STATE OF ___________________________
COUNTY OF _________________________
ON THIS _______ day of ____________________, ____________, before me personally
appeared_________________________________________________________, a licensed attorney
authorized to practice in the State of Florida, to me personally known, whose current business address
and telephone number is ________________________________________
(hereinafter "Affiant"), who, being duly sworn on [his or her] oath, does say:
This Affidavit is given as an inducement to the Florida Governmental Utility Authority, a
legal entity and public body created by interlocal agreement pursuant to Section 163.01(7), Florida
Statutes to accept the dedication or conveyance of ___________________
utility facilities located within or upon the real property described in the attached Exhibit "A", which is
incorporated herein by reference, said land being located in _______ County, Florida.
The Affiant has examined record title information to both the real and personal property
referenced in this affidavit, including but not limited to, information requested from the Office of the
Secretary of State for the State of Florida relative to any Uniform Commercial Code financing statements.
The record owner of the real and personal property described herein is
(hereinafter "Owner"). The Owner acquired record title to the subject real property by instrument
recorded at Official Records Book _______, at Page _____, Public Records, _______ County, Florida. A
copy of the deed is attached hereto as Exhibit "B" and made a part hereof.
As of ____________________, the subject real and personal property was not
encumbered of record, and