Form 4400-290, Pecfa - Waiver/deferral Of Deductible Application

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Return Completed Form with attachments to:
PECFA - Waiver/Deferral of Deductible
Wisconsin Department of Natural Resources
Application
PECFA - Remediation and Redevelopment Program
Form 4400-290 (7/13)
PO Box 8044
Madison, WI 53708-8044
Fax: 608-267-7646
dnr.wi.gov/topic/Brownfields/
Notice: Pursuant to s. 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 Number:
BRRTS Number:
Claimant Information
Last Name
First
MI
Phone Number (incl. area code)
Address
City
State
ZIP Code
Remedial Action Site Location
Remedial Action Site
Remedial Action Site Address
Remedial Action Site City
State
ZIP Code
Section 101.143(4)(ee), Wis. 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
register of deeds of the county in which the petroleum product storage system is located. If the department records 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:
3 most recent years of Federal and State tax records.
A completed PECFA financial statement (RR-945)
A completed Application for waiver/deferral of PECFA deductible (form 4400-290).
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.
A copy of your last tax bill.
Certification
The undersigned claimant is applying for a waiver of the PECFA deductible. The claimant has read the Section 101.143(4)(ee), 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
Date Signed
For DNR Use Only
Application Status:
DNR PECFA Financial Manager
APPROVED
DENIED - Your financial situation does not meet the
Date
requirements of this provision

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