NCC220242_FRO Submitted_20220112

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 Environment and Natural Resources. (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.
2.
3.
4.
5.
6.
7
Project Name St Stephen Missionary Baptist Church
Location of land -disturbing activity: Caurity Nash City or Township Spring Hope
Highway/Street S Pine Street Latitude 35' 935785 Longitude -78.110595
Approximate date land -disturbing activity will commence: August 1, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Church
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.1
Amount of fee enclosed: $ 390 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No X Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name MORST PO P 9 SR E-mail Address
Telephone %ZJ- <{s%Zr� �Q� Cell # Fax # Al
9. Landowner(s) of Record (attach accompanied page to list additional owners):
St Stephen Missionary Baptist Church AAA__ Lf H 5-6W
Name Telephone Fax Number
518 S Pine Street same
Current Mailing Address Current Street Address
Spring Hope NC 27882 same
City State Zip City State Zip
10. Deed Book No. 2683 Page No. 45 Provide a copy of the most current deed
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
St Stephen Missionary Baptist Church
Name E-mail Address
518 S Pine Street same
Current Mailing Address
Spring Hope NC 27882
City State Zip
Current Street Address
same
City
'feiephone '�S'gq g Fax Number n/a
State
122

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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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
Current Mailing Address
City State
Telepho
E-mail Address
Current Street Address
Zip City State Zip
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.
Shirla Sewell -Fisher Trustee
Type r print na a Title or Authority
a r.
.6ignature I Date
I, 6,.,'!Z� " W . i; 0- r 1-- , a Notary Public of the County of V'\C's�-
State of North Carolina, hereby certify that 'S k ; r1a appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 2 b day of _ IIL°`�3 20_LL_
ANGELA M CLARK Nota
ro
SeCTARY PUBLIC ZO Z�
NASH COUNTY NORTH CAROLINA My commission expires `v, 2-0 1
MY COMMISSION EXPIRES