NCC243557_FRO Submitted_20241118

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 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 and/
or fax Information unavailable, place N/A in the blank.)
Part A.
1. Project Name THa vt9Sov' f venv e
2. Location of land-disturbing activity: County S'Am P9°1n City or Township
Highway/Street 1 O'1 ' ' Avt Latitude 3 - 36 Longitude ---713" O
3. Approximate date land-disturbing activity will commence: 1t/ ZS12 02-4-
4. Purpose of development(residential,commercial,industrial,institutional,etc.): 12e:EA Dori A t_
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): S- c/`r
6. Amount of fee enclosed: $ . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes V No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name -51"1`14r. 'MS E-mail Address RC-7 VC-1
Telephone 9ID--S9ro O 2("1 Cell# 9 ilk -fir -p88 3 Fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
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Name ,fir Telephone Fax Number
� C�tA OOJ Lim/.1 p_p 7Z0 50-rrl eas-r (3Ivo
Current Mailing Address Current Street Address
A{ivrllc ' t1 $ 7` r 4 (j.n ron NC- ZrS3OS
City State Zip City State Zip
10. Deed Book No. Zzo3 Page No. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner� or manager may be listed as the financially responsible party.ar
/
V"I H + of tes, I �"1 CZ Z 7 c���7,,,L0.,es_c r`t
Name E-mail Address
OO) e i 'r.,. /�, t L 02 o Sr /3/moo
Current Mailing Address Current Street Address
37$�4 �'Gft,a/1 Nc 28 323
City State Zip City State Zip
Telephone 9{� -S�f(� _ a Zp o Fax Number

2. (a)If the Financially Responsible Party is not a resident of North Carolina,give name and street address
of the designatedsi/ North Carolina Agent
e� 6,reor-Ar;o.r Sy5rLM MATHA1. 1-7- Cjq )-ion1,3n-aeS..G.0-►
Name E-mail Address
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Current Mailing Address Current Street Address
RiNtxJ:` IJC 2?61 ic`it' NC 27& iJ`
City State Zip City State Zip
Telephone )33-— SR — $'f/�14 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
eT CyeorAro" Syj TCM JAB..AN- ITT-6)GfAjr '14,e-•eS..C.a"-t
Name of Registered Agent E-mail Address
i ;,0 t-1 L t c er is Z`J) 16i0 f 1%ne LA-Lt. (,— 5q 0'vo
Current Mailing Address Current Street Address
0—A Fe ti;'^ NC_ Z7lo%r b k_j k Ale_ •276r r
City State Zip City State Zip
Telephone es 31b — $��4 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.
11,iA114wn/ lwe_ Sr:1-1' A55r5-IAA/1- Sec-re TA rD
Type or 'nt name Title or Authority
0,5/2
Signature Date
i, C3 C` `J`\\\� , a Notary Public of the County of 'bk(N-AA
State of With Corulitia, hereby certify that \\ � U\\‘c appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed r
C Wit har 1 � vial seal, this ,3 day of \ CN ,20 a`�
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BK 2203 PG 0385 PILED ELECTRONICALLY
SAWSON COURT! NC
ANITA R. LANE
FILED JuL 24, 2024
AT 08:09:57 AN
BOOK 02203
SMART PAGE 0385
END PAGE 0388
INSTRUMENT $ 03608
EXCISE TAX 8470.00
NORTH CAROLINA
GENERAL WARRANTY DEED
SAMPSON COUNTY
REVENUE:S470.00
PREPARED BY LUTHER D.STARLING,JR.,ATTORNEY AT LAW
Draftsman does not certify title and has made no record search or title examination
Of the property herein described unless the same is shown by his written end signed certification
THIS DEED made this 1 day of July,2024,by and from BREAKIN NEW
GROUND,LLC,a North Carolina limited liability company,with a mailing address of 3050
Pine Ridge Road,Turkey,North Carolina 28393(hereinafter Grantor);to CMH HOMES,INC.,
a Tennessee Corporation,with a mailing address of 5000 Clayton Road,Maryville,Tennessee
37804(hereinafter Grantee);
WITNESSETH:
The designation Grantor and Grantee as used herein shall include said parties,their heirs,
successors,and assigns,and shall include singular,plural,masculine,feminine or neuter as
required by context.
That the Grantor in consideration of the sum of TEN(510.00)DOLLARS and other good
and valuable consideration paid by the Grantee,the receipt of which is hereby acknowledged,
have and by these presents do grant,bargain,sale and convey to the Grantee in fee simple,all
that certain tract or parcel of land situate in Turkey Township,Sampson County,North Carolina,
and bounded and described as follows:
CONVEYANCE OF THIS PROPERTY
HAS BEEN DULY NOTED ON THE
TAX RECORDS
NI
submitted electronically by 'Mark E. Randolph, Attorney At Law" FDT 7AXADt, STRATOR
in compliance with North Carolina statutes overning recordable documents
and the terms of the submitter agreement with the saepson County Register of Deeds.

