Backup Documents 09/10/2013 Item #16A10 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP V L A
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office 10131117,
4. BCC Office Board of Count y
Commissioners \ // 10 VA\
5. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff John Houldswort Phone Number x-5757
Contact/ Department
Agenda Date Item was Sept. 10,2013 \j Agenda Item Number 16-A10
Approved by the BCC VVV
Type of Document Plat Number of Original ONE
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? JH
2. Does the document need to be sent to another agency for additional signatures? If yes, JH
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed JH
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the JH
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip N/
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on September 10,2013 and all changes ^
made during the meeting have been incorporated in the attached document. The �0
County Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
16410
MEMORANDUM
Date: October 11, 2013
To: John Houldsworth, Senior Engineer
Engineering Services Department
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Plat & Construction, Maintenance Agreement and
Performance Bond — Faith Landing 2
Attached for your records is a copy of the documents referenced above,
(Item #16A10) adopted by the Board of County Commissioners on
Tuesday, September 10, 2013.
If you have any questions, please feel free to contact me at 252-8411.
Thank you.
Attachment
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 6A10
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATU
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office
4. BCC Office Board of County
Commissioners � � 1,;��1,\�<,
5. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff John Houldswo Phone Number x-5757
Contact/ Department
Agenda Date Item was Sept. 10,2013 Agenda Item Number 16-A 10
Approved by the BCC
Type of Document Construction&Maintenance Agreement Number of Original 2—Agreement and L/C
Attached and Letter of Credit /Faith Landing 2 Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? JH
2. Does the document need to be sent to another agency for additional signatures? If yes, JH
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed JH
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the JH
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on September 10,2013 and all changes
made during the meeting have been incorporated in the attached document. The
County Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the
Chairman's signature.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
16410
MEMORANDUM
Date: October 11, 2013
To: John Houldsworth, Senior Engineer
Engineering Services Department
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Plat & Construction, Maintenance Agreement and
Performance Bond — Faith Landing 2
Attached for your records is a copy of the documents referenced above,
(Item #16A10) adopted by the Board of County Commissioners on
Tuesday, September 10, 2013.
If you have any questions, please feel free to contact me at 252-8411.
Thank you.
Attachment
16A10
CONSTRUCTION AND MAINTENANCE AGREEMENT
FOR SUBDIVISION IMPROVEMENTS
THIS CONSTRUCTION AND MAINTENANCE AGREEMENT FOR SUBDIVISION
IMPROVEMENTS entered into this y day of September, 2013 between Habitat for Humanity of
Collier County, Inc., hereinafter referred to as "Developer", and the Board of County Commissioners of
Collier County, Florida, hereinafter referred to as the"Board".
RECITALS:
A. Developer has, simultaneously with the delivery of this Agreement, applied for the approval by the
Board of certain plat of a subdivision to be known as: Faith Landing Phase II.
B. Chapters 4 and 10 of the Collier County land Development Code requires the Developer to post
appropriate guarantees for the construction of the improvements required by said subdivision regulations,
said guarantees to be incorporated in a bonded agreement for the construction of the required
improvements.
NOW, THEREFORE, in consideration of the foregoing premises and mutual covenants hereinafter set
forth, Developer and the Board do hereby covenant and agree as follows:
1. Developer will cause to be constructed: Road way, water and sewer utilities, Street lights, Sidewalks
and storm drainage.
Within 24 months from the date of approval of said subdivision plat, said improvements hereinafter
referred to as the required improvements.
2. Developer herewith tenders its subdivision performance security (attached hereto as Exhibit "A" and
by reference made a part hereof) in the amount of$737,300.08 which amount represents 10% of the total
contract cost to complete the construction plus 100% of the estimated cost to complete the required
improvements at the date of this Agreement.
3. In the event of default by the Developer or failure of the Developer to complete such improvements
within the time required by the Land Development Code, Collier County may call upon the subdivision
performance security to insure satisfactory completion of the required improvements.
4. The required improvements shall not be considered complete until such a statement of substantial
completion by Developer's engineer along with the final project records have been furnished to be
reviewed and approved by the County Manager or his.designee for compliance with the Collier County
Land Development Code.
