Mo. Code Regs. Ann. tit. 10, § 20-11.115
PURPOSE: This rule describes the requirements for use of a local government fund for demonstrating financial responsibility.
(1) A local government owner or operator may satisfy the requirements of 10 CSR 20- 11.093 by establishing a dedicated fund account that conforms to the requirements of this rule. Except as specified in subsection (1)(B) of this rule, a dedicated fund may not be commingled with other funds or otherwise used in normal operations. A dedicated fund will be considered eligible if it meets one (1) of the following requirements:
(C) The fund is dedicated by state constitutional provision, or local government statute, charter, ordinance or order to pay for taking corrective action and for compensating third parties for bodily injury and property damage caused by accidental releases arising from the operation of petroleum USTs. A payment is made to the fund once every year for seven (7) years until the fund is fullyfunded. This seven (7)-year period is referred to as the pay-in-period. The amount of each payment shall be determined by this formula:
TF - CF Y
where: TF = the total required financial assurance for the owner or operator; CF = the current amount in the fund; and Y = the number of years remaining in the pay-in-period.
ator has available bonding authority, approved through voter referendum (if this approval is necessary prior to the issuance of bonds), for an amount equal to the difference between the required amount of coverage and the amount held in the dedicated fund. This bonding authority shall be available for taking corrective action and for compensating third parties for bodily injury and property damage caused by accidental releases arising from the operation of petroleum USTs; or
ator has a letter signed by the appropriate state attorney general stating that the use of the bonding authority will not increase the local government’s debt beyond the legal debt ceilings established by the relevant state laws. The letter must also state that prior voter approval is not necessary before use of the bonding authority.
AUTHORITY: sections 319.114, RSMo (Cum. Supp. 1989) and 644.026, RSMo (Cum. Supp. 1993).* Original rule filed Aug. 3, 1993, effective April 9, 1994. *Original authority: 319.114, RSMo (1989) and 644.026, RSMo (1972), amended 1973, 1987, 1993. APPENDIX Wording of Financial Assurance Instruments Form 1—Letter from Chief Financial Officer The following text should be used to comply with the requirements of 10 CSR 20-11.095(4) as follows, except that the instructions in brackets are to be replaced by the relevant information and the brackets deleted: Letter from Chief Financial Officer I am the chief financial officer of [insert name and address of the owner or operator or guarantor]. This letter is in support of the use of [insert “the financial test of self insurance” and/or “guarantee”] to demonstrate financial responsibility for [insert “taking corrective action” and/or “compensating third parties for bodily injury and property damage”] caused by [insert “sudden accidental releases” and/or “nonsudden accidental releases”] in the amount of at least $[insert dollar amount] per occurrence and $[insert dollar amount] annual aggregate arising from operating (an) underground storage tank(s). Underground storage tanks at the following facilities are assured by this financial test by this [insert “owner or operator” and/or “guarantor”]: [List for each facility: the name and address of the facility where tanks assured by this financial test are located and whether tanks are assured by this financial test by the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10.022]. A [insert “financial test” and/or “guarantee”] is also used by this [insert “owner or operator” or “guarantor”] to demonstrate financial responsibility in the following amounts under other EPA regulations or state programs authorized by EPA under 40 CFR parts 271 and 145: Federal Rules Closure (264.143 and 265.143) Post-Closure Care (264.145 and 265.145) Liability Coverage (264.147 and 265.147) Corrective Action (264.101(b)) Plugging and Abandonment (144.63) Closure Post-Closure Care Liability Coverage Corrective Action Plugging and Abandonment Total This [insert “owner or operator” or “guarantor”] has not received an adverse opinion, a disclaimer of opinion or a “going concern” qualification from an independent auditor on his/her financial statements for the latest completed fiscal year. [Fill in the information for Alternative I if the criteria of 10 CSR 20-11.095(2) are being used to demonstrate compliance with the financial test requirements. Fill in the information for Alternative II if the criteria of 10 CSR 20-11.095(3) are being used to demonstrate compliance with the financial test requirements.] Alternative I 1. Amount of annual UST aggregate coverage being assured by a financial test or guarantee 2. Amount of corrective action, closure and post-closure care costs, liability coverage, and plugging and abandonment costs covered by a financial test or guarantee 3. Sum of lines one and two 4. Total tangible assets 5. Total liabilities (if any of the amount reported on line three is included in total liabilities, you may deduct that amount from this line and add that amount to line six) 6. Tangible net worth (subtract line five from line four) _________Yes ____________ No 7. Is line six at least ten (10) million dollars? 