NCC241460_FRO Submitted_20240513

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 N/A in the blank.)
Part A.
1. Project Name WINSTON-SALEM CNI PHASES 2 & 3 SITE PREP
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County FORSYTH City or Township WINSTON-SALEM
CLEVELAND AVENUE 36.114538 -80.230976
Highway/Street Latitude(decimal degrees) Longitude(decimaidegrees)
3. Approximate date land-disturbing activity will commence: 4/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.79 ACRES
6. Amount of fee enclosed: $900 . 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 0 No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Gary Hornsby E-mail Address [e-mail]
Phone: Office# 336-408-9410 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Housing Authority of Winston-Salem 336-727-8500
Name Phone: Office# Mobile#
500 West Fourth St. Suite 300 500 West Fourth St. Suite 300
Current Mailing Address Current Street Address
Winston-Salem, NC 27101 Winston-Salem, NC 27101
City State Zip City State Zip
10. Deed Book No. Page No. 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 or if the landowner(s)is
an individual(s), the name(s) of the owner(s)may be listed as the financially responsible party(ies).
Housing Authority of Winston-Salem [e-mail]
Company Name E-mail Address
500 West Fourth St. Suite 300 500 West Fourth St. Suite 300
Current Mailing Address Current Street Address
Winston-Salem, NC 27101 Winston-Salem, NC 27101
City State Zip City State Zip
Phone: Office# 336-727-8500 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)

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:
FO f9>4VI V6nno►r);c, vex +IAc'e , 'tnc, 336 - 70. 7- ,5O3 33(‘-7V5--,57 ` q
Name Phone: Office# Mobile#
SW Ww 1/ (S--l.� )� eS 4 r° ZOO 500 w. �i 5 1, , s -4� � fl0
Current Mailing Address Current Street Address
\N ; )15 1-50 /r°vi S�G aj[0I IN;)1 rS�fe�, NC. a-71O (
City tate 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#

(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.
Kevin Cheshire Executive Director
Type or n e Title or Authority
ignature Date
I, f11\tYl \L k. l( S , a Notary Public of the County of r h
State of North Carolina, hereby certify that (4)U(n sh 1 w_e appeared personally
before me this day and being duly sworn acknowledged that the above form was executed' by him/her.
Witness my hand and notarial seal, this 1 / day of L)(UIL0--0 , 20 (R4-t
-Notary �J
ry
Seal
Kimberly L.Spragius My commission expires I O/,D. f 2C ) (c
Notary Public
Forsyth County,North Carolina
'�Ty Coiuiitission Expires: