NCC241144_FRO Submitted_20240424

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM is.P€.,t-
SEDIMENTATION POLLUTION CONTROL ACT
11577 •
WATER RESOURCES
105-B Upchurch Street o
Town of Apex, North Carolina 27502
Contact: James Misciagno
Phone: [phone] E-Mail: [e-mail]
No person may initiate any land-disturbing activity on twenty(20)thousand square feet or more before this form has been
completed and filed with the Town of Apex Water Resources Department.
PART A
Name of Project:Retreat at Friendship Ph.4&5
Location of Land-Disturbing Activity:
Approximate Date Land-Disturbing Activity will Commence:04.01.2024
Acreage of Land to be Disturbed: 26.90 acres
Latitude: Longitude:
Land Owner(s)of Record (use blank page to list additional owners):
Name:M/I Homes of Raleigh, LLC Name:
Current Mailing Address: Current Mailing Address
1511 Sunday Dr.
Suite 100
City,State,Zip:Raleigh, NC 27607 City,State,Zip
PART B
Person or firm financially responsible(developer)for this land disturbing activity. Financial responsibility includes,but
may not be limited to: payment of civil fines and criminal penalties and any other costs associated with bringing the
project into compliance with the Town of Apex Soil Erosion and Sedimentation Control Ordinance.
Name of Person or Firm:M/1 Homes of Raleigh, LLC
Telephone:[phone] E-mail:[e-mail]
Current Mailing Address: Street Address (if different from mailing address)
1511 Sunday Dr.
Suite 100
City,State,Zip:Raleigh, NC 27607 City,State,Zip
Revised 9/19/2019 Page 1

If the financially responsible party is not a resident of Wake County,complete the following for an appointed agent, in
Wake County,to receive any notice, process, pleading in any action or legal proceeding arising from a violation of the
Town of Apex Soil Erosion and Sedimentation Control Ordinance. By signing below,it is agreed that any notice,process,
or pleading against the person or firm who is financially responsible for this land-disturbing activity may be served on
the undersigned and shall be of the same force and effect as if served on the financially responsible person or firm. The
intent of this provision is to establish the presumption that the constructive notice from the Town of Apex will be
addressed through the undersigned agent.
Name:N/A
Telephone:
Current Mailing Address: Street Address(if different from mailing address)
City,State,Zip: City,State,Zip
Signature:
If the financially responsible party is a partnership or other person engaging in business under an assumed name,complete
Page 4 of this form, or attach a copy of the Certificate of Assumed Name or Partnership as recorded in the Register of
Deeds. If the financially responsible party is a corporation, complete the information on Page 5 of this form and submit a
current copy of the Annual Report as filed with the Secretary of State.
The information contained in this form is true and correct to the best of my knowledge and belief and was provided by
me while under oath. (This form must be signed by the financially responsible person if an individual or by an officer,
director, partner, or registered agent with authority to execute instruments for a corporation or partnership if it is the
financially responsible party). I agree to provide corrected information should there be any change in the information
provided herein.
Name:Erica Leatham Date:03.42024
Title or Auth ty.VP
Signature:
I, Sara S Clifton a Notary Public of the County of Wake ,State
of North Carolina hereby certify that Erica Leatham personally appeared before me this
day and under oath acknowledged that the above form was executed by him/her. Witness my hand seal this
001%1
22nd dayof March 2024 ,•��`P s• Pis 4.
01/10/2025 =`'' °� ''•�'
Notary My Commission Expires a
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Financial responsibility encompasses personal liability by the person signing this disclosure Tiokc'Qf r in a
partnership or if an officer or director of a corporation which is either:(a)dissolved lawfully under Nort�rC���)ina statutes:
(b) suspended from transacting business in North Carolina by the North Carolina Secretary of State; (c) insolvent; (d) in
bankruptcy; (e) undercapitalized to the extent it is unable to comply with the Soil Erosion and Sedimentation Control
Ordinance;or(f) a "shell" corporation.
Revised 9/19/2019 Page 2