8. Is line six at least ten (10) times line three? $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 9. Have financial statements for the latest fiscal year been filed with the Securities and Exchange Commission? 10. Have financial statements for the latest fiscal year been filed with the Energy Information Administration? 11. Have financial statements for the latest fiscal year been filed with the Rural Electrification Administration? 12. Has financial information been provided to Dunn and Bradstreet and has Dunn and Bradstreet provided a financial strength rating of 4A or 5A? (Answer ‘’Yes’’ only if both criteria have been met.) Alternative II 1. Amount of annual UST aggregate coverage being assured by a test or guarantee 2. Amount of corrective action, closure and post-closure care costs, liability coverage, and plugging and abandonment costs covered by a financial test or guarantee 3. Sum of lines one and two 4. Total tangible assets 5. Total liabilities (if any of the amount reported on line three is included in total liabilities, you may deduct that amount from this line and add that amount to line six) 6. Tangible net worth (subtract line five from line four) 7. Total assets in the United States (required only if less than ninety percent (90%) of assets are located in the United States) ________ Yes __________ No 8. Is line six at least ten (10) million dollars? 9. Is line six at least six (6) times line three? 10. Are at least ninety percent (90%) of assets located in the United States? (If “No” complete line eleven) 11. Is line seven at least six (6) times line three? (Fill in either lines twelve through fifteen or lines sixteen through eighteen) 12. Current assets 13. Current liabilities 14. Net working capital (subtract line thirteen from line twelve) __________ Yes _________ No 15. Is line fourteen at least six (6) times line three? 16. Current bond rating of most recent bond issue 17. Name of rating service 18. Date of maturity of bond 19. Have financial statements for the latest fiscal year been filed with the SEC, the Energy Information Administration or the Rural Electrification Administration? (If ‘’No,’’ please attach a report from an independent certified public accountant certifying that there are no material differences between the data as reported in lines four through eighteen above and the financial statements for the latest fiscal year.) (For both Alternative I and Alternative II complete the certification with this statement.) “I hereby certify that the wording of this letter is identical to the wording specified in 10 CSR 20-11.095(4) as such rules were constituted on the date shown immediately below.’’ [Signature] [Name] [Title] [Date] 10 CSR 20-11 $ $ $ $ $ $ $ $ $ $ $ APPENDIX Form 2—Guarantee The following text should be used to comply with the requirements of 10 CSR 20-11.096(3) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Guarantee Guarantee made this [date] by [name of guaranteeing entity], a business entity organized under the laws of the State of [ ], herein referred to as guarantor, to the Department of Natural Resources and to any and all third parties and obligees on behalf of [owner or operator] of [business address]. Recitals (A) Guarantor meets or exceeds the financial test criteria of 10 CSR 20-11.095(2) or 10 CSR 10.095(3) and 10 CSR 10.095(4) and agrees to comply with the requirements for guarantors as specified in 10 CSR 20-11.096(2). (B) [Owner or operator] owns or operates the following underground storage tank(s) covered by this guarantee: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one (1) instrument is used to assure different tanks at any one (1) facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10.022, and the name and address of the facility.] This guarantee satisfies 10 CSR 20-11.090—10 CSR 20- 11.115 requirements for assuring funding for [insert “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases”; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the above-identified underground storage tank(s) in the amount of [insert dollar amount] per occurrence and [insert dollar amount] annual aggregate. (C) [Insert appropriate phrase: “On behalf of our subsidiary” (if guarantor is corporate parent of the owner or operator); “On behalf of our affiliate” (if guarantor is a related firm of the owner or operator); or “Incident to our business relationship with” (if guarantor is providing the guarantee as an incident to a substantial business relationship with owner or operator)] [owner or operator], guarantor guarantees to department and to