NCC243298_FRO Submitted_20241028

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Shelton Forest Subdivision
2. Location of land-disturbing activity: County Stokes City or Township King
White Road 36.279233 -80.376868
Highway/Street Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: October 2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 62.14
6. Amount of fee enclosed: $fee paid by prior owner 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❑x Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Josh Spiegel E-mail [e-mail]
Phone: Office# Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
LGI Homes-NC, LLC 281-362-8998
Name Phone: Office# Mobile#
1450 Lake Robbins Dr. Suite 430 1450 Lake Robbins Dr. Suite 430
Current Mailing Address Current Street Address
The Woodlands TX 77380 The Woodlands TX 77380
City State Zip City State Zip
10. Deed Book No.0778 Page No. 1700 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
1450 Lake Robbins Dr. Suite 430 1450 Lake Robbins Dr. Suite 430
Current Mailing Address Current Street Address
The Woodlands TX 77380 The Woodlands TX 77380
City State Zip City State Zip
Phone: Office# 281-362-8998 Mobile# [phone]
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:
Corporation Service Company
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
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
Name of Registered Agent E-mail Address
2626 Glenwood Ave, Suite 550 2626 Glenwood Ave
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
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.
Joshua Spiegel Authorized Officer
Type or print Title or Authority
�1 Z Zd. zD z V
Ignature Date
I, f1 v(r - Col w , a Notary Public of the County of I-1 arfi
State of North Carolina, hereby certify that Jo Sh U a Spi e9 e l 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 Zo day of Se pl-efnb , 20 U I
))14/4 riAAA-M---
,. �,,,....CO/NoOE y{ Not
Zs I/4142 h My commission expires / '1 / 3/ z 7