1
PART C
Contractors and/or subcontractors 'person(s)or firm(s)engaging in the land-disturbing .ctivity):
Name Person or Fi-m: Name of Person or Firm:
Allegiance Contractirg Groyp
Telephone:[phone] Telephone:
Email: Email:
[e-mail]
Current MailingAddress
Current Mailing Address
2840 Plaza Place,Suite 40C
City,State,Zip:Raleigh,NC 4612 City,State,Zip
The information containedin this form is true and correct to the best of my knowledge and belief was provided by me
while under oath. (This f9rm must be signed by the person or firm engaging in the hand-disturbing activity of an
individual or by an officer, dirEcto , general partner, attorney-in-fact, or other person with authority to execute
instruments for the entity iengagin in the land-disturbing activity if not an individual. I agree to provide corrected
information should there be any ch nge in the information provided herein.
Name:Chuck Smith Date: re-
Title
or Authority:Fjresideit/ anager
Signature: X
I, KPJ1L ' 2 t-is a Notary Public of the County of Wetk. ,State of North
Carolina hereby certify that Oh c (5r'jith personall,appeared before me this
day and under oath acknowledgEd that the above form was executed by him/her. Witness my hand,at4�'�'e10F�Z,.,'��
day of 20211 ���`` `,����1�6k/%�RB. `P '�°,
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f 2',262CP a ;
I
My Commission Expires 1% ', +,.
e,9141 Ilf'�jfli �it��j�
Revised 9/19/2019 Page 3

CERTIFICATE OF ASSUMED NAME OR PARTNERSHIP
(SEDIMENTATION POLLUTION CONTROL ACT)
The undersigned,proposing to engage in business in Wake County,North Carolina,under an assumed name or partnership
name, do hereby certify that:
The name under which the business is to be conducted is (insert assumed or partnership name):
WI Homes of Raleigh, LLC
The names and residences and mailing addresses of all the owners of the business are(Insert name and address of
each owner):
Mul Homes of Raleigh, LLC, 1511 Sunday Drive, Suite 100, Raleigh, NC 27607
IN WITNESS WHEREOF,this certificate is signed by each of the owners of said business,this 22nd day of
March 2024
Owner's from a ve Sign below:
',ca L Q.a}Leta.-In
State of North Carolina
County of Wake
Sara S Clifton 22nd
a Notary Public,do hereby certify that on this day of
March 2024 Erica Leatham,
, personally appeared before me
VP Land
who are all signers of the foregoing instrument,and each acknowledges the due execution thereof. IN WITNESS
WHEREOF,I have hereunto set my hand and official seal this 22nd day of March oistotwilmo 2024
C3CLN •eiLL9Ar 01/10/2025 $. )....u.,�/� air
Notary My Commission Expires ' .k.\0T4
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Revised 9/19/2019 °''°°°°�Co u l\q,N�'0`,,` Page 4

Name of Corporation:M/1 Homes of Raleigh, LLC
Name of registered agent,street address, mailing address of registered office in Wake County:
Name:Corporation Service Company
Street Address:2626 Glenwood Avenue,Suite 500
City,State,Zip:Raleigh, NC 27608
Current Mailing Address:Same
City, State,Zip:
Enter first,middle,and last name of principal officers. Enter title and street address of principal officers.
Name and Title: Name and Title:
Susan E. Krohne,Secretary
Street Address: Street Address:
4131 Worth Ave.,Suite 500
City, State,Zip: City,State,Zip:
Columbus, OH 43219
Name and Title: Name and Title:
Street Address: Street Address:
City,State,Zip: City,State,Zip:
Enter first, middle,and last name of directors. Enter title and street address of directors. Attach pages as necessary.
Name and Title: Name and Title:
Street Address: Street Address:
City,State,Zip: City,State,Zip:
Name and Title: Name and Title:
Street Address: Street Address:
City,State,Zip: City,State,Zip:
Revised 9/19/2019 Page 5