any and all third parties that: In the event that [owner or operator] fails to provide alternate coverage within sixty (60) days after receipt of a notice of cancellation of this guarantee and the director has determined or suspects that a release has occurred at an underground storage tank covered by this guarantee, the guarantor, upon instructions from the director, shall fund a standby trust fund in accordance with the provisions of 10 CSR 20-11.112, in an amount not to exceed the coverage limits specified above. In the event that the director determines that [owner or operator] has failed to perform corrective action for releases arising out of the operation of the above-identified tank(s) in accordance with 10 CSR 20-10.060—10 CSR 20-10.067, the guarantor upon written instructions from the director, shall fund a standby trust in accordance with the provisions of 10 CSR 20-11.108 in an amount not to exceed the coverage limits specified above. If [owner or operator] fails to satisfy a judgment or award based on a determination of liability for bodily injury or property damage to third parties caused by [“sudden” and/or “nonsudden”] accidental releases arising from the operation of the above-identified tank(s) or fails to pay an amount agreed to in settlement of a claim arising from or alleged to arise from such injury or damage, the guarantor upon written instructions from the director, shall fund a standby trust in accordance with the provisions of 10 CSR 20-11.112 to satisfy such judgment(s), award(s) or settlement agreement(s) up to the limits of coverage specified above. (D) Guarantor agrees that if, at the end of any fiscal year before cancellation of this guarantee, the guarantor fails to meet the financial test criteria of 10 CSR 20-11.095(2) or 10 CSR 10.095(3) and 10 CSR 10.095(4), guarantor shall send within one hundred twenty (120) days of such failure, by certified mail, notice to [owner or operator]. The guarantee will terminate one hundred twenty (120) days from the date of receipt of the notice by [owner or operator], as evidenced by the return receipt. (E) Guarantor agrees to notify [owner or operator] by certified mail of a voluntary or involuntary proceeding under Title 11 (Bankruptcy), United States Code, naming guarantor as debtor, within ten (10) days after commencement of the proceeding. (F) Guarantor agrees to remain bound under this guarantee notwithstanding any modification or alteration of any obligation of [owner or operator] pursuant to 10 CSR 20-10.010—10 CSR 20-11.115. (G) Guarantor agrees to remain bound under this guarantee for so long as [owner or operator] must comply with the applicable financial responsibility requirements of 10 CSR 20-11.090—10 CSR 20-11.115 for the above-identified tank(s), except that guarantor may cancel this guarantee by sending notice by certified mail to [owner or operator], such cancellation to become effective no earlier than one hundred twenty (120) days after receipt of such notice by [owner or operator], as evidenced by the return receipt. (H) The guarantor’s obligation does not apply to any of the following: 1. Any obligation of [insert owner or operator] under Workers’ Compensation, disability benefits or unemployment compensation law or other similar law; 2. Bodily injury to an employee of [insert owner or operator] arising from, and in the course of, employment by [insert owner or opera- tor]; 3. Bodily injury or property damage arising from the ownership, maintenance, use or entrustment to others of any aircraft, motor vehi- cle or watercraft; 4. Property damage to any property owned, rented, loaned to, in the care, custody, or control of or occupied by [insert owner or opera- tor] that is not the direct result of a release from a petroleum underground storage tank; 5. Bodily injury or property damage for which [insert owner or operator] is obligated to pay damages by reason of the assumption of lia- bility in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. (I) Guarantor expressly waives notice of acceptance of this guarantee by the department, by any or all third parties or by [owner or operator]. I hereby certify that the wording of this guarantee is identical to the wording specified in 10 CSR 20-11.096(3) as such rules were constituted on the effective date shown immediately below. Effective date: [Name of guarantor] [Authorized signature for guarantor] [Name of person signing] [Title of person signing] Signature of witness or notary: APPENDIX Form 3—Endorsement The following text should be used to comply with the requirements of 10 CSR 20-11.097(2) as follows, except that the instructions in brackets are to be replaced by the relevant information and the brackets deleted: (A) Endorsement Name: [name of each covered location] Address: [address of each covered location] Policy Number: Period of Coverage: [current policy period] Name of [Insurer or Risk Retention Group]: Address of [Insurer or Risk Retention Group]: Name of Insured: Address of Insured: Endorsement: 