: 800-456-1488

BLACKBURN CREEK COMMUNITY DEVE GRAND PALM PH1BA
C/O FORSBERG CONSTRUCTION INC PO#180601
PUNTA GORDA, FL 33950

OCT 1 4 20i9	 INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1444073	$484.00	41951	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 PH1BA
C/0 FORSBERG CONSTRUCTION INC
645 CHARLOTTE ST

SHIP WHSE.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

180601

SALESMAN

TAE

JOB NAME

PH1BA SOURCE

INVOICE DATE

10/10/19

BATCH
10
81824

ORDERED

880

SHIPPED

880

ITEM NUMBER

SDR21BPK

DESCRIPTION
Source Order#: 1415136
2 SDR21 CL200 PVC GJ BLUE PIPE

INVOICE SUB-TOTAL

UNIT PRICE	UM
J 0.550	FT

AMOUNT

484.00

484.00

LEAD LAWWJ RNING: IT IS ILLEl AL TO INSTALL PRODL CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I ROTHER APPLIC !ABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH 'NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESF ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	NET 10TH PROX	ORIGINAL INVOICE

TOTAL DUE	$484.00

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/content/website-info/terms-of-sale,incorporated by reference. Seller may convert checks to ACH.

rul Ln/"'\.)t: Ul Ut:I l'JU.	/80601

Blackburn Creek Community Development District
c/o
Forsberg Co nstructi on, Inc.
645 Charlotte Street, Punta Gorda FL 33950 Phone: (94 l) 637-8500	Fax, (941) 639-1073
Und erground Utility License liCUC0557 l6
Visit Us at \\Ww.forsl>c rgconstructio n.com

Ven dor: Ferguson Waterworks Addr ess: 18305 Paulson Drive
 Port Charlott e, FL 33954	

Job No.: 18-06

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

Project Addr ess: Obervat ion 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 I 0tll of 2ndMonth Vendor Phon e: 941-624-3494		 	

Quantity	Unit

Description

..

Unit Price

Total Price 	

---

    j

[

I

LS

1Pipe, Valves.Fittin gs and Appurtenanc;e in a ccordance
with Exhibit "A" (pages 1-3)

$

-

68,883.70

$

68,883.70

..	 	

----·

--

-

-

-

-·-

..

-

----

-

---
--
.--

--·	-	-
-	-

--

--

----·

-- .
-----·

I. -

-

--

I

--·

Pricesare good for duration of the project.

---

-----	--·
Project Durat ion: Janu ary 1, 2019 - January I, 2020

I
 L-    ....	

--- --

I 	

---

Total Project Subtotal	s
Sales Tax @ 6 %

----

Discre tio nary Tax @_1.0    %   on

- - --

I st $5,000.00
TOTAL

$

68,883.70
tax exempt tax exempt
68,883.70

A tten tion : _!t   ier  Evenson	 		Vendor Fax: 94 1-627-35 19

Ferg uson  W at er w orks    	 Vendor name	··

_  X-	-F-  -	---'-- -	   J	I	I _J  ---	

Blackburn Creek COD

"-:----'  	-	-	-	:f	,l_,}_fL   

Auth	ze   t\g nt (signature)	Date

Authorized

r  nrde/	};	-	-

 		 A1e !  	

Authori	ze  d  Agent (sig n;i ture)	D a t e
! IMPORTANT!

SEESPECIAL PROVISIONS ABOV E.

Page	of	2	ADDITIONAL TERMS ANO CONDITIONS ON PAGE 2

TERMS AND  CONDITIONS
All material sha ll be as spec ified and warranted in accordance to the Project sp ecifications, pl ans and addencla.
Material sh all be within accepted standards for workmanship and quality, and sha ll be satisfactory to me et approval of the Owner, Owner's representative and Purchaser.

When requestedby Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete se t of shop draw ings for Purchaser's r eview and approval. All items suppli ed without prior approval, that do not meet Project requiremen ts,will be returned to Vendor, by Vendor, at no charge to Purcl1aser.

Tim e is of tl1e essen ce.

Delivery of materials to be coordinated by Purchaser in order to accommodate unloading. Venclor sh all notify Purchaser 24 hours in advance of arrival to j obsite to confirm delivery.

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

Shou ld the Vendor fail to provide materialas scheduled by Purchaser and Vendor, the Purchaser, up on 3 day written notice to Vendor, shall have the right to procure said materials elsewh ere without further responsibility to Vendor.

Quan titi esare approximate and subject to proj ect requirements.

Vendor agrees to accept without charge to Purchaser, all extra, n on-specialty materials in good concli tion which rem ain a er completion of work and will issue full credit for same.

Vendor shall sign ancl return Purchase Order within IO days of Purchase Or der date. Purchas er w ill return an executed Purchase Order to Vendor.

I 0.		To in sure prompt paymen t, Purchase Order number must appear on all invoicesand copies of signed delivery slips attached.

I I.	Neither party will change, alter, nor sub stitu te any part of this Purchase Order without consent of tile opposit e party. All changes so agreed to sh all be initialed and dated by authorized agents of both parties.

No invoices will beprocessed or paid by Purchaserw ith ou t receipt of a properly sign ed and acceptable Pur chase Order.

Sh ipm ent of any materials. be for e signin g this Purchase Order, will be considered an acceptance of this Pur chaseOrder.

If V e nd or fails to properly execu te and return Purchase Order within IO days, Purchaser may consid e r offer rejected.

1 5. This agr eement sh all be governed by the laws of th e State of Florida with venue in Charlo tte Coun ty, Florida.

.	The authorized agent sign in g this Purchas e Orde r for the Vendor must be duly authori zed to do so on b ehalf of the Vendor or on behalf of any such disclosed prin cipal.

In the event any of theseterms are declared to be unenforceable by a court of competent j urisdi ction, then Purch aser and Vendor intend for the remaining terms and conditions to rem ain in full force and effect.

This Purchase Order is the only binding contract between Purchaser and Vendor for this proj ect and the work described. This Purchase Order replaces arr previous contracts and  agreements, whether  written or  verbal, regarding this project. No other document will supersedethe requirements of this Purchase Order u nless signed by an authorized agent of each parly subsequen t to the date of this Purchase Order.

