Underground Storage Tank Cleanup Fund - Claim Forms and Information

Underground Storage Tank Cleanup Fund (USTCF)

Forms and Publications

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Forms | Publications

Forms

These forms are presented in PDF format. At this time there is no provision to submit online forms electronically. Only hard copy submittals will be accepted with original wet signatures, unless otherwise noted below.

General Use

Address Change Form - This form can be submitted via mail, email, or fax.
Request for Appeal Form
Claimant Data Record (Std. 204) - This form can be submitted via mail, email, or fax.
Certification of Non-Recovery
Power of Attorney
Request to Reopen a UST Cleanup Fund Claim
Request for Change in Claimant or Joint Claimant Identification Instructions & Form
- Supporting Documents Checklist
- Process of Transferring a Claim Upon a Claimant or Joint Claimant Death
Fraud Reporting Complaint Form

Claim Eligibility

Payment

Conditions of Payment
Reimbursement Request Information Checklist
- Reimbursement Request Spreadsheet (Sample)
- Reimbursement Request Spreadsheet (Excel)
Proof of Payment Affidavit - This form can be submitted via mail, email, or fax
Proof of Payment Certification - This form can be submitted via mail, email, or fax
Provider’s Complaint Form for Claimant’s Nonpayment of Eligible Costs Form - This form can be submitted via mail, email, or fax
Request for Carrying Cost Reimbursement

Technical