1. This endorsement certifies that the policy to which the endorsement is attached provides liability insurance covering the following under- ground storage tanks: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one (1) instrument is used to assure different tanks at any one (1) facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted for 10 CSR 20-10.022 and the name and address of the facility.] for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental release;” in accordance with and subject to the limits of liability, exclusions, conditions and other terms of the policy; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the underground storage tank(s) identified above. The limits of liability are [insert the dollar amount of the “each occurrence” and “annual aggregate” limits of the Insurer’s or Group’s liability; if the amount of coverage is different for different types of coverage or for different underground storage tanks or locations, indicate the amount of coverage for each type of coverage and/or for each underground storage tank or location], exclusive of legal defense costs which are subject to a separate limit under the policy. This coverage is provided under [policy number]. The effective date of said policy is [date]. 2. The insurance afforded with respect to such occurrences is subject to all of the terms and conditions of the policy; provided, however, that any provisions inconsistent with subparagraphs A through E of this paragraph are hereby amended to conform with subparagraphs A through E: A. Bankruptcy or insolvency of the insured shall not relieve the [“Insurer” or “Group”] of its obligations under the policy to which this endorsement is attached. B. The [“Insurer” or “Group”] is liable for the payment of amounts within any deductible applicable to the policy to the provider of corrective action or a damaged third-party, with a right of reimbursement by the insured for any such payment made by the [“Insurer” or “Group”]. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 10 CSR 20-11.095 through 10 CSR 20-11.102. C. Whenever requested by the director, the [“Insurer” or “Group”] agrees to furnish to the director a signed duplicate original of the policy and all endorsements. D. Cancellation or any other termination of the insurance by the [“Insurer” or “Group”], except for non-payment of premium or mis- representation by the insured, will be effective only upon written notice and only after the expiration of sixty (60) days after a copy of such written notice is received by the insured. Cancellation for non-payment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of ten (10) days after a copy of such written notice is received by the insured. [Insert for claims-made policies] E. The insurance covers claims otherwise covered by the policy that are reported to the [“Insurer” or “Group”] within six (6) months of the effective date of cancellation or non-renewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable and prior to such policy renewal or termination date. Claims reported during such extended reporting period are subject to the terms, conditions, limits, including limits of liability and exclusions of the policy.] I hereby certify that the wording of this instrument is identical to the wording in 10 CSR 20-11.097(2)(A) and that the [“Insurer” or “Group”] is [“licensed to transact the business of insurance or eligible to provide insurance as an excess or surplus lines insurer in this state”]. [Signature of authorized representative of Insurer or Risk Retention Group] [Name of person signing] [Title of person signing] Authorized Representative of [Name of Insurer or Risk Retention Group] [Address of Representative] APPENDIX Form 4—Certificate of Insurance The following text should be used to comply with the requirements of 10 CSR 20-11.097(2) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Certificate of Insurance Name: [name of each covered location] Address: [address of each covered location] Policy Number: Endorsement (if applicable): Period of Coverage: [current policy period] Name of [Insurer or Risk Retention Group]: Address of [Insurer or Risk Retention Group]: Name of Insured: Address of Insured: Certification: 1. [Name of Insurer or Risk Retention Group], [the “Insurer” or “Group”], as identified above, hereby certifies that it has issued liability insurance covering the following underground storage tank(s): [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one (1) instrument is used to assure different tanks at any one (1) facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10.022 and the name and address of the facility.] for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases;” in accordance with and subject to the limits of liability, exclusions, conditions and other terms of the policy; if coverage is different for different tanks or locations: indicate the type of coverage applicable to each tank or location] arising from operating the underground storage tank(s) identified above. The limits of liability are [insert the dollar amount of the “each occurrence” and “annual aggregate” limits of the Insurer’s or Group’s liability; if the amount of coverage is different for different types of coverage or for different underground storage tanks or locations, indicate the amount of coverage for each type of coverage and/or for each underground storage tank or location], exclusive of legal defense costs, which are subject to a separate limit under the policy. This coverage is provided under [policy number]. The effective date of said policy is [date]. 