NCC240560_FRO Submitted (2)_20240228

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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
(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
The aboveinformation is true and correct to the best of myknowledge and belief and was provided
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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.
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Type •r print n. II - Title or Authority
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Sign 'ure Date
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9 varff , a Notary Public of the County of lAtAnfiState of y�j} 1 , hereby certify that �J .�1`.� f� 11v 1S
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appeared personally before a this day and being duly sworn acknowle ged that the above
form was executed by him.
Witness my hand and notarial seal, this . VD y of /r , 20 Itlr
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ISNota
Seal VIX/A) 7:2
My commission expires
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Koyiel Suorez
Notary Public
Henderson County, IBC
Corr�nission expires 07-26-27