Fillable Proof Of Payment Certification Form printable pdf download

Proof Of Payment Certification Form

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State Water Resources Control Board

Underground Storage Tank Cleanup Fund

PROOF OF PAYMENT CERTIFICATION FORM

Claim No.: ________________ Claimant Name:______________________________________________________________

Claimant Phone: ____________________________ Claimant E-mail: ____________________________________________

Site Address:__________________________________________________________________________________________

Payment Detail Table

Payor

Check

Invoice

Amt. Paid

RR No.

Name*

No.

Date

Amt.

No.

Date

Amt.

to Invoice

* Payor Name: Enter the name of the individual or entity that paid the provider exactly as the account holder’s name appears on

the check(s).

Payment Detail Spreadsheet: Attach a spreadsheet with the claimant name, claim number, site address, and provider name in

the header and the payment details with columns showing the payor name, check number, check date, check amount, invoice

number, invoice date, invoice amount, amount paid to the invoice, and RR No. (if known).

Attachment ___ # of pages, including this page

Claimant Certification: I, the undersigned, certify under penalty of perjury that I am the claimant for the above-mentioned claim

and I have paid, or the payor identified has paid on my behalf pursuant to an on-behalf-of agreement previously provided and

approved by the UST Cleanup Fund, by means of the check(s) identified on the Table or attached Payment Detail Spreadsheet,

in the amount stated for the specified invoices.

I acknowledge that the UST Cleanup Fund may require me to provide additional proof of payment verification at any time up to

three years after disbursement of the final reimbursement for this claim.

___________________________________________________ _________________________________________________

Print Name and Title (Claimant)

Signature and Date

___________________________________________________

_________________________________________________

Print Name and Title (Joint-claimant)

Signature and Date

___________________________________________________ _________________________________________________

Print Name and Title (Co-payee)

Signature and Date

(Revised 4/2017)

Proof Of Payment Certification Form

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