NCC221716_FRO Submitted_20220504

PART B. FINANCIALLY RESPONSIBLE OWNER (FRO)/PERSONS INFORMATION
1. PERSON(S) OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND -DISTURBING ACTIVITY PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
�� r�✓� 1 .�� �'y1a-� � 'r �G k L rJ s vun
NAME EMAIL
0:4 WP5)CCV\.v e
ADDRESS
CITY STATE ZIP CODE
-may-S'-s-_ q�3
PHONE
CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA, GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
NAME
ADDRESS
EMAIL
CITY STATE ZIP CODE
PHONE
CELL
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
ADDRESS
CITY STATE ZIP

PHONE
FAx
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.
AW
GNATURE
TITLE OR AUTHORITY
DATE
I, L-Cl4y� u-e-K a Notary Public of the County of
V-Q— State of North Carolina, hereby certify that
?�,,_-.G,vN 4t } �iM 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
AG
N ary
My commission expires 1' L' -gol3
Q1- day of � 20 Z2
Notary Public
Wake
My county
omm Exp.
2 12-04-2023 �4T
CtP"?, \��