NCC243147_FRO Submitted (2)_20241011

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 and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project Name Hope Center Ministries
2. Location of land-disturbing activity: County Harnett City or Township Dunn
Highway/Street NC 55 Latitude 35.299040 Longitude-78.589840
3. Approximate date land-disturbing activity will commence November 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.20 ac
6. Amount of fee enclosed: $ 400.00 . The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount(Example: 8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes X — No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity
Name Brandon Casey E-mail Address [e-mail]
Telephone[phone] Cell# [phone] Fax# N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Hope Center Ministries [phone] N/A
Name Telephone Fax Number
5112 Gaillardia Corporate Place 5112 Gaillardia Corporate Place
Current Mailing Address Current Street Address
Oklahoma City OK 73134 Oklahoma City OK 73134
City State Zip City State Zip
10. Deed Book No 4041 Page No 423 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Hope Center Ministries [e-mail]
Name E-mail Address
7440 NW 39th Expressway 7440 NW 39th Expressway
Current Mailing Address Current Street Address
Bethany OK 73008 Bethany OK 73008
City State Zip City State Zip
Telephone[phone] Fax Number N/A

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Mark Hall [e-mail]
Name E-mail Address
1013 Brownsdairy Road 1013 Brownsdairy Road
Current Mailing Address Current Street Address
Selma NC 27576 Selma NC 27576
City � State Zip City State Zip
Telephone 1'" —�7 10—9.fL2_
�} ( I ) Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
., • __x_ ALL 1 ct k- %.-2- - t DI.,4
print name Title or Authority
Signature Date
I, Ii . j;-P_v, !rah fiSc -, . a Notary Public of the County of 71'btnn_S+ON
State of North Carolina, hereby certify that (;Inrr! s Mcur1 1- 0 II appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,this 09 day of Dc4obe.r , 20 ay
Notary
Seal
My commission expires Apr. lr 1) 0?
D TRENT JOHNSON
NOTARY PUBLIC
Johnston County
North Carolina
My Commission Expires Apr.11,2027