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105RDUE GAP Affidavit PROJECT: FOREST LAKES MSTU 162523 PARCEL No(s): 105RDUE FOLIO No(s): 00259240006 GRANTOR'S NON-FOREIGN, TAXPAYER IDENTIFICATION &"GAP" AFFIDAVIT The Undersigned, rile �-- n , as ;�6s)den - on behalf of FOREST LAKES GOLF & TENNIS CLUB, BUILDING NO. 2, INC. ("Grantor") after being duly sworn, deposes and says: 1. Grantor is the fee simple owner and the only owner of the property located in Collier County and described in Exhibit "A" attached hereto ("Property"). 2. Grantor's Legal Name is: FOREST LAKES GOLF & TENNIS CLUB, BUILDING NO. 2, INC., a Florida non-profit corporation. 3. Section 1445 of the Internal Revenue Code ("IRC") requires a transferee of a U.S. real property interest to withhold tax if the transferor is a foreign person. For U.S. tax purpose (including IRC §1445), the owner of a disregarded entity having legal title to a U.S. real property interest under local law will be the transferor of the property and not the disregarded entity. To inform Collier County, as transferee, that withholding of tax is not required upon disposition the Property, Affiant affirms that the following is true: a. Grantor is not a non-resident alien (if individual) or a foreign corporation, foreign partnership, foreign trust or foreign estate (as those terms are defined by the Internal Revenue Code and Income Tax Regulations.) for purposes of U.S. income taxation. b. Grantor's address is: 1st Toe.6/-LaJ &I •/ Nopeb;>34/6c2 c. Grantor is not a disregarded entity as defined in Treas. Req §1.1445- 2(b)(2)(iii). (NOTE: A disregarded entity for these purposes means an entity that is disregarded as an entity separate from its owner under Treas. Reg. §301.7701-3, a qualified REIT subsidiary as defined in IRC §856(i), or a qualified subchapter S subsidiary under IRC §1361(b)(3)(B). 4. Grantor's Taxpayer Identification Number is: 5c1 - &33 ca 5. For purposes of reporting this Transaction to the Internal Revenue Service on Form 1099-S, the Property is Grantor's (check one) Principal Residence }; Other real estate 6. Grantor is in sole constructive or actual possession of the Property, and there is no other person or entity that has any possessory right in the Property. 7. Grantor has full authority to convey the Property. 8. There are no existing contracts for sale or mortgage commitments other than those being closed affecting the Property. 9. Grantor knows of no defects in the Property's title and, except for real estate taxes for the current year and those items identified on Exhibit "B" attached hereto, there are no liens, encumbrances, mortgages, claims or demands on or against the Property. 10. There are no unrecorded labor, mechanics', materialmen's liens or "Notices of Commencement" against the Property; no material has been furnished to or labor performed upon the Property within the past ninety (90) days which has not been paid for in full; no notices to owner have been delivered to or received by the Grantor. 11. There are no bills, liens or assessments for sanitary sewers, paving or other public utilities, or improvements made by any governmental instrumentality, which are now unpaid, against the Property. Further, Grantor acknowledges responsibility for water, sewer and electrical consumption charges through date of closing or occupancy by Grantor, whichever first occurs. If any bills, liens or assessments are found which relate to the period of Grantor's possession, Grantor will pay same upon demand. Grantor shall obtain any release documents needed which relate to bills, liens or assessments not paid at the time of closing. 12. No notice has been received of any public hearing regarding future or pending zoning changes or assessments for improvements by any governmental instrumentality. 13. Grantor knows of no violations of local or state laws or private covenants, restrictions or conditions which pertain to the Property. 