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ADFP Trust Fund <br />NCDA&CS <br />I certify that the information contained in this document is true and accurate and will follow reporting <br />requirements for use of state funds as mandated by G. S. 143C -6 -23. <br />I certify that i am authorized by the applicant organization or agency to enter into a contractual <br />arrangement on its behalf . with the granting agency, <br />I understand that this application and all attachments submitted with it are public records subject to the <br />Freedom of Information Act. <br />Signature i r» Date tjP aC-)o <br />(Representative Authorized to Sign on Behalf of the Applicant) <br />Title: Co"Af, 11 Y 1q ylci�• <br />Organization: um <br />I agree not to pursue or contract the sales of my property for 240 days after the application date, <br />unless petition to board for reasons of bankruptcy, death, and or financial hardship. <br />Landowner Signature 1lJS��.,��( Date / -e- <br />Please direct all questions and concerns to: <br />Holly Gilroy <br />NCDA &CS <br />ADFP Trust Fund <br />2 W. Edenton Street <br />Raleigh NC 27601 <br />919.733.7125 <br />ncadfpa ncmail.net <br />www.ncadfp.org <br />Page 16 of 16 Easement Application <br />