NCC242695_FRO Submitted_20240830

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 Soil Erosion and
Sedimentation Control Ordinance of the City of Greenville(Title 9, Chapter 8)before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Greenville,
Engineering Department. (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 Bells Fork Village
2. Location of land-disturbing activity: County Pitt City or Township Winterville Township
Old Fire Tower Rd -
Highway/Street SR 2235 Latitude(decimai degrees) 35.564 Longitude(decimai degrees) -77.357
3. Approximate date land-disturbing activity will commence: Spring 2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential, Multi-Family
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.9
6. Amount of fee enclosed: $ 600.00 . The application fee of$100.00 per acre or portion
thereof (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre
application fee is$900).
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 Kevin Banks E-mail Address [e-mail]
Phone: Office# 513-500-2095 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Barbara Jackson Dennis
Graydon Paul Jackson, Jr. 252-714-4032
Name Phone: Office# Mobile#
1903 Red Bud Circle
Current Mailing Address Current Street Address
Greenville NC 27858
City State Zip City State Zip
10. Deed Book No. 620 Page No. 841 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).
Bells Fork Village, LLC [e-mail]
Company Name E-mail Address
9100 Centre Point Drive, Suite 210
Current Mailing Address Current Street Address
Westchester OH 45069
City State Zip City State Zip
Phone: Office# 513-964-1141 Mobile#
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:
Corporation Service Company [e-mail]
Name of Registered Agent E-mail Address
2626 Glenwood Avenue, Suite 550 Same
Current Mailing Address Current Street Address
Raleigh NC 27608
City State Zip City State Zip
Phone: Office# Mobile#
E.J. Dealy
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 information should there be any change in the information provided herein.
Brian McGeady Manager
Type or print name Title or Authority
Li/23/Zy
Signature Date
I, 0 6.r.:�\1,L \ a-rSr;r\ , a Notary Public of the County of ( k
State of North Carolina, hereby certify that Q c'► on appeared personally
before me this day and being duly sworn acknowledged that the above fom was executed by him/her.
rc
Witness my hand and notarial seal, this 2.3 day of P-v c ;\ , 20 94
1.7/otary
Seal
My commission expires -1"‘.)r,e q .L62�{
riLLE '>y Danielle Martin
Notary Public
o,
`'' wr- o In and For the State of Ohio r��,
•t `` .it, o My Commission Expires
AG �,,-la• • June 9, 2024 in and I
°tip . s'(P
My Comm...
June 9, ._

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:
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 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. ''t, 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.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#