NCC241180_FRO Submitted_20240417

PART B. FINANCIALLY RESPONSIBLE OWNER(FRO}/PERSONS INFORMATION
1. PERSON(S)OR FIRMS WHO ARE FINANCIALLY RESPONSIBLE FOR THE LAND-DISTURBING ACTIVITY(PROVIDE A
COMPREHENSIVE LIST OF ALL RESPONSIBLE PARTIES ON AN ATTACHED SHEET):
MSD2 Wake Forest, LLC [e-mail]
NAME EMAIL
155 FIRST STREET MINEOLA, NY 11501
ADDRESS
MINEOLA, NY 11501
CITY STATE ZIP CODE
(516)-644-2222
PHONE CELL
2. IF THE FINANCIALLY RESPONSIBLE PARTY IS NOT A RESIDENT OF NORTH CAROLINA,GIVE NAME AND STREET ADDRESS OF
THE DESIGNATED NORTH CAROLINA AGENT:
Stephen R Kramer [e-mail]
NAME EMAIL
165 Mariner Pointe Lane
ADDRESS
Mooresville NC 28117
CITY STATE ZIP CODE
516-644-2222
PHONE CELL
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 1S A CORPORATION,GIVE NAME AND STREET ADDRESS OF THE REGISTERED AGENT:
NAME OF REGISTERED AGENT E-MAIL ADDRESS
ADDRESS
CITY STATE ZIP

PHONE FAX
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.
ME TITLE OR A TH RITY
C/74
1 G TURF DATE
I, J 1 -L v t- a Notary Public of the County of
, State of Na t a, hereby certify that
1 ' 1d Q ( A,A.,AcdsODappeared personally before me this day and being
duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this day of , 20 23
Gregory S. Fairbend
c , of New York
Nry No. 01 FA612 7
c a uaiified in Seel Caunty,4.i.
Commission Expir April 25, 20i
My commission expires