NCC231904_FRO Submitted_20230707

CITY OF GREENSBORO
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity covered by the Sedimentation Pollution Control Act before this form
has been completed and filed with the Sediment and Erosion Control Section of the City of Greensboro. (Please type
or print and, if questions are not applicable, place N/A in the blank).
Part A:
1. Project Name: Greensboro Friendly Center MOB
2. Location of land-disturbing activity: 3120 Northline Ave,Greensboro,NC 27408
3. Approximate date land disturbing activity will be commenced: April 1,2023
4. Development type: Commercial I Industrial Institutional_ MF residential SF residential
5. Approximate acreage of land to be disturbed: 1.77
6. Has an erosion and sediment control plan been filed? Yes ✓ No
7. Landowner(s) of Record (attach pages to list additional owners):
CBL-Friendly Center CMBS LLC
Name Telephone Email
2030 Hamilton Place Blvd,Suite 500 2030 Hamilton Place Blvd,Suite 500
Current Mailing Address Current Physical Street Address
Chattanooga TN 37421 Chattanooga TN 37421
City State Zip City State Zip
8. Deed County: Guilford Book: R74578 Page: 1908-1913
9. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Davis Moore Acquisition,LLC(Austin koon) Telephone: [phone]
E-mail: [e-mail] Other:
Part B:
1. Company(ies) or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive
list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship the name of the owner
or manager may be listed as the financially responsible party.
Davis Moore Acquisition,LLC(Austin koon) 919.973.6272 akoon@davismoorecapJ .co-v...
Name Telephone Email
2501 Blue Ridge Rd,Suite 330 2501 Blue Ridge Rd,Suite 330
Current Mailing Address Current Physical Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the
designated North Carolina Agent:
N/A
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
(b) 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:
N/A
Name Telephone Email
Current Mailing Address Current Physical Street Address
City State Zip City State Zip
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.
Al&S\-\t\ OACAVI(Aix(C
Type or prin ame Title or Authbtity
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Signature Date
I, Of k, , a Notary Public of the County of
1(-0V
State of , hereby certify that I6n3
Personally accepted before me this day and under oath acknowledged that the above form was
executed by owner(s).
Witness my hand and notarial seal, this « day off , 20
My Commission expires (M- 2& `L`}
`—� R NOTARY MEL PUBMOI
WAKE COUNTY,NC
.m 'sslon Exqs es 3 26P _'.