NCC214002_Contact Update Record_20240814

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Tev.Holloman 8/14/2024 12:02:40 PM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC214002
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-4002
Original NOI No.* 58505
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Arbor Acres United Methodist Retirement Community, Inc.
Project Name Arbor Acres-Aldersgate Square
Address 1240 Arbor Acres,Winston-Salem, NC
County Forsyth
Latitude 36.1180
Longitude -80.2664
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? Q No
C) Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Les Cranfill
(Previous)
Site Contact Title Project Manager
(Previous)
Organization Arbor Acres United Methodist Retirement Community, Inc.
(Previous)
First Name(New)* David

Last Name(New)* Matthews
NEW Site Contact* Reflects any revisions above
David Matthews
NEW Site Contact Vice President
Title
NEW Organization Arbor Acres United Methodist Retirement Community, Inc.
This field is not required on the NOI form and may not pre-populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact [phone]
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 1240 Arbor Road,0,Winston-Salem, NC
Address(Previous) 27104
NEW Site Contact Street Address
Mailing Address* 1240 Arbor Road
Address Line 2
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27104 US
Change Requested David Matthews,Vice President,via email on 8/14/24
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 08/14/2024