NCC233634_FRO Submitted (3)_20231208

(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.
Richard M Eddinger President/ owner
Ty pr. t am Title or Authority
i nature Date
I, r—OP.‘_,_) , a Notary Public of the County of V-K5`.
State of North Carolina, hereby certify that t,(ANN .e jam{ 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 day of , 20D i
otary
OAWNB GINS
Notary Public-North Carolina
COUNTY OF FORSYTH My commission expires c� -t 04.�
,A7 Commission