Page   2  of	2	Ferguson Initi al	Blackburn Creek COD ln ti tal	-

OeliverTo:
rom:	• Tyler A Evenson Comments:

FERGUSON

8		FEI-PT.CHARLOTTE WW 1705 18305 PAULSON DRIVE

WATERWORKS

PORT CHARLOTTE, FL 33954-0000

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

12 :30 :10 FEB 25 2019	Page 1 of 4

FEI-PORT CHARLOTTE #1705

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

XHI	'

B i d No:
Bid Date:
Quoted By:	B247136
02/25/19
TAE	Cust Phone:
Terms:	941-637-8500
NET 10TH PROX	
Customer:	BLACKBURN CREEK COMMUNITY	Ship To:	BLACKBURN CREEK COMMUNITY	
	GRAND PALM PHASE 18a		GRAND PALM PHASE 18a	
	645 CHARLOTTE ST
PUNTA GORDA, FL 33950		645 CHARLOTTE ST
PUNTA GORDA, FL 33950	

Cust PO#:	180601	Job Name:	GRAND PALM PH 1Ba

Item		Description	Quantity	Net Price	UM	Total 'SEWER•
=====-=====-----===-----=
- 8 " PVC GRAV SWR -
SDR26HWSPX 14	8X14 SDR26 HW PVC GJ SWR PIPE	2030	3.980    FT	8079.40
PD3105G4737	3X1000 UGDET SWR GREE	2	28.000   EA	56.00
SUBTOTAL	8135.40
- SINGLE SWR SRV (4)·
MUL067248	8X6 PVC HW SWR GXGXG 'NYE	4	47.530    EA	190.12
MUL067376	6 PVC HW SWR GXS 45 ELL	12	13.470   EA	161.64
MUL067326	6 PVC HW SWR GXG 45 ELL	4	18.240    EA	72.96
SDR26HWSPU14	6X14 SDR26 HWPVC GJ SWR PIPE	168	2.220    FT 	372.96
MUL067206	6 PVC HW SWR GXGXG 'NYE	4	36.570    EA	146.28
MUL040952	6 PVC SWR HUB FEM CO ADPT	4	11.720   EA	46.88
MUL040958	6 PVC SWR REC THRO CO PLUG	4	8.950    EA	35.80
CYPSKPX	2X4X8 YELL PINE STUD	4	3.000    EA	12.00
MUL043988	6 PVC SWR GSKT CAP	8	6.930    EA	55.44
SUBTOTAL	1094.08
- DBL SWR SRV (26) -

8X6 PVC HW SWR GXGXG 'NYE	26	47.530	EA	1235.78	
6 PVC HW SWR GXS 45 ELL	78	13.470	EA	1050.66	
6 PVC HW SWR GXG 45 ELL	26	18.240	EA	474.24	
6 PVC HW SWR GXG DBL WYE	26	68.260	EA	1774.76	
6 PVC SWR HUB FEM CO ADPT	26	11.720	EA	304.72	
6 PVC SWR REC THRO CO PLUG	26	8.950	EA	232.70	
6 PVC SWR GSKT CAP	78	6.930	EA	540.54	
6X14 SDR26 HW PVC GJ SWR PIPE	1092	2.220	FT	2424.24	
2X4X8 YELL PINE STUD	26	3.000	EA	78.00	
3X1000 UG DET SWR GREE	2	28.000	EA	56.00	
SUBTOTAL				8171.64	

MUL067248 MUL067376 MUL067326 MUL067277 MUL040952 MUL040958 MUL043988 SDR26HWSPU14 CYPSKPX PD3105G4737
TOTAL SANITARYSEWER	17401.12

1$ FERGUSON"

Page 2 of 4
FEI-PORT CHARLOTTE #1705
WATERWORKS	Price Quotation
Fax: 941-627-3519

12:30:10 FEB 25 2019
Reference No; B247136

Item	Description	Quantity	Not Price	UM	Total	
	
WATER MAIN•					
	=== =========== g=========					
	4" PVC WATER MAIN·					
DR18BPP	4 C900 DR18 PVC GJ BLUE PIPE	540	2.080	FT	1123.20	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
G1230BHS600	12GA 30MM 500 FT COP TRCR WIRE BLUE	1	89.000	EA	89.00	
SPWPG4	4 SIGMA BELL REST F/ G900 'PVLOK	8	29.700	EA	237.60	
	SUBTOTAL				1477.80	
	-FITTINGS-					
MJ4LAP	4 MJ G153 45 BEND UA	2	29.240	EA	58.48	
SSLCE4AP	4 PVC WDG REST "ONELOK W/A	4	29.990	EA	119.96	
	SUBTOTAL				178.44	
	
4" GATE VLV ASSM (2) -					
AFC2604DLAFMM	4 DI MJ RW OL SS STEM VLV UA	2	318.430	EA	638.86	
SSLCE4AP	4 PVC WDG REST 'ONELOK W/A	4	29.990	EA	119.98	
1481SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMP	3 BRS GATE VLV ID- 4	2	13.000	EA	26.00	
	SUBTOTAL				972.82	
	
- 8" PVC WTR MAIN -					
DR18BPX	8 C900 DR18 PVC GJ BLUE PIPE	2000	6.700	FT	13400.00	
PD3105B52737	3X1000 UG DET WTR BLUE	2	28.000	EA	58.00	
C1230BHS500	12GA 30MM 500 FT COP TRGR WIRE BLUE	4	89.000	EA	358.00	

8 SIGMA BELL REST F/ COOO "PVLOK	42	60.050	EA	2102.10	
SUBTOTAL				15914.10	

SPWPC8

8" FITTINGS -

MJ2LAX	8 MJ C163 22-112 BEND UA	8	88.900	EA	413.40	
MJTLAX	8 MJ C163 TEE UA	1	127.850	EA	127.65	
MJRLAXP	8X4 MJ C153 RED UA	1	46.400	EA	48.40	
SSLCE8AP	8 PVC WDG REST "ONELOK W/A	28	46.150	EA	1292.20	

MJ4LAX	8 MJ C153 45 BEND UA	6	68.700   EA	412.20
SSLGE4AP	4 PVC WDG REST 'ONELOK W/A	1	29.990    EA	29.99

- 8" GATE VLV ASSM (4) -

8 DI MJ RW OL SS STEM VLV UA	
4	

647.000	

EA	

2588.00	
8 PVC WDG REST •ONELOK WIA	8	46.160	EA	369.20	
2PG SC GI VLV BX 19-22 WTR	4	95.000	EA	380.00	
3BRSGATEVLVID-8	4	13.000	EA	52.00	
SUBTOTAL				3389.20	
- FIRE HYD ASSM (2) -					
8X6 MJ G153 SWVL TEE UA	2	122.790	EA	245.58	
8 PVC WDG REST 'ONELOK WIA	4	46.150	EA	184.60	
6 PVC WDG REST 'ONELOK WIA	4	34.040	EA	138.16	
6 MJ C153 BLT GSKT PK UGLAND	2	12.700	EA	25.40	
6 DI MJ RW Ol SS STEM VLV UA	2	406.555	EA	813.11	
2PC SC Ci VLV BX 19-22 WTR	2	95.000	EA	190.00	

SUBTOTAL	2321.84
AFC2608DLAFMM SSLGE8AP 1461SW RBGVTMX

MJSTLAXU SSLGE8AF SSLCE6AP IMJBGPU AFC26060LAFMM
1461SW RBGVTMU DR18BPU

3 BRS GATE VLV ID-6	2	13.000	EA	
6 C900 DR18 PVC GJ BLUE PIPE	20	3.860	FT	

26.00
77.20

� FERGUSON®
WATERWORKS

FEI-PORT CHARLOTTE #1705
Price Quotation

Fax: 941-627-3519

Page 3 of4

12:30:10 FEB 25 2019
Reference No: B247136

Item
AFCB84BlAOlP	Description
5-114 Vo B848 HYO 4'0 ol UA	Quantity	Net Price
------ms:ooo	UM
""EA""	Total

