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r J <br /> B%IIETTO SEEDS Fax:209-466-6377 Sep 22 '97 9:59 P.04r06 <br /> OXHER 00URCE OF FUNDS t <br /> A. I Iave you or anyone acting on your behalf received,or do you or anyone acting on your behalf expect to receive,funds <br /> from any source(including but not limited to insurance claims,legal judgments,and contributions from other potentially <br /> responsible parties,or any other source regardless how the funds were characterized)which were related to or paid in <br /> consideration for the unauthorized release that is the subject of your claim? Vq NO 17 YES <br /> If YES,attach copies of all such documents,and list each source of funds and the amount below: <br /> DATE SOURCE IN PAYMENT OF AMOUNT <br /> B. Have you or anyone acting on your behalf received funds related to the contamination but not directly for the cleanup of the <br /> contamination which is the subject of the claim? � NO YES <br /> If YES,submit documentation(such as a settlement agreement or pleading,judgments or any other such document)that <br /> identifies the purpose(s)for which the money was received. <br /> C. Arc you obligated to repay any part of the funds received? NO YES <br /> If YES,attach documentation indicating what is to be repaid. <br /> AGREEMENTS AND DECLARATIONS <br /> PLEASE READ CAREFULLY BEFORE SIGNING. <br /> "I(we)authorize the Fund to contact the parties identified on this form and to obtain from those parties any <br /> information necessary to determine my(our)eligibility for reimbursement from the Fund and the amount that may be <br /> reimbursed. <br /> "I(we)agree to notify the Fund promptly if I(we)receive payment related to or made in consideration for the <br /> unauthorized release that is the subject of my(our)claim. I(we)farther agree to remit to the Fund any amount that in the <br /> Fund's determination constitutes double payment. <br /> 1(we)assign to the State of California and subrogate the state to any rights that I(we)have to recover from any <br /> person responsible for the unauthorized release that is the subject of my(our)claim corrective action costs for which I(we) <br /> received reimbttrsement. <br /> "I(we)declare under penalty of perjury that all facts and statements set forth herein are true and correct to the best <br /> of my(our)knowledge and belief. 1(we)understand that failure to fully and accurately disclose information or to provide <br /> supporting documentation will constitute grounds for rejecting my(our)claim and barring me(us)from further participation <br /> in the Fund." <br /> r <br /> EXECUTED AT: V U C A <br /> ON THIS DAY OF 19 <br /> t= 3 . Aum! <br /> CLAIMANT SIGNAT15KE PRINTED NAME RAC- LIE -0-61- <br /> - tl A C- L/f� 0 <br /> -61 <br /> JOINT CL NT SI ATTIRE PRtNTF.n NAME <br /> JOINT CLAIMANT SIGNATURE PRINTEDNAME <br /> i tST rn iQ m0W(Rev.3/97) —P 2 ort-- <br />