TOWN OF CARY
FINANCIAL RESPONSIBILITY - OWNERSHIP FORM

No person may initiate any land-disturbing activity covered by the Town of Cary Sedimentation and Erosion Control Ordinance before completing and filing this form with the Town of Cary Erosion Control Division. Indicate N/A if a question is not applicable.

PROJECT NAME ___________________________________________________________________

PROJECT LOCATION _______________________________________________________________

APPROXIMATE DATE OF PROJECT INITIATION _________________________________________

ACREAGE OF LAND TO BE DISTURBED ______________________________________________

PERSON(S) OR FIRM(S) FINANCIALLY RESPONSIBLE FOR THIS LAND-DISTURBING ACTIVITY: (If out of state, a registeredd agent in North Carolina must be used.)

______________________________________________________
Name (Person or Firm)

_______________________________________________________________
Street Address (No PO Box)

_______________________________________________________________
City State Zip

_________________________________________________________
Telephone Number

_________________________________________________________
Fax Number

_________________________________________________________
E-Mail Address

REGISTERED AGENT FOR THE PERSON OR FIRM WHO IS FINANCIALLY RESPONSIBLE:

__________________________________________________
Name

__________________________________________________________
Street Address (No PO Box)

__________________________________________________________
City State Zip

___________________________________________________________________
Telephone Number

___________________________________________________________________
Fax Number

___________________________________________________________________
E-Mail Address

The Town reserves the right to contact either the financially responsible person or registered agent listed below in case of violation. Please indicate your preference below.

____________________________________ OR ________________________________________

Financially Responsible Person ------------------------------------------------------Registered Agent

THE ABOVE INFORMATION is true and correct to the best of my knowledge and belief and as provided by me while under oath. (This form must be signed by the financially responsible person if an individual or by an officer, director, partner, attorney-in-fact, or other person with authority to execute instruments for the financially responsible person if not an individual.

_______________________________________
Date

______________________________________________
Title or Authority

_______________________________________________
Signature Signature

_______________________________________________
Type or Print Name

_______________________________________________
Title - - - - - - - - - - - - - - - - - - - - - - - - - - Date

___________________________________, a Notary Public of the County of _____________, State of North Carolina, hereby certifies that

________________________________________personally appeared before me this day and under oath acknowledged that the above form was executed by him.

Witness my hand and notarial seal, this _________ day of ___________________, ________.

__________________________________
Notary Public
My commission expires ______________.