2850.00	
	SUBTOTAL				4548.05	
	SINGLE SHORT (34) •					
FS90404	4X1 CC BRS SDL C900	9	72.200	EA	849.80	
FS90804	ax1 cc BRS SDL C900	25	102.610	EA	2565.25	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	34	50.240	EA	1708.16	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	600	40.000	C	240.00	
PEC9BG100	"EXC 1X100 CTS ORS HDPE BLUE PIPE	100	40.000	C	40.00	
C1230BHS500	12GA 30MM 500 FT COP TRCR WIRE BLUE	2	89.000	EA	178.00	
PD3105B52737	3X1000 UG DET WTR BLUE	1	28.000	EA	28.00	
FBA43444WNL	LF 1 CTS X MTR ANG BV	34	87.340	EA	2969.56	
FINSERT52	1 CTS PET/ HOPE DR9 INS STFNR	68	1.260	EA	85.68	
CYPSKPX	2X4X8 YELL PINE STUD	34	3.000	EA	102.00	
CWA03111812	11X18X12 BX W/CI RDR LID SUD	34	68.000	EA	2312.00	
	SUBTOTAL				10878.45	
	SINGLE LONG (22) •					
FS90404	4X1 CC BRS SOL C900	6	72.200	EA	433.20	
FS90804	ax, cc BRS SOL C900	16	102.610	EA	1841.76	
FFB10004NL	LF 1 CCX CTS PJ BALL CORP	22	50.240	EA	1105.28	
PEC9BG300	"EXC 1X300 CTS DR9 HOPE BLUE PIPE	1200	40.000	C	480.00	
PEC9BG100	"EXC 1X100 CTS DR9 HDPE BLUE PIPE	100	40.000	C	40.00	
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	22	87.340	EA	1921.48	
FINSERT52	1 CT$ PET/ HOPE DR9 INS STFNR	44	1.260	EA	55.44	
CYPSKPX	2X4X8 YELL PINE STUD	22	3.000	EA	66.00	
CWA03111812	11X18X12 BX W/CIRDR LID SUD	22	68.000	EA	1498.00	
SDR21BPK	2 SDR21 CL200 PVC GJ BLUE PIPE	880	0.550	FT	484.00	
	SUBTOTAL				8046.16	
FBLSLAX	BX12 MJ C110 LONG SLV UA	1	123.300	EA	123.30	
SSLCE8AP	8 PVC WDG REST 'ONELOK WIA	2	48.150	EA	92.30	
	SUBTOTAL				216.60	
	8X8 HOTTAP (2) •					
J4320900X8	8X8 SS TAPN SLV 8.60-9.05	2	788.610	EA	1577.02	
AFC2608DLAFTM	8 DI MJ RWOLSS TAPNVLV UA	2	827.400	EA	1654.80	
1461SW	2PC SC Cl VLV BX 19-22 WTR	2	95.000	EA	190.00	
RBGVTMX	3 BRS GATE VLV ID- 8	2	13.000	EA	26.00	
SSLCE8AP	8 PVC WDG REST "ONELOK WIA	2	46.150	EA	92.30	
	SUBTOTAL				3540.12	
NetTotal:	$68883.70	
Tax:	$0.00	
Freight:	$0.00	
Total:	$68883.70	

Florida Admin Rule 12A-I.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 COD must take title to the tangible personal property from the vendor at the time of purchase or delivery by the vendor (this means the CDD owns the property and all documentation, e.g. bill of sale, warranty materials, etc are in the name of the COD as "Owner").

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

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

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

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

CERTI FICATE OF ENTITLEMEN T
The und ersigned authorized representative of the Blackburn Creek Community Development District, a local unit of specia l purpose government (hereinafter "Go vernme ntal Entity"), Florida Consum er's Ce r ti ficate of Exe mpt io n Num ber 85-8015773053C-0.affir ms that the tangible personal property pur chased pu,·s uan t to Purchase Order Number 180601 from Ferguson Wa terw or ks (Vendor) on or after 2 /22/19 (date) will be incorporated into or become a part of a public facility as par t of a public works contr act pursuant to contract# n.li!. with Forsberg Construction, Inc. (Name of Contractor) for the construction of Grand Palm Phase 1Ba.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Pur chase Ord er meets the following exe mpt ion requirements conta ined in Section 21 2.08( 6). F.S., a nd Rule 12A-l.094, F.A.C.:

You 11111st initial each oft he folfowi11g requirements.

The attached Purchase Order is iss ued directly to the vendor supplyin g the  tangible  personal  pro )Crty the Contractor will use in the identified public works.
The vendo r"s invoice will be issued directly to Governmental Entity.
. Payment of the vendor"s inv oice will be made directly by Governmental Entity to the vend o r from pub ic fund s.
-	Governmental Entity will take title to the tangible personal property from the vendor at the time of pth-cl1ase or of delive1y by the vendor.
A	. 5. Government al Entity assumes the risk of damage or loss at the time of purchase or delivery by the

Go vernment al Entity affirm s that if the tangible personal property identified in the attached Pur chase Ord er does not qualify for the exemption provided in Section 212. 08 (6 ), F.S. and Rule 12 A-1. 0 9 4 , F.A.C.. Governme ntal Entity will be subject to the tax, interest, and penalties due on the tangible personal p roperty purchased. If th e  Florida Department of Revenue deter mines  that the tangible  personal property pur chased
tax-exempt by issu ing this Ce rtifi cate does not qualify for the exemption,Governmenta l Entity will be liable for any tax, penalty, and interest determined to be clue.

I unders tand that if I fraudulently issue th is certificate to evade the payment of sa les 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.

U nder the penalties of perjury. I declare that I hav e read the foregoing Ce rtifi cate of Entitlement and the
facts stated in it are true.

Q	

Blackbu rn Creek Communit y Development District, a local uni t of special pur pose government By:

Federal Empl oyer Identification Numb er: -   --   -   -   -   - -  -	=	­

You must attach a copy of the Pu rc hase Order to this Certificate of Ent itle ment.

Do not send to the Florida Depar tment of Revenue. This Certificate of Entitlement mus t be retain ed in the
vendor's and the cont ractor's books and records.

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

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

Requisition Number:

Name of Payee:

Amount Payable:

2019-49

County Materials Corp.
P.O. Box435 Astatula, FL 34705

$11,144.86

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, ifapplicable):

Direct purchase of material for construction of Grand Palm, Phase 2A(d). Purchase Order# 190402; See attached for iuvoice information

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

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

The undersigned hereby further ce1tifies that such requ1s1t10n contains no item representing payment on account of any retained percentage which the District is at the date of such certificate entitled to retain.