2. The [“Insurer” or “Group”] further certifies the following with respect to the insurance described in Paragraph 1: A. Bankruptcy or insolvency of the insured shall not relieve the [“Insurer” or “Group”] of its obligations under the policy to which this certificate applies. B. The [“Insurer” or “Group”] is liable for the payment of amounts within any deductible applicable to the policy to the provider of cor- rective action or a damaged third-party, with a right of reimbursement by the insured for any such payment made by the [“Insurer” or “Group”]. This provision does not apply with respect to that amount of any deductible for which coverage is demonstrated under another mechanism or combination of mechanisms as specified in 10 CSR 20-11.095 through 10 CSR 20-11.102. C. Whenever requested by the director, the [“Insurer” or “Group”] agrees to furnish to the director a signed duplicate original of the pol- icy and all endorsements. D. Cancellation or any other termination of the insurance by the [“Insurer” or “Group”], except for nonpayment of premium or misrep- resentation by the insured, will be effective only upon written notice and only after the expiration of sixty (60) days after a copy of such written notice is received by the insured. Cancellation for nonpayment of premium or misrepresentation by the insured will be effective only upon written notice and only after expiration of a minimum of ten (10) days after a copy of such written notice is received by the insured. [Insert for claims-made policies] E. The insurance covers claims otherwise covered by the policy that are reported to the [“Insurer” or “Group”] within six (6) months of the effective date of cancellation or nonrenewal of the policy except where the new or renewed policy has the same retroactive date or a retroactive date earlier than that of the prior policy and which arise out of any covered occurrence that commenced after the policy retroactive date, if applicable and prior to such policy renewal or termination date. Claims reported during such an extended reporting period are subject to the terms, conditions, limits, including limits of liability and exclusions of the policy. I hereby certify that the wording of this instrument is identical to the wording in 10 CSR 20-11.097(2)(B) and that the [“Insurer” or “Group”] is [“licensed to transact the business of insurance, or eligible to provide insurance as an excess or surplus lines insurer, in this state”]. [Signature of authorized representative of Insurer] [Type name] [Title] Authorized Representative of [Name of Insurer or Risk Retention Group] [Address of Representative] The following text should be used to comply with the requirements of 10 CSR 20-11.098(2) as follows, except that the instructions in brackets are to be replaced by the relevant information and the brackets deleted: Performance Bond Date bond executed: Period of coverage: Principal: [legal name and business address of owner or operator] Type of organization: [insert “individual,” “joint venture,” “partnership,” or “corporation”] State of incorporation (if applicable): Surety(ies): [name(s) and business address(es)] Scope of Coverage: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one (1) instrument is used to assure different tanks at any one (1) facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10.022 and the name and address of the facility. List the coverage guaranteed by the bond: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases” “arising from operating the underground storage tank”]. Penal sums of bond Per occurrence Annual aggregate Surety’s bond number Know All Persons by These Presents, that we, the Principal and Surety(ies), hereto are firmly bound to the department, in the above penal sums for the payment of which we bind ourselves, our heirs, executors, administrators, successors and assigns jointly and severally; provided that, where the Surety(ies) are corporations acting as co-Sureties, we, the Sureties, bind ourselves in such sums jointly and severally only for the purpose of allowing a joint action(s) against any or all of us, and for all other purposes each Surety binds itself, jointly and severally with the Principal, for the payment of such sums only as is set forth opposite the name of such Surety, but if no limit of liability is indicated, the limit of liability shall be the full amount of the penal sums. Whereas said Principal