NCC221172_FRO Submitted_20220330

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. Project Name Kipling Village Subdivision
2. Location of land -disturbing activity: County Harnett City or Township Black River Neills Creek
Highway/Street Harnett Central Road Latitude N35.476832 Longitude W-78.818923
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 49.8
6. Amount of fee enclosed: $ 3,250 . 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)
7. Has an erosion and sediment control plan been filed? Yes Y No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jack Adcock E-mail Address Jack.Adcock(o)Reliabuilt.biz
Telephone [phone] Cell # 919-398-1098 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harnett Central Holdings, LLC
Name
10305 Penny Road
Current Mailing Address
Raleigh NC 27606
City State Zip
919-239-4747 N/A
Telephone Fax Number
1611Jones Franklin Road Suite 101
Current Street Address
Raleigh NC 27606
City State Zip
10. Deed Book No. 3734 Page No. 0952 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):
Harnett Central Holdinos, LLC
Name
10305 Penny Road
Current Mailing Address
Raleigh NC 27606
City State Zip
Telephone [phone]
Jennifer. Erwin(a-)Reliabuilt.biz and
Accounting(c�-Reliabuilt. Biz
E-mail Address
1611 Jones Franklin Road Suite 101
Current Street Address
Raleigh NC 27606
City State Zip
Fax Number N/A

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
N/A
Current Mailing Address
N/A
E-mail Address
N/A
Current Street Address
N/A N/A N/A N/A N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
(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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Mr�4A-G6,c- S
�R«A"o L, 4a.j__F 'sseL_sC' , mA_4jA415r1L_ Registered Agent for Harnett Central Holdings, LLC
Type or print name Title or Authority
V� 'Z J_r hM4A41�4'L -oar_z
gnature Date
I, �, r.nr Cr Mlln a Notary Public of the County of �( _
State of North Carolina, hereby certify that ,� V�i� IC�SSt 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 ��day of r 20 2-1
Ntry
s10TARY
My commission expires
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