Blackburn Creek Community Development District

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

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

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By:	
AutnzedOfficer

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

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

w	

Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #		Amount	 149188-01	$7,223.66
   149188-02	$3,921.20	
Sub-Total	$11,144.86

COUNT Y

SHIPPED	INVO ICE DATE	I	ORDER NO.	
10 /17 /19	10 /17/ 19	I	149188-01	
l	P.O. NO.		I	PAGE #	
44	l ct	190 40 2		I 1 of 1	

(866) 343-8488 Fax (352) 343 -0 47 1

INVOICE

MATERIALS CORPO RA TI O N

ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38

CUS T  #:	3275	MARA THON, WI 54448-0038
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observat ion Blvd off Cente r Rd Ven ice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRU CTION
BILL TO:	645 CHARLOTTE STREET

I

PUNTA GORD A FL 33950

OCT 2 1 2019

I

LI NE	PRODUC T
NO.	AND DESCRIPTION

QTY .	QTY.	UN IT

l	l

I

SHIPPED	U/ M	, PRICE

AMOUNT (NET)

9	254380	32. 00	LFT	98 . 03	31 36.	96	

10	54 " RCP CL3
25 4	
4. 00	
EA	
0. 00	
0.	
00	

14	54" RCCP GASKET
254889	HK #839453	J 1. 00	
EA	
4086. 70	
4086. 70	
54" FLARED END SECTION GB
Tot al	7223. 66
Invoice Total	7223. 66	

COUNTY

SHIPPED	INVOICEDATE	I	ORDER NO.	
10 /1 7 / 1 9	10 / 17 / 1 9	I	14 9 1 8 8 - 0 2	
I	P.O. NO.		I	PAGE #	
44	I ct	190402		I 1 of 1	

. (866) 343-8488 Fax (352) 343-0471

INVOICE

MATERIALS CORPO R A TI O N

ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #;	3275	MARATHON, WI 54448-0038
Grand Palm Phase 2AD SHIPTO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION

OCT 2 t 2019

BI LL TO:

645 CHARLOTTE STREET PUNTA GORDA FL 33950

LINEI
NO.	AND DESCRIPTION	I
PRODUCT	s/ti ED	I	QUT/MY.	I		/ UNIT PRICE	I	AMOUNT (NET)	
9	254380	40.	00	LFT	7	98 . 03	39 21. 20	
	54" RCP CL3				
10	254	5. 00	EA		0. 00	0. 00	
	54" RCCP GASKET HK #839453				
			Tot al	3921. 20	
			Invoice Tota l	3921. 20	

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

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

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf 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 ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible 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 1O 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.

Neith er 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 ini tialed and dated by authorized agents of both parties.

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

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

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. 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.

17.

18 .

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.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

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

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

Direct Invoice. The vendor's invoice must be issued to the 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 COD as "Owner").

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

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

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

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

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, 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.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.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-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 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:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

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

The undersigned, an Authorized Officer of Blackburn Creek Community Development District (the "District) hereby submits the following requisition for disbursement under and pursuant to the terms of the Master Trust Indenture from the District to U.S. Bank National Association, Fort Lauderdale, Florida, as trustee (the "Trustee"), dated as of March 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 terms used herein shall have the meaning ascribed to such te1m in the Indenture);

Requisition Number:

Name of Payee:

Amount Payable:

2019-50

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

$6,152.08

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

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

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

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

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

Blackburn Creek Community Development District

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

Attached hereto are originals of the invo ice( 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	
Authorized Officer

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

If this requisition is for a disbursement from other than Costs oflssuance, 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 acquisi tion 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 repmt shall have been amended or modified on the date hereof.

 	w	

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	6,152.08	
Total HOURLY	6,152.08	

Invoice No:	14896252
Invoice Date:	Sep 30, 2019 Invoice Amount: $6,152.08
Project No:	148167000.2
Project Name:	BLACKBURN CR CDD DIST ENG
Project Manager: CONERLY, BILL
Client Reference: CONSTRUCTION FUND

For Services Rendered through Sep 30, 2019

Description of Services Performed:
Process REQS for payment; 2018-110 through 2018-112; 2019-33 through 2019-37
Coordinate with staff regarding Reconciliation of previously processed payment REQS

Total Invoice: $6,152.08

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	11.0	104.65	1,151.17	
	PROFESSIONAL	4.5	139.81	629.14	
	SENIOR PROFESSIONAL I	18.0	223.99	4,031.85	
	SUPPORT STAFF	0.5	66.10	33.05	
TOTAL LABOR	34.0		5,845.21	
EXPENSES	OFFICE EXPENSE			306.87	
TOTAL EXPENSES			306.87	
TOTAL LABOR AND EXPENSE DETAIL			6,152.08	

Invoice No:	14896252
Invoice Date:	Sep 30, 2019
Project No:	148167000.2

Project Name:

BLACKBURN CR CDD DIST ENG

Project Manager: CONERLY, BILL

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

31JJM

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

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

(A)

(B)

Requisition Number: Name of Payee:

2019-51

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

Amount Payable:	$9,430.00

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

Direct purchase of material for construction of Grand Palm, Phase 2Ad. Purchase Order ii 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 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 property acquired or the services rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

By

Authorfficer

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 interes t, 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.

Consulting Engineer

PC u:, Cl'i

Blackburn Creek CDD
Materials Invoice Summary

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

    Invoice #		Amount	 1423810	$		8,192.13
1445417	$	267.42
   1445417-1	$	970.45 
Sub-Total	$9,430.00

FERGUSON
WATERWORKS
17323 JE A N S TREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

OCT 2 3 2019

   IN VOICE NUM BER	TOTAL DUE	CUSTOMER	PAGE	
 	1423810	$8,192.12	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 FORSBERGCONSTRUCTION INC PO#190401
PUNTA GORDA. FL 33950

BLACK BURN CREEK COMMUNITY DEVE GRAND PALM PH2AD
OBSERVATION BLVD AND CENTER RD PUNTA GORDA, FL 33950

SHIP WHSE.
1705	SELL
WHSE.
1705	TAXCODE

FLE	CUSTOMER ORDER NUMBER

190401 - SWR FITTING	SALESMAN

TAE	JOB NAME

GRAND PALM PH2AD	INVOICE DATE

10/18/19	BATCH

ID 81861	
ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	

	Source Order#: 1423639			I/	
2	2	MUL067478	8 PVC HW SWR GXG REP COUP	55.730	EA	111.46	
16
48	16
48	MUL067248
MUL067376	8X6 PVC HW SWR GXGXG WYE
6 PVC HW SWR GXS 45 ELL	47.530
13.470	EA EA	760.48 ,
646.56 ,v	
16	1 6	MU L 067326	6 PVC HW SWR GXG 45 ELL	18.240	EA	291.84 ,i,	
16	16	MUL040952	6 PVC SWR HUB FEM CO ADPT	11.720	EA	187.52•1/	
16	16	MUL040958	6 PVC SWR REC THRO CO PLUG	8.950	EA	I,
143.20 i,.	
32	32	MUL043988	6 PVC SWR GSKT CAP	6.930	EA	221.76 '	
27	27	MUL067248	8X6 PVC HWSWR GXGXG WYE	47.530	EA	1283.31 I/	
81	81	MUL067376	6 PVC HW SWR GXS 45 ELL	13.470	EA	1091.07	
27	27	MUL067326	6 PVC HW SWR GXG 45 ELL			18.240	EA	492.48 v	
27	27	MUL067277	6 PVC HW SWR GXG DBL WYE			68.260	EA	1843.021/	
27	27	MUL040952	6 PVC SWR HUB FEM CO ADPT	/		11.720	EA	316.44	
27	27	MUL040958	6 PVC SWR REC THRO CO PLUG			8.950	EA	241.65	
81	81	MUL043988	6 PVC SWR GSKT CAP		./	6.930	EA	561 .33	