5. The County Manager or his designee shall, within sixty (60) days of receipt of the statement of
substantial completion, either: a) notify the Developer in writing of his preliminary approval of the
improvements, therewith specifying those conditions which the Developer must fulfill in order to obtain
the County Manager's approval of the improvements. However, in no event shall the County Manager or
his designee refuse preliminary approval of the improvements if they are in fact constructed and
submitted for approval in accordance with the requirements of this Agreement.
6. The Developer shall maintain all required Improvements for a minimum period of one year after
preliminary approval by the County Manager or his designee. After the one year maintenance period by
the Developer has terminated, the developer shall petition the County Manager or his designee to inspect
the required improvements. The County Manager or his designee shall inspect the improvements and, if
16 A10
Board, the Board shall release the remaining 10% of the subdivision performance security. The
Developer's responsibility for maintenance of the required Improvements shall continue unless or until
the Board accepts maintenance responsibility for and by the County.
7. Six (6) months after the execution of this Agreement and once within every six (6) months thereafter
the Developer may request the County Manager or his designee to reduce the dollar amount of the
subdivision performance security on the basis of work complete. Each request for a reduction in the dollar
amount of the subdivision performance security shall be accompanied by a statement of substantial
completion by the Developer's engineer together with the project records necessary for review by the
County Manager or his designee. The County Manager or his designee may grant the request for a
reduction in the amount of the subdivision performance security for the improvements completed as of
the date of the request.
8. In the event the Developer shall fail or neglect to fulfill its obligations under this Agreement, upon
certification of such failure, the County Manager or his designee may call upon the subdivision
performance security to secure satisfactory completion, repair and maintenance of the required
improvements. The Board shall have the right to construct and maintain, or cause to be constructed or
maintained, pursuant to public advertisement and receipt of acceptance of bids, the improvements
required herein. The Developer, as principal under the subdivision performance security, shall be liable to
pay and to indemnify the Board, upon completion of such construction, the final total cost to the Board
thereof, including, but not limited to, engineering, legal and contingent costs, together with any damages,
either direct or consequential, which the Board may sustain on account of the failure of the Developer to
fulfill all of the provisions of this Agreement.
9. All of the terms, covenants and conditions herein contained are and shall be binding upon the
Developer and the respective successors and assigns of the Developer.
IN WITNESS WHEREOF, the Board and the Developer have caused this Agreement to be
executed by their duly authorized representatives this day of August, 2013.
SIGNED IN THE PRESENCE OF: HABITAT FOR HUMANITY OF COLLIER
COUNTY, ICI --., a Flo 'da j, for-profit
corpor. '.:
`Nyt a5 loheras
SAMUEL . 'I URSO, its President
Lisa Left('w
. t o , 2.013 r.
ATTEST: BOARD Olr C UNTY COMMISSIONERS OF
COLLIER FO NI;V FLORIDA
DWI , T E. BR 1 CK,CLERK V
By:
•� GI A,(. HILLER, Chairwoman
Deputy Clerk es as 0 airman s
signature only.
A.•robed as to form and legal+i ,
•
700 Brickeil Avenue
Miami,Florida 33131
Telephone:(305)372-1000
SWIFT CNORUS3M
� Northern Trust 16A10 '
IRREVOCABLE STANDBY LETTER OF CREDIT NO. SLC500972
ISSUER'S IDENTIFYING NUMBER ABA 066009650
ISSUER: THE NORTHERN TRUST COMPANY, 700 BRICKELL AVENUE, MIAMI, FLORIDA
33131 ATTENTION: LETTERS OF CREDIT DEPARTMENT(HEREINAFTER "ISSUER").
PLACE AND DATE OF ISSUE: 700 BRICKELL AVENUE, MIAMI, FLORIDA 33131
ATTENTION: LETTERS OF CREDIT DEPARTMENT .
DATE: SEPTEMBER 27, 2013
PLACE OF EXPIRY: AT ISSUER'S COUNTERS LOCATED AT 700 BRICKELL AVENUE,
MIAMI, FLORIDA 33131, ATTN: LETTERS OF CREDIT DEPARTMENT.
