Fillable Central Examining Boards Restitution Trust Fund Claim Form (Broward County)

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Central Examining Boards Restitution Trust Fund Claim Form (Broward County)

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Environmental Protection and Growth Management Department
BUILDING CODE SERVICES DIVISION | CONTRACTOR LICENSING & ENFORCEMENT
2307 West Broward Boulevard, Suite 300 • Fort Lauderdale, Florida 33312 • 954-765-4400 • broward.org/building
Central Examining Boards Restitution Trust Fund Claim Form
The Broward County Central Examining Boards Restitution Trust Fund shall be disbursed as provided in
Sec. 9-141, et. seq, on order of the central examining boards or the hearing officer as reimbursement to any
person to whom the central examining boards or the hearing officer have ordered restitution to be paid where the
order for restitution is based upon a violation of Chapter 9 committed by any certified or uncertified contractor,
business organization or financially responsible officer.
Any person seeking recovery from the Restitution Trust Fund after having made a claim and exhausting the limits
of any available bond, cash bond, surety, guarantee, warranty, letter of credit, or policy of insurance must have
made a diligent attempt to collect the restitution awarded by the board or the hearing officer as evidenced by
completion of the sworn affidavit attached to this form.
Any amounts recovered by such person from the judgment debtor, the certified contractor, or uncertified
contractor, business organization or financially responsible officer, or from any other source will be applied to the
amount of restitution ordered by the board.
Claimant Information
Name
Address
City
State
Zip
Home Phone
Mobile Phone
Business Phone
Email
Contractor/Debtor Information
Name
Address
City
State
Zip
License No.
A person is NOT qualified to make a claim for recovery from the Restitution Trust Fund if:
Rev. 11/2017 2
1. The complainant files a claim for recovery more than 2 years after the conclusion of any civil or
administrative action based on the act, whichever is greater.
2. The claimant is the spouse of the judgment debtor or certified contractor or uncertified contractor,
business organization or financially responsible offer or a personal representative of such spouse.
3. The claimant acted as the contractor in the transaction which is the subject of the claim.
4. Such person’s claim is based upon a construction contract in which the certified contractor or uncertified
contractor, business organization, or financially responsible officer was acting with respect to property
owned or controlled by the certified contractor.
5. Such person was associated in a business relationship with the certified contractor or uncertified
contractor, business organization or financially responsible officer other than the contract at issue.
6. The violation was based on a complaint against a tree trimmer.
Claim Details
Please give full details of your claim. Include facts, details and dates. Additional page(s) may be used if necessary.
In addition to your complete written statement, attach documentation of your contractual relationship
with the certified or uncertified contractor, business organization or financially responsible officer and
evidence supporting your claim including, but not limited to, copies of:
1. The final order of the central examining board or hearing officer directing that restitution is paid.
2. Contract with the certified or uncertified contractor, business organization or financially responsible
officer.
3. Applicable bonds, sureties, guarantees, warranties, letter of credit and/or policies of insurance letters,
documents and all other proof of efforts made to collection restitution/judgment.
Claims shall be paid in the order filed. Claims arising from the same transaction are limited to
$5,000.00. No claims will be processed until 45 days have lapsed from the entry of the
restitution order or, if the order is appealed, 45 days after conclusion of the appeal(s).
Please read and complete the following questions. Failure to do so may result in delayed processing of
your application.
Rev. 11/2017 3
1.
Was the contract signed by both parties? Yes No
If yes, contract date:
Please attach a copy of the contract
2.
What was the total contract price?
3.
What was the total amount paid to the contractor, business organization or financially responsible officer?
4.
What is the amount of the claim you are requesting?
5.
When did you discover the violation?
Date of violation:
6.
Was a permit pulled from the building department? Yes No
If yes, was a final inspection passed? Yes No
Please attach a copy of the permit
7.
Did the Central Examining Board or hearing officer enter an order requiring restitution?
Yes No
8.
Did you file a complaint against the certified or uncertified contractor, business organization or
financially responsible officer with the Broward County Central Examining Boards?
Yes No
If yes, how much restitution was ordered?
Please attach a copy of the order
9.
Have you or has someone on your behalf-initiated action against the contractor, business
organization or financially responsible officer through the Florida court system?
Yes No
If yes, is there a final court judgment or an ordered restitution from the court?
Yes No
Please attach a copy of the judgment
10.
Have you made a diligent effort to collect payment from the contractor, business
organization or financially responsible officer?
Yes No
Please explain efforts made to collect payment:
11.
(a) Are you the spouse of the certified or uncertified contractor, business organization or
financially responsible officer?
Yes No
(b) Did you act as the contractor in the transaction which is the subject of the claim?
Yes No
Rev. 11/2017 4
AFFIDAVIT FOR RESTITUTION
STATE OF FLORIDA
COUNTY OF BROWARD
BEFORE ME, the undersigned authority, personally
appeared
(hereinafter the “affiant”) who being first duly sworn, deposes and says:
1. Affiant is the claimant in Broward County case number ___________, which matter is pending before the Broward County
Central Examining Boards (hereinafter the "Board").
2. Affiant was awarded restitution by: the Board Hearing Officer on the _____ day of _____________, 20___, in the
amount of ___________, which amount was to be paid by the Respondent in said case.
3. Affiant has made a diligent effort to collect the restitution amount awarded by the Board or Hearing Officer and has been unable
to recover any amount from the Respondent.
4. Affiant further says:
a) I have exhausted the limits of any available bond, cash bond, surety, guarantee, warranty, letter of credit, or policy of
insurance.
b) I am not the spouse of the Respondent, judgment debtor, certified or uncertified contractor, business organization, or
financially responsible officer in the subject case, or a personal representative of such spouse.
c) I did not act as the contractor in the transaction, which is the subject of this claim, and did not obtain the building
permit for the work.
d) My claim is not based upon a construction contract in which the certified contractor, uncertified contractor, business
organization, or financially responsible officer was acting with respect to property owned or controlled by the
contractor.
e) I am not associated in a business relationship with the certified or uncertified contractor, business organization, or
financially responsible officer, other than the contract at issue.
f) My claim is not based upon a contract in which I knew or had reason to know that the contractor did not hold a valid
certificate of competency or that the business organization or financially responsible officer did not hold a valid
certificate of authority at the time of the contract.
g) I have made efforts to determine whether the contractor, business organization, or financially responsible officer
possess any property or assets with which to satisfy the underlying order of restitution, in whole or in part, and that
no such, or insufficient, property or assets have been identified or located.
h) I have provided documentation showing that efforts have been taken to locate the contractor; if located, to demand
reimbursement from the contractor; and to determine whether or not the contractor is insured and, if insured, I have
filed a claim with the contractor's insurance carrier.
I have read the foregoing, and I verify, on my personal knowledge, that the facts set forth in this affidavit are true.
FURTHER AFFIANT SAYETH NAUGHT.
AFFIANT:
____________________________
Print Name: ___________________
The foregoing instrument was sworn to and subscribed before me in the State and County first above written this _____ day of ________________,
20___, by ______________________ who is:
[ ] Personally Known to me, or
[ ] Produced Identification.
Type of identification produced ______________________.
NOTARY PUBLIC-STATE OF FLORIDA:
___________________________________
Signature of Notary Public
___________________________________
Print, type, or stamp Commissioned Name
My commission expires:
Affix Seal Below
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Central Examining Boards Restitution Trust Fund Claim Form (Broward County)

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Completed 8 February 2021

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