Fillable Proof Of Payment Certification Form (Page 2 of 2) in pdf

Proof Of Payment Certification Form Page 2

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PROOF OF PAYMENT CERTIFICATION INSTRUCTIONS

Use the instructions below to complete the Proof of Payment Certification Form. This form can be

used by the claimant in lieu of providing alternative documentation as adequate proof of payment

(i.e., copies of cancelled checks, etc.) to verify that their services/goods provider(s) have been paid.

All sections of the form must be complete in order for the form to be accepted by the Fund.

The Proof of Payment Certification Form can be obtained from the Fund’s web site at:

(NOTE: This form is the Fund’s preferred method of proof of payment documentation.)

 Section A (Claim Information) – Enter the claim’s information in this section. This information

should match exactly the claim’s information on the Reimbursement Request Form. Failure to

include the correct information will result in the form being rejected.

 Section B1 (Payment Detail Table) – Enter the payor name, check number, check date, check

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

“Payor Name” is the account holder’s name listed on the check. The “Amount Paid to Invoice” is

the amount of the check being applied to the invoice listed. All invoices must be paid by or on

behalf of the claimant pursuant to an on-behalf-of agreement previously submitted and approved

by the UST Cleanup Fund.

 Section B2 (Payment Detail Spreadsheet) – If the Payment Detail Table in section C1 is not

sufficient to list each check, 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).

 Section C (Claimant Certification) – Read the certification in its entirety and sign on the line to

certify that the information contained on this form is complete and accurate. The person signing

should be the claimant or have the authority to act on the claimant’s behalf (as acknowledged in

an on-behalf-of agreement with the Fund). Only original signatures will be accepted. Sign

using

blue

ink.

Proof Of Payment Certification Form Page 2

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