Financial Responsibility/ownership Form - Wake County Page 2
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22. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in
Wake County to receive any notice, process, pleading in any action or legal proceeding arising out of any
matter relating to the Wake County Erosion and Sedimentation Control Ordinance and/or Land
Disturbance Permit:
_____________________________________
___________________________________________
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.
_____________________________________
_______________________________________
Type or print name
Title or Authority
_____________________________________
_______________________________________
Signature
Date
------------------------------------------------------------------------------------------------------------------------------------
I, __________________________________, a Notary Public of the County of _________________
State of North Carolina, hereby certify that _____________________________________ 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 _________________, 20_______
_______________________________________
Notary
Seal
My commission expires_____________________
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Parent category: Financial