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9 WIWMA - Mr -IM -1 0 0 <br />[pa"J'aEll <br />g 77777�� -177---- ­ <br />The undersigned is an agent for Lone Star Planned Developments, LLC ("Develpper"), <br />and requests payment from the City of Paris, Texas (the' ") out of the [PID Project Fund (as <br />defined in the Bond Indenture) / PID Reimbursement Fund] in the amount of $ for labor, <br />materials, fees, and/or other general costs related to the creation, acquisition, or construction of <br />certain PID Projects provng a special benefit to property within Improvement Area #[__] of the <br />Forestbrook Public Improvement District No. 1. Unless otherwise defined, any capitalized terms <br />used herein shall have the meanings ascribed to them in the Reimbursement Agreement, <br />Forestbrook Public Improvement District No. 1, effective 20 (the "Reimbursement <br />AgNgmg�"). In connection with the above referenced payment, Developer represents and <br />warrants to the City as follows: <br />1. The undersigned is a duly authorized officer of Developer, is qualified to execute this <br />Certificate for Payment Form on behalf of Developer, and is knowledgeable as to the matters set <br />forth herein. <br />2. The payment requested for the below referenced PID Projects has not been the subject of <br />any prior payment request submitted for the same work to the City or, if previously requested, no <br />disbursement was made with respect thereto. <br />3. The amount listed below is a true and accurate representation of the PID Project Costs <br />associated with the creation, acquisition, or construction of said PID Projects and such costs: (a) <br />I \ <br />are in compliance with the Reimbursement Agreement; anci (b) are consistent with the Service and <br />Assessment Plan. <br />4. Developer is in compliance with the terms and provisions of the Development Agreement, <br />Developer Continuing Disclosure Agreement, Reimbursement Agreement and the Service and <br />Assessment Plan. <br />5. Developer has timely paid all ad valorem taxes and annual installments of special <br />assessments it owes or an entity Developer controls owes, located in the Forestbrook Public <br />Improvement District No. 1 and has no outstanding delinquencies for such assessments. <br />6. All conditions set forth in the Agreement [and the Bond Indenture] for the payment hereby <br />requested have been satisfied. <br />7. The work with respect to the portion of the PID Project referenced below has been <br />fto <br />completed, and the City has inspected such PID Project. <br />S. Developer agrees to cooperate with the City in conducting its review of the requested <br />payment, and agrees to provide additional information and documentation as is reasonably <br />necessary for the City to complete said review. <br />018581.000001 \490 8-9229- 15 5.v5 <br />