NCC243158_FRO Submitted_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, 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 Jacobs Creek Overall Utility Extension
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the "'-`--infrastructure fr'"il).
2. Location of land-disturbing activity: County Rockingham City or Township Stokesdale
Bennett Farm Rd 36.291210 -79.9393989
Highway/Street LatltUde(decimaldegrees) LongltUdeoecimaldegrees)
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 15
6. Amount of fee enclosed: $ 1500 . 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❑ Enclosed x❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Don Sever E-mail Address [e-mail]
Phone: Office# 919 322 0115 x3239 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LGI Homes-NC, LLC. 980 722 0391
Name Phone: Office# Mobile#
5511 Capital Center Drive 5511 Capital Center Drive
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
10. Deed Book No. 1617 Page No.2541 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).
LGI Homes-NC, LLC. [e-mail]
Company Name E-mail Address
5511 Capital Center Drive 5511 Capital Center Drive
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
Phone: Office# 980 722 0391 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:
Josh Spiegel [e-mail]
Name of Registered Agent E-mail Address
5511 Capital Center Drive 5511 Capital Center Drive
Current Mailing Address Current Street Address
Raleigh NC 27606 Raleigh NC 27606
City State Zip City State Zip
Phone: Office# 980 722 0391 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-
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)

(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.
Type or print name Title or Authority
,C mil. // , z0 e
nature Date
I, N\'(fit ► "/ \ . ) LTO T JO , a Notary Public of the County of tfOrlft'-
State of North Carolina, hereby certify that rYN I SP1-t;I-1G1 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her
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Witness my hand and notarial seal, this 6 day of ft(YR. , 20 23
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NCDEQ NCDEQ DEV LGI Homes. Corporate, LLC
217 W. Jones St. 1450 Lake Robbins Dr.
30004' 9903W-00040578
Raleigh, NC 27603 Apr 19, 2023 $1,500.00
Wells Fargo Bank, NA
1210002484845671874.
Date Invoice Reference Payment Amt Retention Discount , Total Payment
0701 LGI Homes - North Carolina, LLC
04/12/23 CHK#1 BBFOO,ALLOC 1,500.00 0.00 0.00 1,500.00
Total Remittance 1,500.00 0.00 .00 1,500.00
NCDEQ NCDEQ DEV LGI Homes Corporate, LLC
217 W. Jones St. Check. Number 9903W-00040578
3000A Check Date Apr 19, 2023
Raleigh, NC 27603
Date Invoice Reference Payment Amt Retention Discount Total Payment
0701 LGI Homes - North Carolina, LLC
04/12/23 CHK#1 BBFOO,ALLOC 1,500.00 0.00 0.00 1,500.00
Total Remittance 1,500.00 0.00 .00 1,500.00
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twott it.. ,.a xmvi a r 1ea gca _ ••• .
Il Wells Fargo Bank, NA 4
1+ LGI Homes Corporate, LLC 600 South 4th Street, 9th Floor �;
'� 1450 Lake Robbins Dr. Minneapolis, MN 55415
430
I, The Woodlands,TX 77380 i�
jj Date Check Number
0 Apr 19, 2023 9903W-00040578 1
II Amount ',
I
Pay *One Thousand Five Hundred Dollars 00 Cents* $1,500.00 ig
LGI Homes Corporate, LLC 'i
To NCDEQ DEV -
The 217 W. Jones St.
Order 3000A Per ,
Of Raleigh, NC 27603 0'- 1,, +S4., PAYABLE IN US DOLLARS
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VOID AFTER 60 DAYS
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