14. There are no judgments, orders or decrees which have been entered in any state or federal court against the Property or Grantor, and there are no civil or administrative actions pending against Grantor or which involve the Property in any way, including no action for dissolution of marriage or bankruptcy. 15. The Property and all uses of the Property have been and presently are in compliance with all Federal, State and Local laws, regulations and ordinances, including environmental laws, and that the Grantor has no knowledge of any spill or environmental law violation on any property contiguous to or in the vicinity of the Property; and that Grantor has not received notice and otherwise has no knowledge of a) any spill on the Property, b) any existing or threatened environmental lien against the Property or c) any lawsuit, proceeding or investigation regarding the generation, storage, treatment, spill or transfer of hazardous substances on the Property. This provision shall survive closing and/or acceptance and is not deemed satisfied by conveyance of title. 16. Grantor shall indemnify, defend and hold Collier County harmless against and from any and all damages, claims, liabilities, actions, expenses, penalties, fines and costs (including attorney's fees and expenses) incurred by or asserted against Collier County by reason of or arising out of the breach of Grantor's representations under Paragraph 15 above, irrespective of whether the undersigned affiants were negligent in the making of these representations. This provision shall survive closing. 17. There are no unrecorded deeds, judgments, liens, mortgages, easements or rights of way for users, claims, boundary line or other disputes, or demands of any nature asserted against or affecting the Property. 18. There are no matters pending against Grantor that could give rise to a lien that would attach to the Property, or cause a loss of title, or impair title between the effective date of the title insurance commitment (or title search showing ownership and encumbrances) and the time of recording of the instruments evidencing the County's fee simple or other interests in the Property; and that Grantor has not executed and will not execute any instrument that would adversely affect the title to the Property from the date of this Affidavit forward. 19. If the conveyance is of fee simple and by purchase, Grantor agrees that in the event the current real and personal property taxes vary in amount from the figures used in making the prorations used in closing the conveyance of the Property to County, then a new proration and a correct and proper adjustment shall be made upon demand. Grantor understands that all taxes, maintenance charges and assessments due from Grantor for which a bill is rendered prior to closing will be charged against Grantor on the closing statement. 20. If the Property is improved property, then Grantor is the owner of said property, and there are no claims, liens, security interests, claims or demands of any kind against the furniture, equipment, fixtures and personal property located on the Property and being sold as part of this transaction. 21. If the Property is rental property, Grantor hereby represents that Grantor has paid all sales taxes due to the State of Florida to date and will pay any remaining taxes due in respect to said premises before due and will indemnify and hold harmless Collier County from Grantor's failure to do so. 22. Grantor agrees to fully cooperate with Collier County when necessary to correct an error discovered after closing and, in doing so, to execute, without delay, any corrective instrument(s) needed in order to effectuate the intent of the parties to this transaction. This provision shall survive closing. 23. Grantor understands that this certification may be disclosed to the Internal Revenue Service by Collier County and that any false statements made here could be punished by fine, imprisonment, or both. Grantor further authorizes the submission of this affidavit if and when required. 