NCC231583_FRO Submitted_20230525

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM MAR 2 4 2023
SEDIMENTATION POLLUTION CONTROL ACT re
No person may initiate any land-disturbing activity on one or more acres as covered by-T-Te3,73377-VIIIts,
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. Vineyard Trace Ph III
1. Project Name ats-r
2. Location of land-disturbing activity: County Pender City or Township Grady Townsip
Highway/Street Vineyard Trace-Ta i Udeb4D 25' 44" N-ongltude 78D 03' 07" W
3. Approximate date land-disturbing activity will commence:October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential Sub
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.81
6. Amount of fee enclosed: $ 500 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Bernard Morris E-mail Address [e-mail]
Telephone Cell # 910-262-4449 Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Montague Woods, LLC 910-262-4449
Name Telephone Fax Number
6227 Head Road
Current Mailing Address Current Street Address
Wilmington NC 28409
City State Zip City State Zip
10. Deed Book No.3252 Page No.339 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.
Montague Woods, LLC [e-mail]
Name E-mail Address
6227 Head Road 6227 Head Road
Current Mailing Address Current Street Address
Wilmington NC 28409 Wilmington NC 28409
City State Zip City State Zip
Telephone [phone] Fax Number

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 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.
Bernard Morris Managing Member
Type or print nam Title or Authority
PI (2-5
Signature Date
I, al 6 JC)ld,i- , a Notary Public of the County of ,rL
State of North Carolina, hereby certify that i,Q1 L J RCA S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hanker 'n7 axial seal, this nn( ( ay of f , 20 1-3
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Nota qzz
SealoVBLIG " O� '
'9,A�, My commission expires
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