NCC232485_FRO Submitted (2)_20230817

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:
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Name E-mail Address
Current Mailing Address Current Street Address
NCB JI fs-
City State Zip City t State Zip
Telephone \\ Fax Number 1\' Pc
(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:
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Name of Registered Agent E-mail Address
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Current Mailing Address Current Street Address
City State Zip City t State Zip
Telephone N 1 Pk Fax Number Iv k
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.
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Type or print name Title or Authority
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Signatue Date
I, e-0.61 1; gr.11/29_,H— , a Notary Public of the County of (A iA.A
State of North Carolina, hereby certify that /ccr- L2Z-C/!S 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 1,5f day of GZt/g-tiLC." , 20 2 3
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(„ y _- Notary
Seal ! � i,- •� z_ I�(2 �
G; PUB1��G My commission expires 3
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