NCC222928_FRO Submitted_20220818

NT* a u aV
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 NIA in the blank.)
Part A.
1. Project Name Country Walk Subdivision
2. Location of land -disturbing activity: County Brunswick City or Township WinnaboW
S R 1407 34A 126°-78.1191 °
Highway/Street Latitude(aecima�aegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 23.94
6. Amount of fee enclosed: $ previously paid 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:
NarneJ` Phillip Norris, P.E. E-mail Address [e-mail]
Phone: Office # 910-287-5900 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
D FC Country Walk, LLC 904-401-6330
Name Phone: Office #
14701 Philips Hwy. Suite 300 4701 Philips Hwy.
NIA
Mobile #
Suite 300
Current Mailing Address Current Street Address
Jacksonville FL 32256-3742 Jacksonville FL 32256-3742
City State Zip City State zip
4654 10. Deed Book No. Page No. 1397
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).
Dream Finders Homes, LLC
Company Name
14701 Philips Hwy. Suite 300
Current Mailing Address
Jacksonville FL 32256-3742
City State Zip
Phone: Office # 910-486-4864
[e-mail]
E-mail Address
14701 Philips Hwy. Suite 300
Current Street Address
Jacksonville FL 32256-3742
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
Corporate Creations Network Inc.
Name of Registered Agent E-mail Address
15720 Brixham Hill Avenue #300 15720 Brixham Hill Avenue #300
Current Mailing Address Current Street Address
Charlotte NC 28277 Charlotte NC 28277
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
Kerry Avant VP of Land Acquisitions and Development- Carolinas
Type Tintt nam TitleWcorAUorily
Signatur Date
------------------------ ------- -------- —----------- ------------------ ---------------- ------------ --
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a Notary Public of the County of UtV WUY1
State of North Carolina, hereby certify that appeared
personally before me this day and being my swar acknowledged that the above form was
ovAr.iitpri by him ..
01V1irrir1,,, nd notarial seal, this day of
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