Pecfa - Waiver / Deferral Of Deductible For Consultant Agent Application printable pdf download

PECFA – Waiver / Deferral of Deductible

Return Completed Form with attachments to:

Wisconsin Department of Natural Resources

for Consultant Agent Application

PECFA - Remediation and Redevelopment Program

Form 4400-290A (7/13)

PO Box 8044

Madison, WI 53708-8044

Fax: 608-267-7646

dnr.wi.gov/topic/Brownfields/

Notice: Pursuant to ss. 101.143(4)(ee), Wis. Stats., this application must be completed when requesting a waiver or deferral of the

Petroleum Environmental Cleanup Fund Award (PECFA) deductible from the Department of Natural Resources (DNR). This

completed form and all required attachments, as listed below, must be submitted to the address listed above. Personal information

collected will be used for administrative purposes and may be provided to requesters to the extent required by Wisconsin Open

Records Laws (ss. 19.31-19.39, Wis. Stats.).

_ _ _ _ _ - _ _ _ _ - _ _

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PECFA #

BRRTS #

Claimant Information

Last Name

First Name

Phone Number (include area code)

Address

City

State

Zip Code

Remedial Action Site Location

Remedial Action Site Name

Remedial Action Site Address

Remedial Action Site City

State

Zip Code

Section 101.143(4)(ee), Stats., provides the following:

Waiver of deductible. Notwithstanding par. (d)2., (dm)2. or (e)2., the department may waive the requirement that an owner or

operator pay the deductible amount if the department determines that the owner or operator is unable to pay. If the department

waives the requirement that an owner or operator pay the deductible, the department shall record a statement of lien with the

statement of lien, the department has a lien on the property on which the petroleum product storage system is located in the

amount of the deductible that was waived. The property remains subject to the lien until that amount is paid in full.

The following documents must be provided before a decision can be made on a PECFA Waiver/Deferral of

Deductible Application:

 This completed Waiver/Deferral of Deductible form; and

 A copy of a document that includes a full legal description of the property for which the waiver of the PECFA

deductible is requested. The Deed to the property will include this information.

Certification

The undersigned claimant is applying for a waiver of the PECFA deductible. The claimant has read s. 101.143(4)(ee), Wis. Stats.,

referenced above. The claimant understands that if the application for waiver of the PECFA deductible is approved, a lien will be

placed on the property on which the petroleum product storage tank system is located and for which the waiver of the PECFA

deductible is requested. The claimant assumes the responsibility for notifying all current owners about this application.

Claimant’s Signature(s)

Date Signed

For DNR Use Only

Application Status:

PECFA Financial Manager

APPROVED

Date

DENIED -

Your financial situation does not

meet the requirements of this provision

Pecfa - Waiver / Deferral Of Deductible For Consultant Agent Application

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