NCC241264_FRO Submitted_20240424

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (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 Rogers Road Widening Improvements
2. Location of land-disturbing activity: County Wake City or Township Town of Rolesville
Highway/Street SR 2052 Latitude(decimal degrees)35.928900Longitude(decimal degrees)-78.473370
3. Approximate date land-disturbing activity will commence: June 1, 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Street Improvement
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1.3 acres
6. Amount of fee enclosed: $ 200 . The application fee of$100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ® Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Eric Marsh E-mail Address [e-mail]
Phone: Office# 919-556-3506 Mobile# NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT 919-733-7759 NA
Name Phone: Office# Mobile#
1575 Mail Service Center 4009 District Drive
Current Mailing Address Current Street Address
Raleigh NC 27699-1575 Raleigh NC 27607
City State Zip City State Zip
10. Deed Book No. NA Page No. NA Provide a copy of the most current deed.

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).
Town of Rolesville [e-mail]
Company Name E-mail Address
PO Box 250 502 Southtown Circle
Current Mailing Address Current Street Address
Rolesville NC 27571 Rolesville NC 27571
City State Zip City State Zip
Phone: Office# 919-556-3506 Mobile# NA
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:
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)
(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 infor /�aa/tion shouldo/ there be any change in the information provided��'fff/���/- herein.
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I, i'`ri / �/ , a Notary Public of the County of ,• 2tt7/k-
State of North Carolina, hereby certify that /04 ,'yb,,/G appeared personally
before me this day and being duly sworn acknowledted that the above form was executed by him/her.
Witness my hand and notarial seal, this /7'day of AOre4 ,
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Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Brent and Brittany Laughlin-McDermott NA NA
Name Phone: Office# Mobile#
4808 Rogers Road 4808 Rogers Road
Current Mailing Address Current Street Address
Rolesville, NC 27571 Rolesville, NC 27571
City State Zip City State Zip
Deed Book No. 019123 Page No. 00848 Provide a copy of the most current deed.
Landowner 3 of Record:
Eric and Tammy Boyle NA NA
Name Phone: Office# Mobile#
4806 Rogers Road 4806 Rogers Road
Current Mailing Address Current Street Address
Rolesville, NC 27571 Rolesville, NC 27571
City State Zip City State Zip
Deed Book No. 008548 Page No. 02687 Provide a copy of the most current deed.
Landowner 4 of Record:
Patricia and Brenda Rogers NA _ NA
Name Phone: Office# Mobile#
4134 Donnelly Ln 4134 Donnelly Ln
Current Mailing Address Current Street Address
Wilmington, NC 28409-2699 Wilmington, NC 28409-2699
City State Zip City State Zip
Deed Book No. 019027 Page No. 00214 Provide a copy of the most current deed.
Landowner 5 of Record:
Robert and Diane Bowline NA NA
Name Phone: Office# Mobile#
4804 Rogers Road 4804 Rogers Road
Current Mailing Address Current Street Address
Rolesville, NC 27571 Rolesville, NC 27571
City State Zip City State Zip
Deed Book No. 005554 Page No. 00572 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Lee Ward and Samantha McPherson NA NA
Name Phone: Office# Mobile#
115 Wellspring Farms Lane 115 Wellspring Farms Lane
Current Mailing Address Current Street Address
Rolesville, NC 27571-9471 Rolesville, NC 27571-9471
City State Zip City State Zip
Deed Book No. 016169 Page No. 02608 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.