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OTHER SOURCE OF FUNDS <br /> A. HAVE YOU C)k ANYONE ACTING ON YOUR.BEHALF RECEIVED,OR DO YOU OR ANYONE ACTING ON YOUR BEHALF EXPECT TO <br /> RECEfYE,FUNDS FROM ANY SOURCE(INCLUDING t1tJ1-NOT LIMITED TO INSI)RANCB CLAIMS,LEGAL JU11K)MENTS,AND <br /> CONTRIBUTIONS FROM OTHER FUrENTIALLY RFSPONStaLE pAR.TlEs.OR ANY QTtIER SOURCE REGARDLESS ROW THE FUNDS WERE. <br /> CHARAC,T FUZED)WHICH WERE PSLATED TO OR PAID IN CONSIDERATION FOR T1412-UNAUTHORIZED RELEASE.THAT IS THE SUBJECT <br /> OF YOUR CLAIM? <br /> 0N ❑VES IF YES,ATTACH COPIES OI:ALL SUCH POC:UMPMN. <br /> IF YES,LIST EACH SOURCE OF FUNDS AND THE AMOUNT: <br /> DATE, SOURCE IN PAYMFNTOF AMOUNT <br /> a. HAVE YOU OR ANYONE AC IING ON YOUR SFHAI,F RECEIVE FUNDS REI.ATF.D TO THE CONITAMINA'rION Otfr NOT DIRECTLY FOR THE <br /> CLEANUP OF THE CONTAMINATION WH[CH IS THE SUBJECT OF THE CLAIM? <br /> MO OYER <br /> IF YUS,SUBMIT DOCUMENTATION(SUCH AS A SETTLEMENT AGREEMENT OP KFADINC.)UT)(mwi-S OR ANV()TnER SUCH <br /> DOCUMEN"[')THAT IDENTIFIES Tf IE PURPOSES(S)FOR WHICH THE MONEY WAA RKPIVED. <br /> C. ARE YOU OBL10ATE.D TO REPAY ANY PART OFTWFUNDS RECEIVED? IF VES,ATTAIN{IKfI UM!'N7'A't'ION INDICATING WHAT <br /> IS TO tiff REPAID- <br /> © NO ❑YES <br /> AGREEMENTS AND DECLARATIONS <br /> PLEASE READ CAREF[IUYBEFORE SIGNING: <br /> "1(we)authorize the Fund to contact the parties identified on this form and to obtain from those parties any <br /> information necessary to deterinitte my(our)eligibility for reimbutsemeni from the Fund and the amount that may <br /> be reimbursed- <br /> "I(we)agree to notify the Fund promptly if I(we)receive payment related to OT made in consideration for <br /> the unauthorized release that is the subject of my(our)claim. I(we)further agree to remit IQ the Fund any amount <br /> that In the Fund's determination constitutes double pa)ment. <br /> "I (we)assign to the State of Catifomia and subrogate the state to any rights that I (we)have to recover <br /> from any person responsible for the unauthorized release that is the subject of my(our)claim corrective action costs <br /> for which I(we)received reimbursement. <br /> "1(we)declare under penalty of perjury that ali facts and statements set forth herein are true and correct to <br /> the best of my (our) knowledge and belief. I (we) understand that railure to fully and accurately disclose <br /> information or to provide supporting doeumeritation will constitute grounds for rejecting my(aur)claim and barring <br /> me(us)from fttrther participation in the Fund." <br /> EXECUTED AT: <br /> ON THIS PAY OF 14 <br /> (:LAIAIAMT$IGHATUItx W«1sAINTGU NANO <br /> ,JOINTC J,K1MA+tSUaNA'rURB PmmunNAu¢ <br /> JOINT ClAIMANT SIGNATURE I'Kln�er/NAMBY <br /> USTCFIl 19.NON(RFv.3297) <br /> 906 0GZ'011 82T0t79t?60EL6 F UNnJ dnNU31D iSfl 9V:TT LG/80B0 <br />