NCC230035_FRO Submitted (3)_20230109

(c) if the Financially ReWns:ble Party � engaging in business ur4e+ an a584irned name. give name under
why+ the company is arxr'g Business As If M Financially Responsible Party is an individual, General
Parrtershp. or other company not registered and do+rig business under an assumed name, attach a COPY
of the Certifkato of Assunmid Nam*.
Company DBA Name
The above information is true and con va 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 individuals)
or his attorney -in -Tact. or r} not an lndm(lual, by an officer, directflr, partner. or regl5tered agent with
the authority to execute instruments for the Financially Responsible Party) I agree to provide
correCtea information should there be any change in the information provided herein.
Bradley Scott eagle
Type or print name
� Signature
Member -Manager
Title or Autnorrty
1111 BJ22
Date
a IVaisry Pub.11Ec of the County of
Sate of North Carolina hereby certify that .4bl&-0t4 ;+ _appeared personally
before me this day and being duly sworn ackno ledgedr"that the above farm was executed by him(her.
Witness my hand and notarial seat, this —2 8 dsy of ) I , 20 -'�L =
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WttW4 C WTrr
%OUry pt.-Jk Nartri e,ratens
Awtiii County
*Y Coemm"00" Explrq Oct 15. 2026
Notary /
My commission expires lee f�� � 0) fc