20240450 Ver 1_0565_001_20240319

AGENT AUTHORIZATION FORM
Property Legal Description
PIN:
Address: 6334 Jacks Creek Road
Property Owner : Chad Smoker
The undersigned, registered property owners of the above noted property, do hereby authorize
Derek Goddard
(Agent)
of BREC, PA
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing , issuance and acceptance
of this permit or certification and all standard and special conditions attached. In addition I
hereby authorize BREC & it's staff to have full access to my USDA & NC Ag Cost Share Applications,
Files & Documents.
Property Owner Street Address (if different than property above):
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature- Print and Sign
Date: i 1