NCC221380_FRO Submitted_20220408

FINANCIAL RESPONSIBILITYIOWNERSHIIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project NameWildwood Subdivision Lots 1, 27 47 101 12-14
2. Location of land -disturbing activity: County Harnett City or Township Grove
Highway/Street S R 1769 Latltude(decimal degrees) 35.3617 Longitude(decimal degrees)-78.7112
3. Approximate date land -disturbing activity will commence: 02.01.2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.6
6. Amount of fee enclosed: $ 500.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameSteve Jernigan E-mail Address [e-mail]
Phone: Office # 910-892-1231 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Freedom Constructors of Dunn, Inc 910-892-1231
Name Phone: Office # Mobile #
P.O. BOX 608 2004 W. Cumberland St.
Current Mailing Address
Dunn NC 28335
City State
10. Deed Book No. 4108
Current Street Address
Dunn NC 28335
Zip City State Zip
Page No 315 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Freedom Constructors of Dunn, Inc [e-mail]
Company Name
P.O. Box 608
Current Mailing Address
Dunn NC 28334
E-mail Address
2004 W. Cumberland St.
Current Street Address
Dunn NC 28335
City State Zip City State Zip
Phone: Office # Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party
is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Steve/J�nigan Director of New Construction
S
Title or Authority
_..I-2-7
Date
U �
I d a Notary Public of the County of i'056
State of orth Carolina, hereby certify that -e erg=` V) appeared personally
before me this day and being duly sworn acknowledged that the 46ove form was executed by him/her.
Witness my hand and notarial seal, this day of Ala to 4 20 29
Notary
Seal /
`®�0ea�tatasrirf� My commission expires
20
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No,
Page No.
Provide a copy of the most current deed,
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No,
Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #

FRFFI]OM CONSTRLICTORS. INC. ntINN_ NORTH CAROLINA 28335
n111111
DATE INVOICE NO. DESCRIPTION
INVOICE AMOUNT
DEDUCTION
BALANCE
3-01-22 30122 WILDWOOD LOTS
500.00
.00
500.00
CHECK
DATE
CHECK
NUMBER /
TOTALS
500.00
.00
500.00
Pay:***************************************Flue hundred dollars and no cents
pqy NCDEQ
TO THE
ORDER
OF
DATE CHECK NO. AMOUNT
3-01-22 31113 $********500.00
II0031L13E1' ii:053LO1120:000S202743724
TORS, INC.
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FREEDOM CONSTRUCTORS, INC. DUNN, NORTH CAROLINA 28335 031113
32443650,PDF 5123119SW M009321