24. Under penalties of perjury, I, the undersigned affiant, state that I have examined this affidavit and to the best of my knowledge and belief it is true, correct and complete as of the date of execution hereof; that I am authorized to execute this affidavit as or on behalf of Grantor and to bind Grantor thereby; that I will immediately notify Collier County of any change to the representations contained herein and that, in the absence of such notification, Collier County may rely on the representations contained herein on the day of closing; that Grantor intends for Collier County, its agents and attorneys, the title company issuing the title policy (if title insurance is to be issued), its underwriter and its employees, any escrow/settlement agent and other parties and their attorneys participating in this transaction, to rely on these representations, and Grantor will indemnify said parties for all damages, loss, liability, claims, cost and expenses, including attorney fees, which arise out of or result from their reliance upon these representations, irrespective of whether I was negligent in making these representations or executing this Affidavit. FOREST LAKES GOLF & TENNIS CLUB, I BUILDING NO. 2, INC., a Florida non-profit corp. i ,/,A. iA/La. '4 , itn 's ( ign. u e) ( By: � Print: 1 Voi.-- � Print: '- ref S - y� Title: —71'?. \0 / 4L ( /(- Witness (Signatw`e) Print: fI, 1/111;-A % ah.At Y STATE OF COUNTY OF � a17-006L- 2013b SWORN TO AND SUBSCRIBED b me this day of by Ll4/ J A7r✓tI , as befRre ie ,2i�F4 , on behalf of FOREST LAKES GOLF & TENNIS CLUB, BUILDING NO. 2, INC., who is grsQnal .._known to me or who has produced as identification. WITNESS my hand and official seal thisa7 day of q c.2013. J ,RFP• 1P �'•., MAR�j'ANN GRACEY � �.1�_ i i 44'Y_a b s -State of Florida My Comm. E (SI lf of Notaty_Public) �A 1 �; xpires Feb 13,2014 �� �I / 's;F ��°• Commission#OD 933510 ✓r/A/€.�/'AR/ `2 -/ Bonded Through National Notary Assn. (Print Name of Notary Public) Approved as to form an lega NOTARY PUBLIC Serial/Commission #:(if any) Assis ntCo>IintyAtt My Commission Expires: -e 0 • • LEGAL DESCRIPTION PARCEL 105RDUE A ROAD, DRAINAGE AND UTILITY EASEMENT OVER THE SOUTHERLY 60 FEET OF FOREST LAKES GOLF & TENNIS CLUB BUILDING NUMBER 2 PER CONDOMINIUM BOOK 19, PAGE 115 OF THE PUBLIC RECORDS OF COWER COUNTY, FLORIDA. LYING IN SECTION 14, TOWNSHIP 49 SOUTH, RANGE 25 EAST, COLLIER COUNTY, FLORIDA AND BEING MORE PARTICULARLY DESCRIBED AS FOLLOWS. BEGINNING AT THE SOUTHWEST CORNER OF FOREST LAKES GOLF & TENNIS CLUB BUILDING NO. 2, AS SHOWN IN CONDOMINIUM BOOK 19, PAGE 115 OF THE PUBLIC RECORDS OF COLLIER COUNTY, FLORIDA; THENCE ALONG THE WESTERLY BOUNDARY OF SAID FOREST LAKES GOLF & TENNIS CLUB N10-00'43"W FOR 60,00 FEET TO THE BEGINNING OF A NON—TANGENTIAL CURVE; THENCE 327.90 FEET ALONG A CURVE TO THE RIGHT, HAVING A RADIUS OF 2030.00 FEET, THROUGH A CENTRAL ANGLE OF 09'15'18", AND WHOSE LONG CHORD BEARS N84'36'56"E FOR A DISTANCE OF 327.55 FEET; THENCE N89'14'35"E FOR 81.36 FEET, TO A POINT ON THE EASTERLY BOUNDARY OF SAID FOREST LAKES GOLF & TENNIS CLUB BUILDING NO. 2; THENCE ALONG THE OVERALL PERIMETER OF SAID FOREST LAKES GOLF & TENNIS CLUB, THE FOLLOWING THREE (3) DESCRIBED COURSES: 1) THENCE 500'45'25"E FOR 60.00 FEET; 2) THENCE S89'14'35"W FOR 81.36 FEET TO THE BEGINNING OF A TANGENTIAL CURVE; 3) THENCE 318.21 FEET ALONG A CURVE TO THE LEFT, HAVING A RADIUS OF 1970.17 FEET, THROUGH A CENTRAL ANGLE OF 09'15'15", AND WHOSE LONG CHORD BEARS S84736'56"W FOR A DISTANCE OF 317.86 FEET, TO THE POINT OF BEGINNING OF THE PARCEL DESCRIBED HEREIN. CONTAINING 24265.3 SQUARE FEET OR 0.56 ACRES MORE OR LESS. SUBJECT TO EASEMENTS AND RESTRICTIONS OF RECORD. .,77 12g12oi( MILHAELi4. WARD '•'' DAT SI NED • FLORIDAI 1rR©FESSIONAL'LAND SURVEYOR CERTIFICATE No. LS# 5301 NOT,'VALID WITI OUT_;THE,SIGNATURE AND THE ORIGINAL RAISED SEAL OF A FLORIDA-;LICEIiSED-`SURRVFYOR AND MAPPER. ■ L THIS'4$ NOT A SURVEY. : • ;j r i1` .. `-� so • TECM - ROW JUL 2 2 2011 EXHIBIT_A_ ='age I of 22,2011 9D1 AM S:\2027\070190.06.00 la...1 Lakes 14750,0001 Skeen Aaa Oua50lbn,\R.,00\0 7015 00 60 0-10 5R0UEa.9 DUTAA`. PROJECT: FOREST LAKES MS1U V .tio9 LEGAL DESCRIPTION C JL.NS1 TI AL sr, PARCEL 105RDUE (ROAD, DRAINAGE AND UTILITY EASEMENT) 6610 Willow Pa1X 0,wa,Sage 200 Naples,Florida 34109 PREPARED FOR: COLLIER COUNTY Phone:(239)597-0575 FAX:12391597.0575 La Na.:6952 JOB NUMBER REVISION SECTION TOWNSHIP RANGE SCALE DATE DRAWN BY FILE NAME SHEET 070190.06.00. 