Form Dep6077 - Payment Waiver Form printable pdf download

Form Dep6077 - Payment Waiver Form

DEP6077 (April 2011)

401 KAR 42:250

PAYMENT WAIVER FORM

FOR STATE USE ONLY

Mail completed form to:

KENTUCKY

DIVISION OF WASTE MANAGEMENT

DEPARTMENT

UNDERGROUND STORAGE TANK BRANCH

FOR

300 SOWER BLVD, SECOND FLOOR

FRANKFORT, KENTUCKY 40601

ENVIRONMENTAL

(502) 564-5981

PROTECTION

THIS WAIVER OF RIGHT TO PAYMENT (the "WAIVER") IS MADE EFFECTIVE THIS

DAY OF

(Name of Declarant; the

"DECLARANT"). DECLARANT, BEING FIRST DULY SWORN, STATE, UNDER PENALTY OF LAW, AS FOLLOWS:

1. Declarant is a vendor or subcontractor who has performed work or supplied materials related to corrective action at the

facility listed below:

COUNTY:

FACILITY NAME:

CITY:

AGENCY INTEREST #:

2. Declarant has submitted to

(Person with whom the Declarant is under contract

with; the "Contractor") invoices for work performed, or materials supplied, for or to the Contractor, related to corrective action

at the Facility. These invoice numbers and invoice amounts are as follows:

# OF

INVOICE #

INVOICE AMOUNT

INVOICES

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(Attach additional sheets, if necessary)

All, or any one or more, of the invoices listed above or on additional sheets attached hereto are hereinafter referred to as "the

Invoices."

3. Notwithstanding any legal rights or remedies that Declarant may otherwise have, Declarant hereby waives, for itself and f or its

heirs, successors; and assigns its right to full payment of the Invoices before a person files a claim for reimbursement with the

cabinet, where the Invoices form a basis for at least part of that claim for reimbursement.

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Form Dep6077 - Payment Waiver Form

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