Ill. Admin. Code tit. 41, § 270.APPENDIX A – Application for Reimbursement Form

Hazardous Materials Emergency Response Reimbursement Application

SECTION 1 – APPLICANT INFORMATION

Organization Name _________________________________________________________________
Address ________________________________________	Phone Number ____________________
Tax Identification Number _________________________	Fax Number ______________________

SECTION 2 – CONTACT INFORMATION

Name ____________________________________________________________________________
Title __________________________________________	Work Phone ______________________
E-Mail ________________________________________	Cell Phone ______________________

SECTION 3 – RESPONSIBLE PARTY

If the responsible party is unknown, please check this box

Name ____________________________________________________________________________
Address ________________________________________	Phone Number ____________________
________________________________________	Fax Number ______________________
Date Notification for Reimbursement Provided to Responsible Party __________________________

SECTION 4 – INCIDENT NARRATIVE

Incident Date ___________________________

(Application must be submitted within 90 days after the incident date)

SECTION 5 – INCIDENT EXPENSES

You may claim expenses for a mutual aid responder if you have a mutual aid agreement. Indicate expenses of mutual aid responders in the column provided below and attach a copy of the mutual aid agreement to this application.

Itemized List of Expenses	Mutual Aid Expense (Y or N)	Qty	Amount




TOTAL (Must equal or exceed $500. If not you are not eligible to apply)

SECTION 6 – REIMBURSEMENT CALCULATION

Line 1: Total Annual Budget*

Line 2: Multiply Line 1 by 2% (Line 1 x 2% = Line 2)

Line 3: Cost of Incident Response (from Section 5)

If Line 3 is less than Line 2, STOP. You are not eligible to apply.

Line 4: Enter the amount from Line 3. If Line 3 is greater than $10,000,

then enter $10,000. This is your reimbursement claim.

* Exclude personnel costs (i.e., salary, benefits, training expenses and any other personnel costs) and costs to acquire capital equipment (i.e., buildings, vehicles and other major capital cost items). A copy of your approved budget or appropriation ordinance must be attached to this application.

SECTION 7 – ATTESTATION AND SIGNATURES

I attest that the information contained in this application is true and accurate to the best of my knowledge. (Signature should be from the head of the organization.)

_________________________________ _____________________ ______________

Signature Title Date

_________________________________

Print Name

You MUST attach the following documentation to your application:

Copy of an approved budget or appropriation ordinance for your agency

Copy of mutual aid agreements (if applicable)

(Source: Added at 40 Ill. Reg. 12790, effective August 18, 2016)