BK 2203 PG 0386
SEE ATTACHED EXHIBIT"A"
The above described property does does not include the primary residence of the
Grantor.
TO HAVE AND TO HOLD,the aforesaid tract or parcel of land,and all privileges and
appurtenances thereunto,belonging to the Grantee,in fee simple forever.
And the Grantor covenants with the Grantee that Grantor is seized of the premises in fee
simple,has the right to convey in fee simple,that title is marketable and free and clear of all
encumbrances,and that Grantor will warrant and defend the title against the lawful claims of all
persons claiming by,under or through Grantor,other than the following exceptions:
I. Easements and restrictions of record,if any.
2. Unpaid Ad Valorem taxes for 2024,if any.
IN WITNESS WHEREOF,the Grantor has hereunto caused this instrument to be
signed the day and year first above written.
BREAKIN NEW GROUND,a North Carolina Limited
Liability Company
BY: jr- urn, % f�
.(�,,. _ (SEAL)
1AM 'O.BURCH,Manager
L_.

BK 2203 PG 0387
STATE OF NORTH CAROLINA
COUNTY OF SAMPSON
I, U + kx-t...- - e( ,a Notary Public of Sampson County,
North Carolina,do hereby certify that JAMES 0-.13URCH,personally came before me this day
and acknowledged that he is Manager of Breakin New(hound,LLC,a North Carolina limited
liability company,and that he,as Manager,being authorized to do so,executed the foregoing on
behalf of the company.
WITNESS my hand and notarial seal,this/day ofia4i ,2024.
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BK 2203 PG 0388
EXHIBIT"A"
Sampson County Tax Parcel: 18028360003
That certain tract or parcel of land situate in Turkey Township,Sampson County,North Carolina
and being more particularly described as follows:
BEING all of those certain lots designated as Lots 1,2,3,5,6,7,and Son map entitled,
"THOMPSON LANE,"prepared by Jim Blanchard Associates P.C.,A Professional Services
Company,on September,2023,which map is recorded in Map Book 116 at Page 27,Sampson
County Registry and incorporated herein by reference for a more complete description by metes
and bounds.
For title history,see deed recorded in Deed Book 2150 at Page 439,of the Sampson County
Registry.

2061
0821 FILED
SAMPSON COUNTY
BK:02061 PG;p$21 GRAHAM F.BUTLER
REGISTER OF DEEDS
FILED May 28.2020
AT 01:45:41 pm
BOOK 02061
START PAGE 0821
END PAGE 0821
INSTRUMENT# 02600
ASSUMED BUSINESS NAME CERTIFICATE tNCGS B6641.51
Meese prior legibly.
1. The assumed business name is:
Clayton Homes#227
(You may include no more than five(5)assumed business names on this foam,)
2. The real name of the person or entity engaging in business under the assumed business name Is:
CMH Homes,Inc.
SOS(D-0135510 _
(Corporations,LLCs,limited partnerships must provide the exact name registered with the NC Secretary ofState's office and
the SOSto number assigned at the time of formation.Go to www,sosrcaoy/br/search to logic up your Information.)
3. The nature/type of the business is:Retail Sales of Manufactured Homes _
_
4. The street address of the principal place of business is:(PO Boxes are not acceptable)
720 South East Blvd,Clinton,NC 28328
5. The mailing address,if different from the street address,is:
PO Box 4098,Maryville,TN 37802
6. The counties where the assumed business name will be used to engage in business are:
a AR 100 North Carolina counties
This certifica -- sl ed by the owner/legal representative of the person or entity named above,
this 28th d. . April 2020
Signature: ,, . ,
—
Printed/Typed Name: Daniel Warrick —
Title: President
(Sae instructions for who must sign for various business entity types,)
Assumed Business Name Certificate
10.03.17