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CERTMCAnON OF NON-RECOVERY FROM OTHER SOURCES UNDERGROUND STORAGE TANK CLEANUP FUND The purpose of this certification is to identify ail funds received, or to be received, from any source in consideration of the unauthorized underground storage tank release which is the subject of this claim. Section 2810 . 1(a) (6) of the Petroleum Underground Storage Tank Cleanup Fund Regulations provides that an eligible claimant is "A person who has paid or will pay for the costs claimed. " section 2812 . 2 (b) of the Cleanup Fund Regulations provides "Only corrective action and third party compensation claim costs incurred by or on behalf of a claimant shall be reimbursable from the Fund. Pio claimant shall be entitled to double payment on account of any corrective action or third party compensation claim cost. Where a claimant receives reimbursement on account of. any cost from the Fund and also receives reimbursement on account of such cost from another source, the claimant shall remit to the Fund an amount equal to the sum disbursed from the Fund on account of such cost. . . . " CERTIFICATION Have you, or anyone acting on your behalf, received funds from any source (including lawsuits, settlements, judgments, contributions from other potentially responsible parties, insurance claims, lending institutions or any other source no matter how the funds were' 'characterized) which were related to or paid in consideration of the underground storage tank release. which is the subject of this claim? YES YNO -- If yes, list each source of funds below, attach a copy of insurance agreement or court . settlement with this form and 'submit with the reimbursement request: , Obligated to Date Source In Payment of Amount Renay Funds? I (we) hereby declare under penalty of perjury that all facts and statements set forth hezein are true and correct to the best of my (our) knowledge and belief. I (we) also declare that if funds are received after completion of this certification, I (we) will notify the Division promptly. If funds are received from the Fund and also received from other sources, I (we) will remit to the Division funds determined by the Division to be on account of any cost reimbursed from the Fund. Claim No. � Date: Claimant Signature Printed Name Claimant Signature Printed Name USTCF 007(Rev 6193)