0 I, 14 49S ( 25E I N/A I 7/21/11 I R.A.K. I 105RDUE 1 OF 2 CA • N W E S 0 50 100 GRAPHIC SCALE 1"..100' FOREST LAKES GOLF & TENNIS CLUB BUILDING NO. 2 CONDOMINIUM FOREST LAKES C.B. 19, PG. 115 GOLF AND TENNIS FAIRWAY FOREST DECLARATION OF CONDOMINIUM O.R. CLUB GARDEN VILLAS, A 952 PG. 1952 RECREATIONAL CONDOMINIUM, C.B. FACILITIES, C.B. 15, 29, PG. 95-98 L=327.90' PG. 44 DECLARATION OF R=2030.00' CONDOMINIUM, O.R. /1:,=.9115'18' CONDOMINIUM, 03.4484'36'56'E 8136' 1267 PG. 4 23.- X , 327.55' N— — 00 4 FOREST z r 105RDUE a cm.. LAKES _ — o, °^' BLVD .cam+ 18.21' S89'14'3 m R=1970.17' 81.36' --------------------/ 6=9"15'15' SOUTHERLY BOUNDARY GB= 84 36'56"W OF FOREST B LAKES UILDING(:OZLF POB C=317.86' S.W. CORNER OF FOREST LAKES GOLF TURTLE LAKE GOLF COLONY & TENNIS CLUB CONDOMINIUM .APTS, BLDG. 11 BUILDING 2 C.B. 14, PG. 42-53 TURTLE LAKE GOLF DECLARATION OF CONDOMINIUM COLONY CONDOMINIUM O.R. 835 G. 479 APTS, BLDG. 10 TURTLE LAKE GOLF C.B. 7, PG. 2 COLONY DECLARATION OF CONDOMINIUM CONDOMINIUM, O.R. 566 APTS, BLDG. 1 PG. 365 DECLARATION OF CONDOMINIUM, O.R. 583 PG. 652 LEGEND POB = POINT OF BEGINNING O.R. = OFFICIAL RECORDS BOOK PG. = PAGE P.8. = PLAT BOOK C.B. = CONDOMINIUM PLAT BOOK NO. = NUMBER SF = SQUARE FEET BLVD BOULEVARD L = LANE EXHIBIT_&-, R = RADIUS 4 = DELTA 9 of CB = CHORD BEARING Page C = CHORD C1 = SEE CURVE TABLE • July 22.2011 0:01 AN s:\2007\070190.05.00 ran..Lai.11510,0001 61.*9 A0e O.acdpsu,r\aw 00\0701900600_10R0LC,oq PROJECT: FOREST LAKES MSTU MIMING Visualization SKETCH OF LEGAL DESCRIPTION CONSULTING CivilElgineeing AL t V VA. .. Surveying&Mapping PARCEL 105RDUE (ROAD, DRAINAGE AND UTILITY EASEMENT) 6610 Wiwi Park Drive.So0e 200 Naple,Florida 34109 PREPARED FOR: COLLIER COUNTY Phone:(239)597-0575 FAX(2391567-a578 LB No.:0952 JOB 0701 0 06.00 REVISION I SECTION TOWNSHIP 1P_ RANGE I 1 SCALE= 00' I 7/21/1 1 _DRAWN R.A.K. FILE NAME _ 2 SHEET 2 I 1 0 EXHIBIT "B" Declaration of Condominium of Forest Lakes Golf & Tennis Club Building No. 2, dated August 15, 1979 and recorded December 31, 1981 in Official Records Book 952, Page 1952; Assignment of Easement recorded September 24, 1986 in Official Records Book 1219, Page 2169; Amendment recorded January 30, 1995 in Official Records Book 2025, Page 1894, all of the Public Records of Collier County, Florida. Restrictions, conditions, reservations, easements and other matters contained on the Plat of Forest Lakes Golf & Tennis Club Building No. 2 as recorded in Condominium Plat Book 19, Page 115, of the Public Records of Collier County, Florida; but deleting any covenant, condition or restriction indicating a preference, limitation or discrimination based on race, color, religion, sex, handicap, familial status, or national origin to the extent such covenants, conditions or restriction violate 42 USC 3604(c). Resolution No. 2010-168 approving the preliminary assessment roll for the purpose of providing and regulating Solid Waste Collection and Disposal Services, dated September 14, 2010 and recorded October 1, 2010 in Official Records Book 4610, Page 2307, of the Public Records of Collier County, Florida. Resolution No. 2011-150 approving the preliminary assessment roll for the purpose of providing and regulating Solid Waste Collection and Disposal Services, dated September 13, 2011 and recorded September 22, 2011 in Official Records Book 4721, Page 1527, of the Public Records of Collier County, Florida. Rights of tenant(s) in possession, if any, under lease(s) not recorded in the Public Records. Terms and conditions of the Easements creating the interest insured hereunder. CA