IN VOICE SUB -TOTAL	8192 .12

LEAD LAW WJR NING: IT IS ILLE AL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL 1DR OTHER APPLI< !ABLE LAWIN POTABLE WATER SYSTEMS ANTICIPATEDFOR HUMAN CONSUMPTION PRODUCTS \A TH •NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLEDIN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business	
TERMS:	CASH ON DEMAND	ORIGINAL INVOICE	TOTAL DUE	$8,192.12V

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

Please contact with Questions: 800-456-1488

UL I  l.	l.U1:,

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1445417	$267.42	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 P0#190401
PUNTA GORDA, FL 33950

AMOUNT

UM

UNIT PRICE

DESCRIPTION

ITEM NUMBER

SHIPPED

ORDERED

BATCH
10
81859

INVOICE DATE

10/18/19

JOB NAME

GRAND PALM PH2AD

SALESMAN

TAE

CUSTOMER ORDER NUMBER

190401 - SWR FITTING

TAX CODE

FLE

SELL
WHSE.
1705

SHIP
WHSE.
1705

16	6
16	16

MUL067206 CYPSKPX

Source Order#: 1423810
Source Order#: 1423810
6 PVC HW SWR GXGXG WYE
2X4X8 YELL PINE STUD

/ 36.570
3.000

INVOICE SUB-TOTAL

219.42 [/

EA
EA

48.00 V
2a1.42 V

LEAD LAW W RNING: IT IS ILLE SAL TO INSTALL PRODL CTS THAT ARE NOT ' LEAD FREE" IN ACCORDANCE WITH
US FEDERAL I ROTHER APPLIIIABLE LAW IN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS W TH 'NP IN THE DI SCRIPTION ARE NOT L AD FREE AND CAN ONLY BE INSTALLEDIN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	CASH ON DEMAND	ORIGINAL INVOICE	TOTAL DUE	$267.42 /i

� FERGUSON4D
WATERWORKS
17323 JEAN STREET
FT MYERS, FL 33967-9998

Please contact with Questions: 800-456-1488

OCT 2 8 2019

   INVOICE NUMBER	TOTAL DUE	CUSTOMER	PAGE	
 	1445417-1	$970.45	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.
1705

SELL WHSE.
1705

TAX CODE

FLE

CUSTOMER ORDER NUMBER

190401 - SWR FITTING

SALESMAN

TAE

JOB NAME

GRAND PALM PH2AD

INVOICE DATE

10/21/19

BATCH
10
81869

ORDERED	SHIPPED	ITEM NUMBER	DESCRIPTION	UNIT PRICE	UM	AMOUNT	
			Source Order#: 1423810				
			Source Order#: 1423810				
8	8	MUL067248	8X6 PVC HW SWR GXGXG WYE	47.530	EA	380.24	
10	10	MUL067206	6 PVC HW SWR GXGXG WYE	36.570	EA	365.70	
	1	FNWCGAALP	4 ALUM QCK COUP A	14.511	EA	14.51	
	1	A1148400050CE	4X50 PVC DISCHRG HSE MXF QC BLUE	210.000	EA	210.00	

···········••·••••1 .....................tt,,••····..•••••••••................................................

INVOICE SUB-TOTAL

970.45 l/

LEAD LAW WP NING: IT IS ILLE1BAL TO INSTALL PRODl CTS THAT ARE NOT "LEAD FREE" IN ACCORDANCE WITH
US FEDERAL 1DR OTHER APPLICABLE LAWIN POTABLE WATER SYSTEMS ANTICIPATED FOR HUMAN CONSUMPTION PRODUCTS VI. TH 'NP IN THE DI SCRIPTION ARE NOT L D FREE AND CAN ONLY BE INSTALLED IN
NON-POTABLI APPLICATIONS. UYER IS SOLELY RESI ONSIBLE FOR PRODUCT SELECTION.

Thank you for your business

TERMS:	CASH ON DEMAND	ORIGINAL INVOICE	 	TOTAL DUE	ss10.4sV

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, Florida, as trustee (the "Trustee"), dated as of March 1, 2013 (the "Master Indenture"), as amended and supplemented by the Fourth Supplemental Trust Indenture from the  District  to  the Trustee, dated as of February 1, 2019 (the Master Indenture  as  amended  and supplemented is hereinafter referred to as the "Indenture") (all capitalized terms  used herein shall have the meaning ascribed to such term in the Indenture);

(A)

(B)

Requisition Number: Name of Payee:

2019-52

County Materials Corp. P.O.Box435
Astatula, FL 34705

(C)	Amount Payable:	$27,448.40

(DJ 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 2A(d). Purchase Order ii 190402; See attached for invoice information

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

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

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

Blackburn Creek Community Development District

If this requisition is for a disbursement from other than the Costs 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 disbmsements 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 se rvices rendered with respect to which disbursement is hereby requested.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

B//

: ��	

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.

 		.\l.:,,..,..,_, _C:,	
Consulting Engineer

Blackburn Creek CDD
Materials Invoice Summary

Supplier:	County Materials Project:	Phase 2A(d)

    Invoice #	Amount	
149188-03	$3,921.20	
149188-04	$3,921.20	
149188-05	$3,921.20	
149188-06	$3,921.20	
149188-07	$3,921.20	
149188-08	$3,921.20	
   149188-10	$3,921.20	
Sub-Total	$27,448.40

COUNTY

SHIPPED	INVOICE DATE	I	ORDER NO.	
10/18/19	10/18/19	I	149188-03	
I	P.O. NO.		I	PAGE #	
44	I ct	190402		I 1 of 1	

. (866) 343-8 488 Fax (352) 343-0471

OCT 2 4 20'i9	INVOICE

MATERIALS CORPO RA T I O N
CU ST #:	3275
Grand Palm Phase 2AD
SHIP TO : Sarasota County

ASTATULA, FL 34705 -0 435

REMIT TO:
PO BOX 38
MARATHON, WI 54448 -0038

Observation Blvd off Center Rd Venice FL 34292

BI LL TO :

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION 645  CHARLOTTE  STREET PUNTA GORDA FL 33950

LINEI	PRODUCT
AND DESCRIPTION	I	S	atv.	j
'flPPED	OTY. I	PRICE	I
UNIT	AMOUNT J NET)	
9	254380		V	40. 00	LFT	98. 03	3921. 20	
54" RCP CL3
10 254			
5. 00	
EA	
0. 00	0.00	
54" RCCP GASKET	HK #839453						
Total	3921. 20
Invoice Total	3921. 20	

NO.