DATE OF EXPIRY: THIS CREDIT SHALL BE VALID UNTIL SEPTEMBER 29, 2014, AND
SHALL THEREAFTER BE AUTOMATICALLY RENEWED FOR SUCCESSIVE ONE-YEAR
PERIODS ON THE ANNIVERSARY OF ITS ISSUE UNLESS AT LEAST SIXTY (60) DAYS
PRIOR TO ANY SUCH ANNIVERSARY DATE, THE ISSUER NOTIFIES THE BENEFICIARY IN
WRITING TO STAFF (AT ENGINEERING REVIEW SERVICES, 2800 N. HORSESHOE DR.,
NAPLES, FL 34104) BY REGISTERED MAIL THAT THE ISSUER ELECTS NOT TO SO RENEW
THIS CREDIT.
APPLICANT: HABITAT FOR HUMANITY OF COLLIER COUNTY, INC., (HEREINAFTER
"APPLICANT") 11145 TAMIAMI TRAIL E.,NAPLES,FLORIDA 34113.
BENEFICIARY: THE BOARD OF COUNTY COMMISSIONERS, COLLIER COUNTY,
FLORIDA (HEREINAFTER "BENEFICIARY") COLLIER COUNTY COURTHOUSE COMPLEX,
NAPLES, FLORIDA 34112.
AMOUNT: USD737,300.08 (SEVEN HUNDRED THIRTY SEVEN THOUSAND THREE
HUNDRED AND 08/100 U.S.DOLLARS(U.S.)UP TO AN AGGREGATE THEREOF.
CREDIT AVAILABLE WITH: ISSUER.
BY: PAYMENT AGAINST DOCUMENTS DETAILED HEREIN AND BENEFICIARY'S DRAFTS
AT SIGHT DRAWN ON THE ISSUER.
PAGE 1 OF 2
Wage - SL. C500972
700 Brickell Avenue
Miami,Florida 33131
Telephone:(305)372-1000
SWIFT:CNORUS3M 16 A 1 0
Northern Trust
PAGE 2 OF 2
IRREVOCABLE STANDBY LETTER OF CREDIT NO. SLC500972
DOCUMENTS REQUIRED: AVAILABLE BY BENEFICIARY'S DRAFT(S) AT SIGHT DRAWN
ON THE ISSUER AND PRESENTED AT PLACE OF EXPIRY ACCOMPANIED BY
BENEFICIARY'S STATEMENT PURPORTEDLY SIGNED BY THE COUNTY MANAGER,
CERTIFYING THAT: '`HABITAT FOR HUMANITY OF COLLIER COUNTY, INC. HAS FAILED
TO CONSTRUCT AND/OR MAINTAIN THE ROAD WAY, WATER AND SEWER UTILITIES,
STREET LIGHTS AND SITE DRAINAGE, EXTENSIONS AND/OR IMPROVEMENTS AS
SHOWN ON THE PLANS FOR `FAITH LANDING PHASE H', OR PRIOR TO THE DATE OF
EXPIRY THE APPLICANT FAILED TO COMPLETE THE REQUIRED FINAL ACCEPTANCE
PROCEDURES AS REQUIRED BY THE COLLIER COUNTY UTILITIES STANDARDS AND
PROCEDURES ORDINANCE, AND THE APPLICANT FAILED TO PROVIDE THE COUNTY
WITH SATISFACTORY ALTERNATIVE PERFORMANCE SECURITY AS REQUIRED BY THAT
ORDINANCE."
DRAFT(S) DRAWN UNDER THIS LETTER OF CREDIT SHALL BE MARKED: "DRAWN
UNDER THE NORTHERN TRUST COMPANY, LETTER OF CREDIT NO. SLC500972 DATED
SEPTEMBER 27, 2013". THE ORIGINAL LETTER OF CREDIT AND ALL AMENDMENTS, IF
ANY, MUST BE PRESENTED FOR PROPER ENDORSEMENT.
THIS LETTER OF CREDIT SETS FORTH IN FULL THE TERMS OF THE ISSUER'S
UNDERTAKING, AND SUCH UNDERTAKING SHALL NOT IN ANY WAY BE MODIFIED,
AMENDED, OR AMPLIFIED BY REFERENCE TO ANY DOCUMENTS, INSTRUMENT, OR
AGREEMENT REFERENCED TO HEREIN OR IN WHICH THIS LETTER OF CREDIT RELATES,
AND ANY SUCH REFERENCE SHALL NOT BE DEEMED TO INCORPORATE HEREIN BY
REFERENCE ANY DOCUMENT, INSTRUMENT OR AGREEMENT.
