NCC230679_FRO Submitted_20230313

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 N/A in the blank.)
Part A.
1. Project Name
2.
Collinswood
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Location of land -disturbing activity: CountyMoore City or Township Aberdeen
Highway/StreetC011inSWOOd Drive Latitude(decimaidegrees) Long ltude(decimaidegrees)
3. Approximate date land -disturbing activity will commence: ASAP J
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 53.7
6. Amount of fee enclosed: $ Pald 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:
Name Robert Stuart
Phone: Office #
E-mail Addresstmdayis1 @drhorton.com
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D.R. Horton Inc 9194972163
Name
2000 Aerial Center Parkway Suite 100
Current Mailing Address
Morrisville NC 27560
City
Phone: Office #
Current Street Address
State Zip City
State
9194972163
Mobile #
Zip
10. Deed Book No. 5973 Page No. 10 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
D. R. Horton Inc. Raleigh Division tmdavis1 @drhorton.com
Company Name T� E-mail Address
7208 Falls of Neuse Road Suite 201
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Phone: Office # 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 consent for 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 Party 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) 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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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 Name.
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 individual(s)
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.
Tracey M Davis
Ty or print name
Signature
Division NPDES Administrator
Title or Authority
2/24/23
Date
a Notary Public of the County of
a-)E40�
State of North Carolina, hereby certify that L�Q _ t41� X-,�jLS appeared personally
before me this day and being duly sworn acknowledge'd that the above form was executed by him/her.
Witness my hand and notarial seal, this day of 20_
F
Notary
Seal
My commission expires
Janis Perez
NOTARY PUBLIC
Johnston County
North Carolina
My Commission Expires August 4, 2026

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

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