NCC242906_FRO Submitted_20240919

Check if this project is ARPA-funded
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 Union-Anson County Habitat for Humanity, Inc. Ruben Road Subdivision
.
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Union City or Township Buford Township
Highway/Street Ruben Road 80.61
Latitudeoecima,degrees,34.86 Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 5/20/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .4
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 Ci Enclosed E3 No E3
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Mike Reece E-mail Address [e-mail]
Phone: Office# 704-296-9414 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Union-Anson County Habitat for Humanity Inc 704-296-9414 704-254-3013
Name Phone: Office# Mobile#
PO Box 1688 3702 Old Charlotte Hwy.
Current Mailing Address Current Street Address
Monroe NC 2811 Monroe NC 28110
City State Zip City State Zip
10. Deed Book No. 8113 Page No. 864 Provide a copy of the most current deed.

Par1B.
1 CVmpany(iee)who are financially responsible for the land-disturbing activity(Provide e comprehensive list
of all responsible parties on accompanied page.) If the company ise sole proprietorship o/if the/andowoer(s)ix
en,ndimdual(s). the nen/o(s)of the owm*r(o)may ho listed eo the financially responsible party(ies).
Union-Anson County Habitat for Humanity' Inc. NOreec69@un'o[lhab'faf'org
Company Name E-mail Address
P.O. Box 1688 3702 Old Charlotte Hwy.
Current Mailing Address Current Street Address
MODD0B NC 28111 Monroe NC 28110
City Gtmba Zip City State Zip
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NVby� It the Financially Responsible Party is not the owner ofthe land to be disburbed, 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 hn 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 regiutry. give name and street address ofthe Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip city State Zip
Phone� C]ffice# Mobile#
Name ofIndividual to Contact (if Registered Agent in acompany)
(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 nf Registered Agent E-mail Address
Current Mailing Address Current Street Address
Cib/ State Zip City State Zip
Phone: Office# K4obiie#
Name nf Individual to Contact(if Registered Agent iaacompany)

(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 individuai, 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.
Mike Reece Director of Development
Type or print name Title or Authority
3/21/24
Signature Date
1, E&AGL--S. Ulf a Notary Public of the County of 0116A,
State of North Carolina, hereby certify that (LUCK) e.t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this LI day of XihCIA,_ 20_24
01144,0 S • cit4A. 4t4_
KETURAH S.CLARK-KEY Notary
NOTARY PUBLIC
Union County
North Carolina My commission expires thigYKIZT (ye, I
My Commission Expires November 06,20271