NCC221502_FRO Submitted_20220419

Telephone _ I Fax Number
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:
Jonathan Rackley [e-mail]
Name E-mail Address
491 Little Elbow Mtn Rd
Current Mailing Address
I'll Toxaway NC 28747
City State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Numberl
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
Michael Masingill Owner
Type o pri t n me Title or Authority
Signature Date
1, a Notary Public of the County of� '✓t-)
State ofJd=, hereby certify that appeared
personally before me this day and being duty sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this [EEjday of G��-�-� �h 2 ! a z
' Notary
Am
My commission expires 6