NCC223137_FRO Submitted_20220906

FINANCIAL RESPONSIBILITYJOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name The Villages at Reedy Fork Ranch Tracts 9A and 9B
2. Location of land -disturbing activity: CountyGuilford City or Township Greensboro
4900 Turner Smith Road 36,187532-79.686760
Highway/Street Latltude(decimaldegrees) LQn�ltude�dac�ma�degrees)
3. Approximate date land -disturbing activity will commence: 22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):GL.O
0. Amount of fee enclosed: $ I1./A . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameKevin Pegram E-mail [e-mail]
Phone: office # 336-669-3209 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
AF-Reedy Fork LLC 919-861-2929 919
Name Phone: Office # Mobile #
1330 Sunday Drive Suite 105 1330 Sunday Drive Suite 105
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27697
City State Zip n City State Zip
10, Deed Book No.007425 Page No.00286 Provide a copy of the most current deed.

Part B.
1, Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the names) of the owners) may be listed as tha financially responsible parfy(Iss)-
AF-Reedy Fork LLC [e-mail]
Company Name E-mail Address
1330 Sunday Drive Suite 105 1330 Sunday Drive Suite 105
Current Mailing Address
Raleigh NC 27607
City State Zip
Phone: Office # 919 851-2929
Current Street Address
Raleigh NC 27607
City State Zip
Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consentfor the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) if the Financially Responsible Parry is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
State Zip
E-mail Address
Current Street Address
City State zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(h) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed flame.
Company DBA Name
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 individuals}
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Jeff White
4iu
priUa�r}e re '[,][�
Manager
Title or Authority
Date
a Notary Public of the County of A kgyy,llt t,_
T
State of North Carolina, hereby certify that _ '-Te Z"�- V)h' �-e_ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her
Witness my hand and notarial seal, this 5 day of S'C`�b �r' 201
Diary
00 T)-So
My commission expires �A�B t

Continued from items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for midtiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Name
Phone: Office #
Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State ZIP
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State zip City
Deed Book No. Page No.
Landowner 5 of Record:
state Zip
Provide a copy of the most current deed.
Aflame Phone: Office #
Current Mailing Address Current Street Address
City State
Deed Book No.
Mobile #
Zip City State Zip
Page No, Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address
City State zip
Phone: Office #
Currert Street Address
City State Zip
Mobile #