)	U/M

COUNTY

M A TER I A L S C O RPO R A TI O N

( 866 ) 343 -8488 Fax (352) 343-0 471
ASTATULA, FL 347 05 -0 435

REM IT TO: PO BOX 38

OCT 2 1t  2019	INVOICE

SHIPPED	INVOICE DA TE	I	ORDER NO.	
10 /1 8 /1 9	10 /1 8 /19	I	149 188 -04	
l	P.O. ND.		I	PAGE #	
44	I c t	1 90 40 2		I 1 of 1	

CUST #:	3 2 75	M A RAT HON, WI 544 48 -00 38
Grand Palm Phase 2AD
SHIP TO: Sarasota Count y
Observat ion Blvd off Cent er Rd Ven ice FL 34292

BI LL TO :

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION 645 CHARLOTTE STREET
PUNTA GORDA   FL 33950

I

LINE	PRODUC T
NO .	AND DESCRIPT ION

I	SH,- ED	I QTY.      I

UNIT PRICE

AMOU NT

I

) N ET)

U/M

9	254380	"' 40. 00 LFT
54" RCP CL3
10  254	5. 00	EA
5 4 " RCCP GASKET HK #839453

98. 03

0. 00

392 1. 20

0. 00

Total
Invoice Tot al

392 1. 20
392 1. 20

COU NTY

MATERIALS CORPORATION

(866) 343-8488 Fax (352) 343-0471
ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

OCT 2 8 2019	INVOICE

SHIPPED	INVOICE DA TE	I	ORDER NO.	
10/21/19	10/21/19	I 149188-05	
I	P.O. NO.	I	PAGE K	
44	I ct	190402	I 1 of 1	

CUST#:	3275	MARATHON, WI 54448-0038
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION
BILL TO:	645 CHARLOTTE STREET
PUNTA GORDA FL 33950

OCT 2 8 2019

LINEI	PRODUCT

9	254380		40. 00	LFT	98. 03	3921. 20	

10	54" RCP CL3
254		
5. 00	
EA	
0. 00	
0.00	
	54" RCCP GASKET	HK #839453					
Total	3921. 20
Invoice Total	3921. 20	

NO .	ANO DESCRIPTION	I

I	I

OT )' .	Q TY .
SHJl'PED	U/M

UNIT PRICE

AMOUNT

I

)NETI

COUNTY

SHIPPED	INVOICE DA TE	I	ORDER NO .	
10 /2 1 /19	10 / 21 /19	I	149188-06	
I	P.O . NO .	I	PAG E #	
44	I ct	190402	I 1 of 1	

. (866) 343-8488 Fax (352) 343-0471

OCT 2 8 zm

INVOICE

MATERIALS CORPORATION

ASTATULA, FL 34705-0435

REMIT TO: PO BOX 38

CUST #:	3275	MARATHON, WI 54448-0038
Grand Palm Phase 2AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION
BILL TO:	645 CHARLOTTE STREET
PUNTA GORDA FL 33950

OCT 2 8 2019

I

LINE	PRODUCT
NO.	AND DESCRIPTION

QTY.

;	I	I,-

I

S	ED	U/M

UNIT PRICE

Af,\OUNT

I

pN ETI

9	254380	40. 00 LFT
54" RCP CL3
10   254	5. 00	EA
54" RCCP GASKET HK #839453

98. 03

0. 00

"  392 1. 20

0. 00

Total
Invo ice Total

3921. 20
3921. 20

COUNTY

SHIPPEO	INVOICE DATE	I	ORD ER NO .	
10 /22 /19	10 / 22/19	I	1491 88 -07	
7	P. O . NO .		I	P AGE #	
44	I ct	190402		I 1 of 1	

. (866) 343-8 488 Fax (352) 343-0 471

OCT 2 8 2019

INVOICE

M ATE RI A L S C O RPO RAT I O N

ASTATULA, FL 3470 5-0 435

REMIT TO:
PO BOX 38

cus T #:	3275	MARATHON, WI 54448-0038
Grand Palm Phase 2AD
SHIP TO : Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK COD
C/0 FORSBERG CONSTRUCTION

OCT 2 8 2019

BILL TO:

645 CHARLOTTE STREET PUNTA GORDA FL 33950

LINE NO.	I	PRODUCT AND DESCRIPTION	I	QTY.	I	PRICE	I
UNIT	M OUNT
,,{ NET}	
9	254380		40. 00	LFT	98 . 03	3921. 20	

10	54" RCP CL3
254		
5. 00	
EA	
0.00	
0.00	
54" RCCP GASKET HK #839453
Total	3921. 20
Invoice Total	3921.20	

I	S-;  rPED	U/M

COUNTY

SHIPPED	INVOICE DATE	I	ORDER NO.	
10 /22 /19	10 /22 /19	I	14 9188 -08	
I	P.O. NO.		I	PAGE #	
44	I ct	190 40 2		I 1 of 1	

. (866) 343-8488 Fax (352 ) 343-0 47 1

OCT 2 8 2019	INVOICE

M ATE RI A LS C O RPO R A TI O N
CU ST #:	3275
Grand Palm Phase 2AD
SHIP TO : Sarasota Count y

ASTATULA, FL 3470 5-0 435

REMIT TO:
PO BOX 38
M ARATHON, WI 54448 -0038

Observat ion Blvd off Center Rd Venice FL 34292

OCT 2 8 2019

BI LL T O:

BLACKBURN  CREEK COD
C/O FORSBERG CONSTRUCTION 645 CHARLOTTE STREET

LINE I	AND DESCRIPTION	I
PRODUCT	I	QT Y.	I	UNI T PRICE	I	AMOUNT (NET)	
9	254380		40 . 00	LFT	98.03	/	3921. 20	
54" RCP CL3
10 25 4		
5. 00	
EA	
0 . 00		
0 . 00	
54" RCCP GASKET	HK #839453						
	Total	39 21. 20
Invoice Tot al	3921.20	

PUNTA GORDA FL 33950

NO .

Ss$ Pr·ED	U/M

COUN TY

SHIPPED	INVOICE OATE	I	ORDER NO.	
10 /23 /1 9	10 /23/1 9	I	149188 -10	
I	P.O. NO.		I	PAGE#	
44	I ct	190402		I 1 of 1	

. (866) 343-8488 Fax (352) 343-0 471

OCT 2 8 2019	INVOICE

MATERIALS CO RPO R AT IO N

ASTATULA, FL 34705-0435

REMIT TO:
PO BOX 38

CUST #:	3275	MARATHON, WI 54448 -00 38
Grand Palm Phase 2 AD
SHIP TO: Sarasota County
Observation Blvd off Center Rd Venice FL 34292

BLACKBURN CREEK CDD
C/0 FORSBERG CONSTRUCTION
BILL TO:	645 CHARLOTTE STREET
PUNTA GORDA FL 33950

		PRODUCT		S- -ED
I/  40. 00

5. 00	I	QTY.  I	UNIT
U/M	PRICE
LFT	98. 03

EA	0. 00

Total
Invoice Total	I	AMOUNT JNET)
t/   39 21. 20

0. 00

3921.20
3921. 20	
NO.		AND DESCRIPTION	I						
9	254380								
	54" RCP CL3								
10	254								
	54" RCCP GASKET	HK #839453							

