Okaloosa County BOCC — May 15, 2013 — General Information, Wet Slip, Gross Income Reporting and Certification Forms — reading text

SOVEREIGNTY SUBMERGED LANDS LEASE ANNUAL WET SLIP REVENUE REPORT As a submerged lands lessee, you are required to report annually to the Division of State Lands all income derived directly or indirectly from the lease area, to report the number and type of wet slips and to certify that all information provided is correct. This includes reporting any income collected by you or someone else. The three attached forms must be completed and returned by ail lessees. Directions for completing forms WET SLIP INFORMATION FORM - This form is for reporting the number and type of wet slips. Please enter the correct number of each type of wet slip at the lease facility and total. GROSS INCOME REPORTING FORM - This form is for reporting direct and indirect income that has been generated within the lease boundary during the timeframe specified. This is required under the terms of your lease and under subsection 18- 21.011(1)(a)2. Florida Administrative Code. Please enter the amount of both direct and indirect income generated by month within the lease boundary. The definition of income can be found at the bottom of the form. CERTIFICATION FORM - This form is the lessee's confirmation that all information provided is true and correct. This form must be notarized. General Lease Fee Information income is defined in Rule 18-21.003, Florida Administrative Code, as the gross revenue derived directly or indirectly from the use of state-owned submerged lands such as slip rental, lease or sublease fees, dock or pier admission fees, club membership, stock ownership or equity interest in activities where increased revenue Is attributable to the use of the submerged land. However, gross revenue shall not include pass-through fees for utility services, sale of the facility or sales of products not occurring on sovereignty submerged lands. Gross revenue shall include all future payments made for the transfer of the interest in a slip originally obtained from the Board's lessee, including transfer of slip rights by slip sublessee, slip “sellers”, slip interest transfers, new club memberships, and other similar transactions. If you are required to pay 6% of the income generated on the lease area, you will receive a supplemental invoice for any additional fees owed. To view Chapter 18-21 Florida Administrative Code, on Sovereignty Submerged Lands Management in its entirety go to: http://www. firules.org/gateway/ChapterHome.asp?Chapter=18-21 FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF STATE LANDS/BUREAU OF PUBLIC LAND ADMINISTRATION 3900 COMMONWEALTH BOULEVARD, MS 130 TALLAHASSEE, FLORIDA 32399-3000 (850) 245-2720 2012/2013 Wet Slip Information Form SIALOOSA COOMTY Lessee: wee Instrument No: 4600/7681 |. INFORMATION ON WET SLIPS LOCATED ON STATE-OWNED LANDS 4. Number of Temporary Slips - Slips that are not rented and are used as fuel docking, launching or removing boats, restaurants, or store purchases. These slips should be Non revenue generating slips. OQ 2. Number of Transient Slips- Slips that are rented on a short term basis. Oo 3. Number of Public Siips - open to the public on a "first come, first served" basis. - Rental term shall be no longer than one year and with no automatic renewal rights or conditions. OQ 4, Number of Slips Not Usable - Slips that are silted in or are in tow water. (a) 5. Number of Slips Sold, Subleased, Licensed, Assigned, etc. - Attach a copy of the document which represents the sale, sublease, license or assignment. The document should include the sublessee’s name, unit number, the slio number, and the amount of the transaction. oO 6. Number of Private Slips, not rented to the public - Slips used for personal mooring, Association common area, etc. (a) “Total Number of 8 Is your facility a Pier with Admission Fees? (ves NO Circle One Boating has a tremendous economic impact on the State of Florida each year. In an effort to learn if boaters have an adequate number of slips around the state, we are requesting information on wet slips that are not within a state-owned submerged land lease. No income generated from these slips is to be reported. ll. INFORMATION ON WET SLIPS LOCATED ON PRIVATELY-OWNED LAND 4. Number of Slips Sold, Subleased, Licensed, Assigned, etc: 2. Number of Public Slips - open to the public on a "first come, first served" basis. 3. Number of Private Slips, not rented to the public - Slips used for personal mooring, Association common area, etc. Total.Number.of Slips on Privately-Owned Lands, Add. lines. 1 through 2012/2013 GROSS INCOME REPORTING FORM Lessee: CIKALOCOSA COUNTY BCC Instrument#: 46001768 | Month Year Direct Income Indirect Income The beginning month is the All income received directly by Lessee from |All income received by someone other than Anniversary month of your lease. | transactions within the lease boundary. * the Lessee for transactions involving the use of state-owned submerged land within the Lessee's lease boundary. May 2012 _|s it 3a? § 5,604 4¢ June 2012, |s 3 96,490 # July 2012 |g 3 99, 431°" August 2012, |s_ 5 5G 325 °° September 2012, |s_ 5 38,497% October 2012 ¢ | $ 83,8147 November 2012, |s_— 5 17, 596 December 2012 ¢ g 10,588 63 January 2013 gs ¢ 7,518 * February 2013 |g ¢ 8570 % March 2013 Is $ 40,6717" April 2013 |g 5 39,4754 TOTALS $ 135,819 2% $ 518, 582°? _. Every month must be filled out even if incom: Enter Zero if slips are non-revenue generating or generated $0.00" * Income is defined in chapter 18-21.003, Florida Administrative Code, as the gross revenue derived directly or indirectly from the use of state-owned submerged lands such as slip rental, lease or sublease fees, dock or pier admission fees, club membership, stock ownership or equity interest in activities where increased revenue Is attributable to the use of the submerged land. However, gross revenue shall not include pass-through fees such as fees for utility services, sale of the facility or sales of products not occurring on sovereignty submerged lands. Gross revenue shall include all future payments made for the transfer of the interest in a slip originally obtained from the Board’s lessee, including transfer of slip rights by slip sublessee's, slip “sellers”, slip interest transfers, new club memberships, and other similar transactions, PLEASE ATTACH A LIST OF ANY SLIP TRANSFERS AS DEFINED ABOVE INCLUDING THE SLIP NUMBER, AMOUNT OF INCOME RECEIVED, SUBLESSEE'S NAME AND UNIT NUMBER, IF APPLICABLE. FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF STATE LANDS/BUREAU OF PUBLIC LAND ADMINISTRATION 3900 COMMONWEALTH BOULEVARD, MS #130 TALLAHASSEE, FLORIDA 32399-3000 (850) 245-2720 CERTIFICATION Instrument No. Lessee Name: Billing Address City/State/Zip Telephone: Facility Address: City/County/Zip: i, being first duly sworn, hereby certify under penalty of perjury that the following statements are true: (1) To the best of my knowledge and belief, the information contained on the Wetslip Information Form and the Gross Income Reporting Form is true and correct; (2) | have read and understand the terms and conditions of the sovereignty submerged lands lease, and the facility is in full compliance with all the terms and conditions of the sovereignty submerged lands lease; (3) lam authorized to execute this certification on behalf of the lessee; and (4) | am aware that any intentional false 460017681 OKALOOSA Conury BCC Baz _N. Wiesos Sr Suite 302 Ckesrvicuw), Co (850 _) ©89- 57°76 (Please provide area code) 300 Pree. ReaD Ec _watzoul Benen | okaroosa / 32548 statement herein will be grounds for cancellation of the sovereignty submerged lands lease. STATE OF Signature of Lessee Printed Name of Signature Title COUNTY OF Date Sworn to or affirmed and subscribed before me the by day of ; 20 : Personally Known OR Produced Identification Type of identificaiton produced Notary Signature Commission Expires (SEAL)