NCC231112_FRO Submitted_20230425

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 Madison River Park Expansion
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name' belu«
under which you applied for funding through the Division of Water Infrastructure (DW'
2. Location of land-disturbing activity: County Rockingham City or Township Madison
Highway/Street Lindsey Bridge Rd Latitude(dear„aI degrees)36 375137 Longitudeaw-mai degr_es,-79 993636
3. Approximate date land-disturbing activity will commence:4/15/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc). park
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas) 3
6. Amount of fee enclosed: $300 . 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 ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Kris Bass E-mail Address [e-mail]
Phone: Office# 919.960.1552 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Town of Madison 336.427.0221
Name Phone: Office# Mobile#
120 N Market St
Current Mailing Address Current Street Address
Madison NC 27025
City State Zip City State Zip
10. Deed Book No.669, 808 Page No.665+ 2003 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 name(s)of the owner(s)may be listed as the financially responsible party(ies).
Town of Madison kbaughn©townofmadison.org
Company Name E-mail Address
120 N Market St 120 N Market St
Current Mailing Address Current Street Address
Madison NC 27025 Madison NC 27025
City State Zip City State Zip
Phone: Office# 336.427.0221 Mobile#
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 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)

(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.
Kevin Baughn Town Manager
Type or print name Title or Authority
3 — I - ao.) 5
nature i Date
to
/141\ � ,, a Notary Public of the County of
1
State of North Carolina, hereby certify that f itV t hY} appeared personally
before me this day and being duly sworn acknowledged that t bove form was executed by him/her.
Witness my hand and notarial seal, this g day of , 20 2_,3
RoPPle
,gyTgQ.
'01/81.1c My commission expires /12E ,

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
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 State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 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

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 Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# 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 Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#