ISSUER HEREBY ENGAGES WITH BENEFICIARY THAT DRAFT(S) DRAWN UNDER AND IN
COMPLIANCE WITH THE TERMS OF THIS CREDIT WILL BE DULY HONORED BY ISSUER
IF PRESENTED WITHIN THE VALIDITY OF THIS CREDIT.
THIS CREDIT IS SUBJECT TO THE UNIFORM CUSTOMS AND PRACTICE FOR
DOCUMENTARY CREDITS (2007 REVISION) INTERNATIONAL CHAMBER OF COMMERCE
PUBLICATION NO. 600 .
THE NORT '•N fi'UST COMPANY
B • _.
LUIS G. if•• • • i, ICE P' ESIDENT
TELEPH$NE (305 '18-60'1
2I1' age - SI. C500972
16A10The Northern Trust ( tnitp,lu}-
7 i Bricked :Avcn,,s,.
mi_mi. FIOrida 31131
fit;i 72-10)o
� Northern Trust
LETTERS OF CREDIT
AUTHORIZED SIGNATURE LIST
THE FOLLOWING INDIVIDUALS ARE AUTHORIZED TO SIGN LETTERS OF
CREDIT RELATED TRANSACTIONS ON BEHALF OF NORTHERN TRUST, N.A.
1
THELMA K. RESTREPO
VICE PRESIDENT
///j7
LILSPANA
SECOND`VICE PRESIDENT
..
�- ri-
,�%EDC/ARD CASTILLO
✓ VICE PRESIDENT
JANET M. HODDER
SECOND VICE PRESIDENT
/
- - TS'6:-, -1ORV
I `'ICE.RRESIDENT
,_0..),_,.: (4_7_,A,c___ ________
�
IVIVIAN M.'MURCIA
OFFICER
l6AlO Phase Two 50 Units
Faith Landing (50 �
Engineer's Opinion of Probable Costs-June 21,2013
Habitat for Humanity of Collier County-JEI#20078890
Part 1-GENERAL
ITEM DESCRPTION UNIT QUANT. UNIT COST COST
MAINTENANCE OF TRAFFIC LS 1 $4,500.00 $4,500.00
MOBILIZATION LS 1 $15,000.00 $15,000.00
STAKED SILT FENCE,TYPE III LF 8800 $1.00 $8,800,00
SOIL TRACKING PREVENTION DEVICE(50'X20') EA 1 $2,000.00 $2,000.00
SITE LIGHTING EA 12 $1,000.00 $12,000.00
ESTIMATED SUB-TOTAL $40,300.00
Pot 2-ROADWAY
ITEM DESCRIPTION UNIT QUANT. UNIT COST COST
STABILIZED SUBGRADE(12-DEPTH.LBR 40) SY 4800 $3.80 $16,560.00
8'LIMEROCK BASE,LBR 100 SY 3710 $10.00 $37,100.00
1.5'ASPHALTIC CONCRETE TYPE S SY 3710 $8.00 $29,880.00
4'LIMEROCK BASE,LBR 40(SIDEWALK) SY 1490 $8.00 $11,920.00
4'CONCRETE SIDEWALK(REINFORCED) SY 1490 $22.00 $32,780.00
2'VALLEY GUTTER CURB LF 2814 $8.00 $20,912.00
SIGNAGE AND STRIPING LS 1 $7,000.00 $7,000.00
ESTIMATED SUB-TOTAL $155,052.00
Part 3-SANITARY SEWER
ITEM DESCRIPTION UNIT QUANT. UNIT COST COST
REHAB AND CONNECT TO EXISTING MANHOLE EA 1 $2,000.00 $2,000.00
4'SANITARY MANHOLE(3'4'DEEP) EA 7 $4,200.00 $29,400.00
4'SANITARY MANHOLE(8'-10'DEEP) EA 2 $4,800.00 $9,200.00
4'SANITARY MANHOLE(10'-14'DEEP) EA 3 $5,000.00 $15,000.00
8'PVC-SDR 26(Y-8'DEEP) LF 1813 $28.00 $50,784.00
8'PVC-MR 28(8'-10'DEEP) LF 348 $33.00 $11,484.00
8'PVC-SDR 28(10'-14'DEEP) LF 783 $40.00 $30,520.00
DOUBLE SANITARY SERVICE/CLEANOUT EA 54 $800.00 $43,200,00
SINGLE SANITARY SERVICE/CLEANOUT EA 1`\``\\N 11111/6/AA���//i' $700.00
\ T tiwort/ / $192,288.00
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Page 1 of 2
16A10
Part 4-WATER MAIN
ITEM DESCRIPTION UNIT QUANT. UNIT COST COST
DOUBLE WATER SERVICE EA 17 $800.00 $13,600.00
