Sample Owner Affidavit - FGUA

This taxpayer identification number is being provided in connection with a real and/or personalproperty transaction.The undersigned understand that this Certificate may be disclosed to the Internal Revenue Serviceby the Florida Governmental Utility Authority and that any false statement contained herein could bepunished by fine, imprisonment or both.Under penalties of perjury, I declare that I have examined this certification and to the best of myknowledge and belief it is true, correct and complete, and I further declare that I have authority tosign this document as or behalf of the Owner, and that the number shown on this document as or onbehalf of the Owner, and that the number shown on this statement is Owner’s correct TIN or SSN.Owner states that this instrument is given for the express purpose of inducing the FloridaGovernmental Utility Authority, to accept the interest in the Property as described in Exhibit "A."C. SECTION 286.23 REPRESENTATIVE CAPACITY DISCLOSURE(Section C is only required if Developer is conveying a fee interest in the Property to the FGUA via aWarranty Deed.)In 1974 the Florida State Legislature enacted legislation, Section 286.23, providing that persons orentities, with few exceptions, holding real property in the form of a partnership, limited partnership,corporation, trust, or in any form of representative capacity shall make a written public disclosure underoath of the name and address of every person having a beneficial interest in the real property before theproperty held in such capacity is conveyed to the FGUA.Please furnish the names and addresses of each person holding a beneficial interest in the Property orproof that the Owner is exempt from the reporting requirements of section 286.23 of the FloridaStatutes and attach the pertinent data specified hereto as Exhibit "B." As this disclosure should bemade under oath subject to the penalties prescribed for perjury and returned to the FGUA at least ten(10) days prior to the date of conveyance of the Property, if Exhibit "B" is attached it shall be consideredpart of this affidavit and incorporated herein with equal status as all other parts of this affidavit.[Remainder of page intentionally left blank.]3

Further Affiant sayeth naught.This Affidavit is made under the full understanding of the law regarding liability for anymisrepresentation herein.Dated this day of ____________, 20____.Signature_Print Name & TitleSTATE OF _________________COUNTY OF ________The foregoing affidavit, including Exhibit(s) A&B, was sworn and subscribed before me this ___day of _ _ , 20____, by ______ __________________________.Who is personally known to me or has producedasidentification and did take an oath.By:Notary PublicPrint Name:Commission No:_______Commission Expires: ___________________4

EXHIBIT AINSERT LEGAL DESCRIPTION OF LAND CONTAINING UTILITY FACILITIESAll of the infrastructure being conveyed lies within the Public Right-of-Way of____________________, the ___ Public Utility Easement indicated on the ____side of Lot _________, of ______________ as recorded on PB _____, PG _____, ofthe Public Records of ____________ County, Florida and the described UtilityEasementPLEASE CONTACT THEDEVELOPMENT TEAM FOR ACUSTOMIZED EXHIBIT “A”5

EXHIBIT BINSERT NAMES AND ADDRESSES OF ALL PERSONS HAVING A BENEFICIAL INTEREST IN THEPROPERTY OR REASON OWNER IS EXEMPT FROM THE DISCLOSURE REQUIREMENTS OF SECTION286.23 OF THE FLORIDA STATUTES.(Exhibit B is only required if Developer is conveying a fee interest in the Property to the FGUA via aWarranty Deed.)6