PURCHASE ORDER No. 	/90402	

Blackburn Creek
Co1nmunity Develop1nent District
c/ o
Forsberg Construction, Inc.
645 Charlotte Street, Punta Gorda FL 339 50
Phone: (94L) 637 -8500	Fax: (941) 639-1073
Underground Utility License #CUC055716 Visit Us at www.forsbergconsrruction.com

Vendor: County Materials Corporation

Address:   P.O. Box 435	

   Astatula, FL 34705	

Attention: Johnny Smith 941-915-3671

Job No.: 19-04

P.O. Date: April 15, 2019

Project Name: Grand Palm Phase 2Ad

Project Address: ObeNation Blvd off of Center Road Venice, Florida
Legal Desc.:   Sec  19&20,  Twp: 39S,	Range 20E	

County:  Sarasota      	  Payment Terms:  Net 30 days	                                    Vendor Phone: 866-343-8488
Vendor Fax:  352-343-0471	

Quantity	Unit	Description	Unit Price	Total Price	
						
184	+/-	LF	18"RCP	s	16.05		s	2,953.20	
776	+/-	LF	24" RCP	$	24.45		s	18,973 .20	
744	+/-	LF	30" RCP	s	34.73		s	25,839.12	
192	+/-	LF	36" RCP	s	48.53		$	9,317.76	
400	+/-	LF	54"RCP	s	98.03		$	39,212.00	
3	+/-	EA	24 " Flared End Section	s	1,012.00		s	3, 036.00	
2	+/-	EA	30 " Flared End Section	$	1,3 15.40		s	2,630.80	
I	+/-	EA	36• Flared End Section	s	1,562.00		s	, 1 562.00	
I	+/-	EA	54• Flared End Section	$	4,086.70		s	, 4 086 .70	

						
						
		Prices ar e good for duration of the project.				
						
		Project Duration : April I 5, 2019 - April I 5, 2020				
!	Total Project Subtotal	s	107,610.78	
Sales Tax @ 6 %	tax exempt	
Discretionary Tax @ 1.0 % on 1st $5,000.00	tax exempt	
TOTAL	s	107,6 10.78	

Blackburn Creek COD Chairman

 	-
Authorized Agent /signa tur e}
! IMPORTANT !

Date

Page	 		of	2

,1SEESPECIAL PROVISIONS ABOVE

ADD ITION AL TERMSAND CONDITIONSON PAGE 2

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

When requested by Purchaser, Vendor will provide, at no additional cost to Purchaser, a complete set of shop drawings for Purchaser's review and approval. Alf 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 ord er to accommodate unloading. Vendor shall notify Purchaser 24 hours in advance of arrival to jobsite to confirm delivery.

Material shall arrive in such time that it will allow for unloading before quitting time, or Vendor and/or transporter will be required to hold over until the following work day to be unloaded. Purchaser will not beresponsible 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 1O 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.

Neith er 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 ini tialed and dated by authorized agents of both parties.

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

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

If Vendor fails to properly execute and return Purchase Order within 1O days, Purchaser may consider offer rejected.

I 5. This agreeme n t shall be governed by the laws of the Stat e of Florida with venue in Charlotte Coun ty, Florida.

16. 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.

17.

18 .

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.

This Purchase Order is the only binding contract betw een Purchaser and Vendor for this project and the work

r

described. This Purchase Order replaces all previous contracts and agreements,w heth  er written or  verbal, regaro1ng mis proJecr. No otner aocumenr will superseaeme requirements of this Purchase Order unless signed
by an authorized agent of each	ty subsequent to the date of this Purchase Order.

Page

2   of	2	Coun,y Ma ria>s'"" 1'-

m a d<bum  C ek COO ,n,;m,Ci---

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

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

Direct Invoice. The vendor's invoice must be issued to the 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 COD as "Owner").

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

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

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

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

CERTIFICATE  OF ENTITLEMENT
The undersigned authorized representative of the Blackburn Creek Community Development District, a local unit of special purpose government (hereinafter "Governmental Entity"), Florida Consumer's Certificate of Exemption Number 85-80157730 53C-0. affirms that the tangible personal property purchased pursuant to Purchase Order Number 190402 from County Materials (Vendor) on or after 4/15/19 (date) will be incorporated into or become a part of a public facility as part of a public works contract pursuant to contract# n/a with Forsberg Construction. Inc. (Name of Contractor) for the construction of Grand Palm Phase 2Ad.

Governmental Entity affirms that the purchase of the tangible personal property contained in the attached Purchase Order meets the following exemption requirements contained in Section 212.08(6), F.S., and Rule lZA-1.094, 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.
Th e vendor's invoice will be issued directly to Governmental Entity.
Payment of the vendor's invoice will be made directly by Governmental Entity to the vendor from p funds.
'ti,2::::-4. Governmental Entity will take title to the tangible personal property from the vendor at the time of
purchase or of delivery by the vendor.
'etJs.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-l.094, F.A.C., Governmental Entity will be subject to the tax, interest, and penalties due on the tangible personal property purchased. If the Florida Department of Revenue determines that the tangible personal property purchased tax-exempt by issuing this Certificate does not qualify for the exemption, Governmental Entity will be liable for any tax, penalty, and interest determined to be due.

1 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:  	

C:/..(../.OtY'	_

Fede ral Employer Identification Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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

Do not s end to the Florida De pa r tme nt of Revenue. This Certificate of Entitlement must be retained in the vendor's and the contractor's books and records.

BLACKBURN CREEK COMMUNITY DEVELOPMENT DISTRICT

Review of District Financial Statements

Blackburn Creek CDD Statement of Financial Position As of 10/31/2019

Debt Service -	Debt Service -	Debt Service -	Capital Proiects	Capital	Capital Project	Long Term Debt	
2013 & 2019	2015	2018	- 2013 & 2019	Projects - 2015	Fund - 2018	Group	

General Fund	Total

Current Assets
General Checking Account
Debt Service Reserve 2013A Bond Debt Service Reserve 2019A Bond Revenue 2013A Bond
Revenue 2019A Bond Prepayment 2013A Bond Sinking Fund 2013A Bond
Capitalized Interest 2019A1 Bond Capitalized Interest 2019A2 Bond Debt Service Reserve 2015A1 Bond Debt Service Reserve 2015A2 Bond Revenue 2015A Bond
Prepayment 2015A1 Bond Prepayment 2015A2 Bond Sinking Fund 2015A1 Bond Revenue 2018A Bond Prepayment 2018A1 Bond
Debt Service Reserve 2018A1 Bond Prepayment 2018A2 Bond
Capitalized Interest Account 2018A2 Bond Acquisition/Construction 2013A Bond Acquisition/Construction 2019A Bond Acquisition/Construction 2015A Bond Aquisition/Construction 2018A Bond
Total Current Assets	

