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NORTH CAROLINA <br />ADFP <br />- rRusr FUND <br />�����,L}LT tI►;�� <br />tri <br />+ - <br />ADFP Trust Fund <br />NCDA &CS <br />I certif _ that the information contained in this document is tree and accurate and will follow re ortin <br />requirements for use of state funds as mandated by G. S, 1430 -6 -23. <br />I certify that I am authorized by the ap,oticant organization or agency to eater into a contractual <br />arrangement on its behalf with the ctrantinp agency! <br />I understand that this app lication and all attachments submitted with it are .?Ljbric records subject to the <br />,freedom of Information Act. <br />Signature Date <br />(Representative Authorized to Sign on Behalf of the Applicant) <br />Title: <br />Organization° <br />I agree not to pursue or contract the sales of mZ property for 240 days after the apolication date <br />unless petition to board for reasons of bankruptcy, death and or financial hardship <br />Landowner Signature 11 - <br />(Please Print Name) ;^ : <br />Co -owner Signature <br />Date <br />Date <br />Date <br />Date <br />Date <br />Please direct all questions and concerns to: <br />Elizabeth Heath <br />NCDA &CS <br />ADFP Trust (Fund <br />2 W. Edenton Street <br />Raleigh NC 27601 <br />919.707,3071 <br />ncadfp ncagr,gov <br />www. ncadfp, org <br />Page 20 of 20 <br />Easement Application <br />Attachment number 1 <br />K3M Page 188 <br />