SINGLE WATER SERVICE EA 15 $500.00 $9,00090
ESTIMATED SUB-TOT x,500.00
Part 5-DRAINAGE
ITEM DESCRIPTION UNIT QUANT. UNIT COST COST
TYPE'C'INLET EA 2 $2,800.00 $5,800.00
VALLEY GUTTER INLET EA 14 $3,50000 $49.00000
ADS YARD DRAIN EA 1 $1,200.00 $1,200.00
JUNCTION BOX EA 2 $6,000.00 $12,000.00
15'PVC LF 106 $25.00 $2,650.00
24'REINFORCED CONCRETE PIPE LF 250 $40.00 $10,000.00
30'REINFORCED CONCRETE PIPE LF 389 $50.00 $19,450.00
36'REINFORCED CONCRETE PIPE LF 123 $70.00 $8,610.00
42'REINFORCED CONCRETE PIPE LF 238 $90.00 521,420.00
48'REINFORCED CONCRETE PIPE LF 358 $120.00 $42,960.00
54'REINFORCED CONCRETE PIPE LF 433 $140.00 $60,620.00
ESTIMATED SUB-TOTAL $233,510.00
Patti.LANDSCAPE
ITEM DESCRIPTION UNIT QUANT. UNIT COST COST
SEED AND MULCH SY 38000 $0.50 $19,000.00
ESTIMATED SUB-TOTAL $19,000.00
PHASE TWO ESTIMATED TOTAL $953,83090
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Page 2 of 2
2013 FLORIDA NON PROFIT CORPORATION ANNUAL REPORT FILED
DOCUMENT#742136 Apr 22, 2013
Entity Name: HABITAT FOR HUMANITY OF COLLIER COUNTY, INC. Secretary of Stag 6 A 1
Current Principal Place of Business: j
11145 TAMIAMI TRAL EAST
NAPLES, FL 34113
Current Mailing Address:
11145 TAMIAMI TRAL EAST
NAPLES, FL 34113 US
FEI Number: 59.1834379 Certificate of Status Desired: No
Name and Address of Current Registered Agent:
DURSO,SAMUEL JM.D.
1240 EMBER COURT
MARCO ISLAND,FL 34145 US
The above named entity submits this statement for the purpose of changing its registered office or registered agent,or both,in the State of Florida.
SIGNATURE:
Electronic Signature of Registered Agent Date
Officer/Director Detail Detail :
Title P Title S
Name DURSO,SAMUEL JMD Name MUELLER,MICHAEL
Address 1240 EMBER COURT Address 1109 STRAWBERRY COURT
City-State-Zip: MARCO ISLAND FL 34145 City-State-Zip: MARCO ISLAND FL 34145
Title VP Title T
Name SWIHART,STANARD MD Name CUNNINGHAM,JOHN W
Address 789 REGENCY RESERVE CIR APT Address 841 PARTRIDGE CT
4603 City-State-Zip: MARCO ISLAND FL 34145
City-State-Zip: NAPLES FL 34119
Title EVP
Title EVP
Name KOULOHERAS,NICK
Name LEFKOW,LISA REV.
Address 6130 CYPRESS HOLLOW WAY
Address 1490 NOTTINGHAM DR
City-State-Zip: NAPLES FL 34109
City-State-Zip: NAPLES FL 34109
I hereby certify that the information indicated on this report or supplemental report is true and accurate and that my electronic signature shall have the same legal effect as i made under
oath;that lam an officer or director of the corporation or the receiver or trustee empowered to execute this report as required by Chapter 617,Florida Statutes;and that my name appears
above,or on an altadunent with all other like empowered.
SIGNATURE:SAMUEL J. DURSO PRESIDENT 04/22/2013
Electronic Signature of Signing Officer/Director Detail Date