$34,131.20

$34,131.20	

$178,150.00 91,674.93
274,895.96
134.12
27,885.24
5,039.64
89,155.83
40,534.26

$707,469.98	

$233,662.50 106,406.25
135,003.87
18,432.83
127,178.54
25,025.80

$645,709.79	Assets

$344,984.77
2,562.00
172,505.48
150,789.00
177,796.50

$848,637.75	

$20,877.74 2,106,219.88

$2,127,097.62	

$190,351.78

$190,351.78	

$509,975.49
$509,975.49	

$0.00	

$34,131.20 178,150.00
91,674.93
274,895.96
134.12
27,885.24
5,039.64
89,155.83
40,534.26
233,662.50
106,406.25
135,003.87
18,432.83
127,178.54
25,025.80
344,984.77
2,562.00
172,505.48
150,789.00
177,796.50
20,877.74
2,106,219.88
190,351.78
509,975.49

$5,063,373.61	

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

Total Assets	

$0.00

$34,131.20	

$0.00

$707,469.98	

$0.00

$645,709.79	

$0.00

$848,637.75	

$0.00

$2,127,097.62	

$0.00

$190,351.78	

$0.00

$509,975.49	

$2,201,817.52 23,130,182.48
$25,332,000.00

$25,332,000.00	

$2,201,817.52 23,130,182.48

$25,332,000.00

$30,395,373.61	

Blackburn Creek CDD Statement of Financial Position As of 10/31/2019

Debt Service -	Debt Service -	Debt Service -	Capital Proiects	Capital	Capital Project	Long Term Debt	
2013 & 2019	2015	2018	- 2013 & 2019	Projects - 2015	Fund - 2018	Group	

General Fund	Total

Liabilities and Net Assets	
Current Liabilities Retainage Payable Developer Advance Retainage Payable Retainage Payable
Total Current Liabilities	

$0.00		

$0.00		

$0.00		

$0.00		

$62,755.92 13,827.00

$76,582.92		

$16,006.15

$16,006.15		

$131,997.14

$131,997.14		

$0.00		

$62,755.92 13,827.00
16,006.15
131,997.14

$224,586.21	

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

Total Liabilities	

$0.00

$0.00		

$0.00

$0.00		

$0.00

$0.00		

$0.00

$0.00		

$0.00

$76,582.92		

$0.00

$16,006.15		

$0.00

$131,997.14		

$25,332,000.00

$25,332,000.00

$25,332,000.00		

$25,332,000.00

$25,332,000.00

$25,556,586.21	

Net Assets
Net Assets, Unrestricted
Current Year Net Assets - General Government

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Net Assets, Unrestricted
Current Year Net Assets, Unrestricted

Total Net Assets	

$67,694.54 (33,563.34)

$34,131.20		

$707,719.95
(249.97)

$707,469.98		

$595,275.08 50,434.71

$645,709.79		

$803,405.05 45,232.70

$848,637.75		

$2,118,700.26 (68,185.56)

$2,050,514.70		

$174,345.63
0.00

$174,345.63		

$379,490.73 (1,512.38)

$377,978.35		

$0.00		

$67,694.54 (33,563.34)

707,719.95
(249.97)

595,275.08
50,434.71

803,405.05
45,232.70

2,118,700.26
(68,185.56)

174,345.63
0.00

379,490.73
(1,512.38)

$4,838,787.40	
																		
Total Liabilities and Net Assets	$34,131.20		$707,469.98		$645,709.79		$848,637.75		$2,127,097.62		$190,351.78		$509,975.49		$25,332,000.00		$30,395,373.61	

Blackburn Creek CDD
Budget to Actual
For the Month Ending 10/31/2019	
Year To Date	
		
Actual			
Budget			
Variance	FY 2020
Adopted Budget	

Revenues												
On-Roll Assessments
Net Revenues	$
$	-
-		$
$	12,062.92
12,062.92		$
$	(12,062.92)
(12,062.92)	$	144,755.00

$	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
Total General & Administrative Expenses	

$	800.00
2,423.00
3,889.84
-
-
-     276.50
22,500.00
-
-
-
-
-
-
-
-
- 175.00
- 3,499.00
-

$	33,563.34	

$	1,000.00
216.67
1,333.33
2,083.33
833.33
833.33
1,666.67
1,250.00
83.33
375.00
83.33
16.67
37.50
12.50
416.67
16.67
225.00
16.67
833.33
312.92
416.67

$	12,062.92		

$

$	

(200.00)
2,206.33
2,556.51
(2,083.33)
(833.33)
(833.33)
(1,390.17)
21,250.00
(83.33)
(375.00)
(83.33)
(16.67)
(37.50)
(12.50)
(416.67)
(16.67)
(225.00)
158.33
(833.33)
3,186.08
(416.67)
21,500.42	

$	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

$	144,755.00	

Total Expenses	
  $	33,563.34	
   $	12,062.92		
  $		
21,500.42	
  $	144,755.00	
Income (Loss) from Operations	$	(33,563.34)		$	-		$	(33,563.34)		$	-	
Net Income (Loss)	$	(33,563.34)		$	-		$	(33,563.34)		$	-	

Blackburn Creek CDD Statement of Activities As of 10/31/2019

Debt Service -	Debt Service -	Debt Service -	
2013 & 2019	2015	2018	

Capital
General Fund	Proiects - 2013
& 2019

Capital	Capital Project -	Long Term Projects - 2015		2018	Debt Group

Total

Revenues																		

Inter-Fund Group Transfers In Other Assessments
Other Assessments Inter-Fund Transfers Inter-Fund Transfers In
Inter-Fund Transfers			
($249.97)		

$50,434.71		

$45,259.00
(26.30)		

$249.97				

$26.30				
($249.97) 50,434.71
45,259.00
(26.30)
249.97
26.30	
Total Revenues	

$0.00		

($249.97)		

$50,434.71		

$45,232.70		

$249.97		

$0.00		

$26.30		

$0.00		

$95,693.71	

Expenses																		

Supervisor Fees	
$800.00																
$800.00	
Insurance	2,423.00																2,423.00	
Trustee Services	3,889.84																3,889.84	
District Counsel	276.50																276.50	
Assessment Administration	22,500.00																22,500.00	
Dues, Licenses, and Fees	175.00																175.00	
General Insurance	3,499.00																3,499.00	
Capital Expenditure									$68,435.53								68,435.53	
Capital Expenditure													$1,538.68				1,538.68	
Total Expenses	

$33,563.34		

$0.00		

$0.00		

$0.00		

$68,435.53		

$0.00		

$1,538.68		

$0.00		

$103,537.55	

Other Revenues (Expenses) & Gains (Losses)																		
Total Other Revenues (Expenses) & Gains (Losses)	$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00		$0.00	

Change In Net Assets	
($33,563.34)		
($249.97)		
$50,434.71		
$45,232.70		
($68,185.56)		
$0.00		
($1,512.38)		
$0.00		
($7,843.84)	

Net Assets At Beginning Of Year	
$67,694.54		
$707,719.95		
$595,275.08		
$803,405.05		
$2,118,700.26		
$174,345.63		
$379,490.73		
$0.00		
$4,846,631.24	

Net Assets At End Of Year	
$34,131.20		
$707,469.98		
$645,709.79		
$848,637.75		
$2,050,514.70		
$174,345.63		
$377,978.35		
$0.00		
$4,838,787.40