NCC231507_FRO Submitted_20230517

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WILSON
Financial Responsibility-Ownership Form
No person may partake in any land disturbing activity within the confines of the City of Wilson
Sedimentation and Erosion Control Ordinance before completing and filing this form with the City of
Wilson Erosion Control Division.(*Indicate N/A if a question is not applicable)
PROJECT NAME:Sunbelt GT-Wilson(PC#1873)
PROJECT LOCATION:4773 Old Merck Road, Wilson, North Carolina 27893
APPROXIMATE PROJECT START DATE:March 15, 2023
(#)ACRES TO BE DISTURBED 6.14 X$150.00/ACRE=$921.00
Person(s)or Firm(s)financially responsible for this land disturbing activity:(If out of state,a registered
agent in North Carolina must be used.)
Moffat Properties, LLC
Name(Person or Firm)
701 Finger Lakes Drive
Street Address(No P.O.BOX)
Wake Forest, North Carolina 27587
City,State,Zip
[phone]
Telephone#
Fax#
[e-mail]
E-mail address
Registered agent for the person or firm who is financially responsible:
Craig T. Moffat, Member
Name(Person or Firm)
701 Finger Lakes Drive
Street Address(No P.O.BOX)
Wake Forest, North Carolina 27587
City,State,Zip
[phone]
Telephone#
Fax#
cmoffat@ moffatp roperties.com
E-mail address
PROJECT NAME:Sunbelt GT-Wilson (PC#1873)

WLN
In case of a violation please list the preferred contact(either the Financially Responsible Person or
Registered Agent on the line below:
Craig T. Moffat or
Financially Responsible Person Registered Agent
The above information is true and correct to the best of my knowledge and belief and as provided by
me while under oath.(This form must be signed by the Financially Responsible Person if an individual or
by an officer,director,partner,and attorney-in-fact,or other person with authority to execute
instruments for the financially responsible person if not an individual.)
Date
Moffat Properties, LLC
Title or Authority
lam/
Signature
Craig T. Moffat
Type or Print Name
Member /, 3® • Z'?�
Title Date
Jessica f t.wg lt(.L ,a Notary Public of the County of IAM k'
State of North Carolina hereby certifies
U'Ql a personally appeared before me this day and under
oath acknowledggeedd that the above form was executed by him.
Witness my hand and notary seal,this 3041 day of c Jan tLa.rri , a 3
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(Notary Public) {l,, � - a�L `�o' ,o", %��p
My commission expires / '-J/O/l J . -
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