Laserfiche WebLink
JOINT CLAIMANT AND CO—PAYEE STAFF USE ONLY <br /> IDENTIFICATION FORM <br /> Where muibple owners and/or operators have incurred or are responsible for different costs at the same site, they may consolidate <br /> the claims into a Joint Claim <br /> XII. JOINT CLAIMANT <br /> NO-PROCEED TO THE NEXT SECTION <br /> IS THIS CLAIM A JOINT APPLICATION? <br /> YES-PROVIDE THE FOLLOWING INFORMATION FOR EACH JOINT CLAIMANT <br /> AL JOINTCLAIMANT NAME B JOINT CLAIMANT NAME <br /> MAIUNG ADDRESS MASJNG ADDRESS <br /> CITY STATE ZIP CODE <br /> CITY STATE ZIP CODE <br /> TELEPHONE NUMBER TELEPHONE NUMBER <br /> TAX IDENTIFICATION NO TAX IDENTIFICATION NO <br /> C DESCRIBE THE NATURE OF THEJOINT CLAMANT(S)RELATIONSHIP TO THE PRIMARY CLAIMANT WITH REGARDS TO THE FZLING0F THIS CLAIM? <br /> D WHEN JOINT CLAIMS ARE SUSMITTEIA CLAIMS ARE BASED ON THE LOWEST PRIORITY APPROPRIATE FOR ANY JOINT CLAIMANT IDENTIFY THE APPROPRIATE PRIORITY CLASS FOR ALLJOWIT CLAIMANTS <br /> NAME OWNER OPERATOR DATES OF OWNERSHIPJOPERATIOM PRIOAITYCLASS <br /> FROM TO A B C D <br /> A JOINT CLAIMANT <br /> J FROM TO <br /> a A R C D <br /> B JOINT GWMANT <br /> Owners and operators may designate a representative (bank or Insurance company who may have advanced funds for cleanup) <br /> as a Co—Payee <br /> IV. CO—PAYEE <br /> IS A CO-PAYEE TO BE NAMED IN PAYMENT L X NO-PROCEED TO THE NEXT PAGE <br /> OF THIS CLAIM? <br /> YES-PROVIDE THE FOLLOWING INFORMATION FOR EACH CO-PAYEE <br /> ,A.CO-PAYEE NAME <br /> 11 <br /> LWUNGADDRESS <br /> �I <br /> CITY STATE <br /> 21P(',ODE <br /> i <br /> TELEPHONE NO I TAX iDENTFICATION NO <br /> I <br /> {REVISED AN4 PAGE:2 <br />