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<br /> <br />(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under <br />which the company is Doing Business As. If the Financially Responsible Party is an individual, General <br />Partnership, or other company not registered and doing business under an assumed name, attach a copy <br />of the Certificate of Assumed Name. <br /> <br />______________________________________ <br />Company DBA Name <br /> <br /> <br />The above information is true and correct to the best of my knowledge and belief and was provided <br />by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s) <br />or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with <br />the authority to execute instruments for the Financially Responsible Party). I agree to provide <br />corrected information should there be any change in the information provided herein. <br /> <br />_____________________________________ _______________________________________ <br />Type or print name Title or Authority <br /> <br />_____________________________________ _______________________________________ <br />Signature Date <br />------------------------------------------------------------------------------------------------------------------------------------ <br /> <br />I, __________________________________, a Notary Public of the County of _________________ <br /> <br />State of North Carolina, hereby certify that ______________________________appeared personally <br />before me this day and being duly sworn acknowledged that the above form was executed by him/her. <br /> <br />Witness my hand and notarial seal, this ______day of _________________, 20_______ <br /> <br /> <br /> _______________________________________ <br /> Notary <br /> Seal <br /> My commission expires_____________________ <br /> <br />BONNIE HAMMERSLEY COUNTY MANAGER <br />DocuSign Envelope ID: A6ECD43A-4359-4D26-A9B6-DA39647F9A40 <br />2/16/2023