NCC241619_FRO Submitted_20240528

WILSON
+4O11TN CAROf1
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson
Sedimentation and Erosion Control Ordinance before completing and filing this form with the City of
Wilson Erosion Control Division.(*Indicate N/A if a question is not applicable)
PROJECT NAME:Sallie B Howard HS Addition 2024
PROJECT LOCATION:1004 Herring Ave..Wilson NC 27893
APPROXIMATE PROJECT START DATE:6/1/2024
(#)ACRES TO BE DISTURBED 1.9 X$150.00/ACRE=285.00
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered
agent in North Carolina must be used.)
Youth Enrichment Program of Wilson. Inc.
Name(Person or Firm)
1004 Herring Ave
Street Address(No P.O.BOX)
Wilson NC 27893
City,State,Zip
252-293-4150
Telephone#
Fax//
iwoodardca(sallieb.n e•
E-mail address
Registered agent for the person or firm who is financially responsible:
JoAnne Woodard
Name(Person or Firm)
1004 Herring Ave.
Street Address(No P.O.BOX)
Wilson NC 27893
City,State,Zip
252-293-4150
Telephone//
Faxll
iwoodard(@sallieb.net
E-mail address
PROJECT NAME:Sallie B Howard HS Addition 2024

s
WILSON
N f?f IN C*RnLIMA
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
or
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by
me while under oath.(This form must be signed by the Financially Responsible Person if an individual or
by an officer,director,partner,and attorney-in-fact,or other person with authority to execute
instruments for the financially responsible person if not an individual.)
14--1 •fie a4
Date
Executive Director
T e or thorny,
nature
JoAnne Woodard
Type or Print Name
Executive Director _
Title Date
Ai Y tat maticig P Co c f e Up ,a Notary Public of the County of IV 11(Oh
State of North Carolina hereby certifies
50 Anne WOOGICird personally appeared before me this day and under
oath acknowledged that the above form was executed by him.
Witness my hand and notary seal,this t&+ day of Apr 'pm .
(Notary Public) t " C .44 t.,
My commission expires 2111 I Z a �G-
AIRENE MARIAE P COSTELO
NOTARY PUBLIC
Wilson County
North Carolina
My Commission Expires 2/12/2028 `"