NCC240364_FRO Submitted_20240209

Check if this project is ARPA-funded n
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT (APRIL 2023)
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the City of
Archdale ACE Integrated Stormwater Management Program. Submit the completed form and current deed to
the appropriate personnel. (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 200 Lantana Drive- Providence Pointe
*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)
2. Location of land-disturbing activity County Randolph City or Township Archdale
Highway/Street Suits Road 'Latitude(decimal degrees) 15 R93506 •Longitude(decimal degrees) 79.917996
3. Approximate date land-disturbing activity will commence- Winter 2023
4. Purpose of development (residential,commercial,industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including of site borrow and waste areas): 109.84 AC
6. Amount of fee enclosed: $ 0 . The application fee is defined in the published City
of Archdale fee structure which is typically$0 when a Technical Review Committee (TRC) evaluation is
required. Checks should be addressed to City ofArchdale
7 . Has an erosion and sediment control plan been filed? Yes Enclosed C No
8• Person to contact should erosion and sediment control issues arise during land-disturbing actvity:
Name Brian Keith Kime E-mail Address [e-mail]
Phone: Office# 336.395.8289 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners);
MG Suits, LLC 336.395.8289 336-215-2970
Name Phone: Office # Mobile#
P.O. Box 10784 7B Corporate Center Court
Current Mailing Address Current Street Address
Greensboro NC 27404 Greensboro NC 27408
City State Zip City State Zip
10. Deed Book No 9894 Page No. 1221

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)
MG Suits, LLC [e-mail]
Company Name E-mail Address
P.O. Box 10784 7B Corporate Center Court
Current Mailing Address Current Street Address
Greensboro NC 27404 Greensboro NC 27408
City State Zip City State Zip
Phone: Office # 336.395.8289 Mobile#_ 336,215.2970
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:
Northwest Registered Agent Service. Inc. [e-mail]
Name of Registered Agent E-mail Address
4030 Wake Forest Road, STE 349 4030 Wake Forest Road, STE 349
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Phone: Office# 336.395.8289 Mobile# [phone]
Brian Keith Kime
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.
Type or print name Title or Authority
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2-s-/.2 o 271
Signature Date
4^1^"AAI P 0g-1/ . a Notary Public of the County of 6✓/114'Z
certify 3u}.� Kt. rte+1 MO I4P- -- iL ME- CJ.JY,G�
State of North Carolina, herebythat 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 14 day of J 1 , 20 z'
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