107RDUE GAP AffidavitPROJECT: FOREST LAKES MSTU 162523
PARCEL No(s): 107RDUE
FOLIO No(s): 00259200004
GRANTOR'S NON - FOREIGN, TAXPAYER IDENTIFICATION & "GAP" AFFIDAVIT
The Undersigned, ! I e LV as li ; dcn t
on behalf of FOREST LAKES GOLF & TENNIS CLUB, BUILDING NO. 1, 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. 1, 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.
L/O C;Prn (o70+ mane- Cb_V_ 9 ( V6
b. Grantor's address is:
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: 5D CQ Q(09 I ea
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
C�9 r
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.
Witoss ($ignature)
Print: A11lJ -K-
Witness (Sigma irre)
Print: r rrr i ft
FOREST LAKES GOLF & TENNIS CLUB,
BUILDING NO. 1, INC., a Florida non - profit corp.
By:
Prin . PciL,r C° c'
Title:
STATE OF
COUNTY OF
WORN TO AND SUBSCRIBED before me this /-� day of�'� , 2013 by
as � � ';vi , on behalf_of FOREST LAKES
GOLF & TENNIS CLUB, BUILDING NO. 1, INC., whoti.personally known to meior who
has produced as identification. - - -
WITNESS my hand and official seal this day of�-, 2013.
(affix notarial seal)
�.,�.r,...�a db
MARYANN GRACEY
Notary Public - State of Florida
• = My Comm. Expires Feb 13, 2014
Commission # DD 933510
Pnnded Through National Notary Assn.
of NotarJ Pub
%n/41C'rY ,fi11AJ Gle-1#6Z
(Print Name of Notary Public)
NOTARY PUBLIC
Serial /Commission #:(if any)
My Commission Expires: _
Approved as to form and legality
CAO
A at ��3
Assistant County A key ��
LEGAL DESCRIPTION
PARCEL 107RDUE
A 60 FOOT WIDE ROAD, DRAINAGE AND UTILITY EASEMENT OVER THE SOUTHERLY 60 FEET OF FOREST LAKES
GOLF AND TENNIS CLUB BUILDING NUMBER ONE, A CONDOMINIUM PER CONDOMINIUM BOOK 15, PAGE 40 OF
THE PUBLIC RECORDS OF COLLIER 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 AND TENNIS CLUB BUILDING NUMBER ONE, A
CONDOMINIUM PER CONDOMINIUM BOOK 15, PAGE 40 OF THE PUBLIC RECORDS OF COLLIER COUNTY, FLORIDA.
THENCE ALONG THE WESTERLY BOUNDARY OF SAID FOREST LAKES GOLF AND TENNIS CLUB, N00'45'25"W FOR
60.00 FEET;
THENCE N89'14'35 "E FOR 58.66 FEET TO THE BEGINNING OF A TANGENTIAL CURVE:
THENCE 320.00 FEET ALONG A CURVE TO THE RIGHT, HAVING A RADIUS OF 1145.90 FEET, THROUGH A
CENTRAL ANGLE OF 16'00'00 AND WHOSE LONG CHORD BEARS S82'45'25 "E FOR A DISTANCE OF 318.96
FEET, TO THE BEGINNING OF A NON— TANGENTIAL CURVE:
THENCE 296.77 FEET ALONG A CURVE TO THE LEFT. HAVING A RADIUS OF 1057.98 FEET, THROUGH A CENTRAL
ANGLE OF 16'04'18 ", AND WHOSE LONG CHORD BEARS S82'47'34 "E FOR A DISTANCE OF 295.80 FEET:
THENCE ALONG THE OVERALL PERIMETER OF SAID FOREST LAKES GOLF AND TENNIS CLUB BUILDING NUMBER
ONE, THE FOLLOWING FOUR (4) DESCRIBED COURSES:
1) THENCE S00'49'42 "E FOR 50.00 FEET TO THE BEGINNING OF A NON — TANGENTIAL CURVE;
2) THENCE 313.60 FEET ALONG A CURVE TO THE RIGHT, HAVING A RADIUS OF 1117.98 FEET, THROUGH A -
CENTRAL ANGLE OF 16'04'18", AND WHOSE LONG CHORD BEARS N82'47'34,W FOR A DISTANCE OF 312.57
FEET, TO THE BEGINNING OF A NON — TANGENTIAL CURVE:
3) THENCE 303.24 FEET ALONG A CURVE TO THE LEFT, HAVING A RADIUS OF 1085.90 FEET, THROUGH A
CENTRAL ANGLE OF ISOO'DO ", AND WHOSE LONG CHORD BEARS N82'45'25W FOR A DISTANCE OF 302.26
FEET;
4) THENCE S89'14'35 "W FOR 58.66 FEET, TO THE POINT OF BEGINNm OF THE PARCEL HEREIN DESCRIBED;
CONTAINING 40528.0 SOUARE FEET OR 0.93 ACRES MORE OR LESS, SUBJECT TO EASEMENTS AND
RESTRICTIONS OF RECORD.
P
-lilt
MICH4EL A. WARD DATE-15IGNEiD
FLORIDA PROFESSIONAL'- -LAND SURVEYOR CERTIFICATE No, LS# 5301
NOT VALID WITHOUT THE SIGNATURE AND THE ORIGINAL RAISED SEAL OF A
FLOI�IOA LICENSED SURVEYOR AND MAPPER.
THIS IS NOT.A SURVEY
TECm - R.c,1.>v/
JUL 2 2 2011
EXH I BIT.._
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DATE
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PARCEL 107RDUS (ROAD. DRAINAGE AND UnLTTY EASEMENT)
,J• d Awe
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PREPARED FOR! COLLIER COUNTY
N. -,FWd.84IW
P4 , (289) 597 -0575 FAIT: 12") 597 -0578
Le No.. 8952
j
SOB NUMBER
REVISION
SECTION
TOWNSHIP
RANGE
SCALE DATE
DRAWN Br vi:[ NARK SHEET
070190.06.00
0
14
49S
25E
1" = 100' 7/21411
R.A.K. 107RDUE 2 DF 2
Paine � of
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EXHIBIT "B"
Declaration of Condominium of Forest Lakes Golf & Tennis Club Building No. 1, dated
February 21, 1980 and recorded February 21, 1980 in Official Records Book 856, Page
916, 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. 1 as recorded in Condominium Plat Book
15, Page 40, 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
141 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.
l.)