NCC222509_FRO Submitted_20220713

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name: MAPLE LEAF FARM SINGLE FAMILY SUBDIVISION — PHASE 2
2. Location of land -disturbing activity: County: STOKES City or Township: KING
Highway/Sire et_S PA I N H O U R_ROAD—
Latitude 36015'50.20"N Longitude 80°2W11.55"E
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional,etc.): Single Family Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16,7AC_ > 17.0
6. Amount of fee enclosed: $ 100 X 17 = $1,700.00 The application fee of $100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Matt Silmser E-mail Address misilmsed-Dgmail.com
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MJ Silmser Corporation
Name
P.O. Box 428
Current Mailing Address
[phone]
Telephone
Kn_g NC 27021
City State Zip City
Fax Number
Current Street Address
State
10. Deed Book 647, Pg 1233, DB 647 PG 1235 Provide a copy of the most current deed.
Part B.
Zip
1. Person(s) or frm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
MJ Silmser Corporation
Name
P.O. Box 428
Current Mailing Address
misilmsertag mail. com
E-mail Address
Current Street Address
Kinq NC 27021
City State Zip City State
Telephone [phone] Fax Number
Zip

2. (a) if the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Matt Silmser PRESIDENT
Type or print name Title or Authority
Signature Date
I, LLi2bj �al)/I/Q-A—,a Notary, Public of the County of
�A ke I .
State of North Carolina, hereby certify that hud S't I M�'[1/�� _appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20.
FMIiLY' BOWMAN �M�h
Notary Public
Stokes Co., North Carolina Notary
My Commisssm&pires June 6, 2026
My commission expires