NCC221038_FRO Submitted_20220315

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:
Name
Current Mailing Address
City State Zip
Telephon
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
D Ra h Huff Ili Managing Partner, Windy Ridge FF LLC
Typ int n Tie Title or Authority
o I ZZoZ2o2Z
Signature _ Date
I, ri+lY1 m , a Notary Public of the County of Lunn bell aA r)
State of North Carolina, hereby certify that Ral t2" µ« F 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 _day of J Qnu QV 20 a
'� NpTARy � Seal My Not 6
COMMUION EXPIRES -
nG 714rM My commission expires 43
XV44! PUBLIC
y' ..._,4 Cow, '