is required under Subtitle I of the Resource Conservation and Recovery Act (RCRA), as amended, to provide financial assurance for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases”; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the underground storage tanks identified above, and Whereas said Principal shall establish a standby trust fund as is required when a surety bond is used to provide such financial assurance; Now, therefore, the conditions of the obligation are such that if the Principal shall faithfully [“take corrective action, in accordance with 10 CSR 20-10.060—10 CSR 20-10.067 and the director’s instructions for,” and/or “compensate injured third parties for bodily injury and property damage caused by” either “sudden” or “nonsudden” or “sudden and nonsudden”] accidental releases arising from operating the tank(s) identified above, or if the Principal shall provide alternate financial assurance, as specified in 10 CSR 20-10.090—10 CSR 20-11.115, within one hundred twenty (120) days after the date the notice of cancellation is received by the Principal from the Surety(ies), then this obligation shall be null and void; otherwise it is to remain in full force and effect. Such obligation does not apply to any of the following: (A) Any obligation of [insert owner or operator] under Workers’ Compensation, disability benefits or unemployment compensation law or other similar law; (B) Bodily injury to an employee of [insert owner or operator] arising from, and in the course of, employment by [insert owner or operator]; (C) Bodily injury or property damage arising from the ownership, maintenance, use, or entrustment to others of any aircraft, motor vehicle or watercraft; (D) Property damage to any property owned, rented, loaned to, in the care, custody, or control of or occupied by [insert owner or operator] that is not the direct result of a release from a petroleum underground storage tank; (E) Bodily injury or property damage for which [insert owner or operator] is obligated to pay damages by reason of the assumption of liability in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. The Surety(ies) shall become liable on this bond obligation only when the Principal has failed to fulfill the conditions described above. Upon notification by [the director] that the Principal has failed to [“take corrective action, in accordance with 10 CSR 20-10.060—10 CSR 20-10.067 and the director’s instructions,” and/or “compensate injured third parties”] as guaranteed by this bond, the Surety(ies) shall either APPENDIX Form 5—Performance Bond : $ $ : perform [“corrective action in accordance with 10 CSR 20-10.060—10 CSR 20-10.067 and the director’s instructions,’’ and/or ‘’third-party liability compensation”] or place funds in an amount up to the annual aggregate penal sum into the standby trust fund as directed by the director under 10 CSR 20-11.108. Upon notification by [the director] that the Principal has failed to provide alternate financial assurance within sixty (60) days after the date the notice of cancellation is received by the Principal from the Surety(ies) and that the director has determined or suspects that a release has occurred, the Surety(ies) shall place funds in an amount not exceeding the annual aggregate penal sum into the standby trust fund as directed by the director under 10 CSR 20-11.108. The Surety(ies) hereby waive(s) notification of amendments to applicable laws, statutes and regulations and agrees that no such amendment shall in any way alleviate its (their) obligation on this bond. The liability of the Surety(ies) shall not be discharged by any payment or succession of payments hereunder, unless and until such payment(s) shall amount in the annual aggregate to the penal sum shown on the face of the bond, but in no event shall the obligation of the Surety(ies) hereunder exceed the amount of said annual aggregate penal sum. The Surety(ies) may cancel the bond by sending notice of cancellation by certified mail to the Principal, provided, however, that cancellation shall not occur during the one hundred twenty (120) days beginning on the date of receipt of the notice of cancellation by the Principal as evidenced by the return receipt. The Principal may terminate this bond by sending written notice to the Surety(ies). In Witness Thereof, the Principal and Surety(ies) have executed this Bond and have affixed their seals on the date set forth above. The persons whose signatures appear below hereby certify that they are authorized to execute this surety bond on behalf of the Principal and Surety(ies) and that the wording of this surety bond is identical to the wording specified in 10 CSR 20-11.098(2) as such rules were constituted on the date this bond was executed. PRINCIPAL [Signature(s)] [Name(s)] [Title(s)] [Corporate seal] CORPORATE SURETY(IES) [Name and address] State of Incorporation: Liability limit: $ [Signature(s)] [Name(s) and title(s)] [Corporate seal] [For every co-surety, provide signature(s), corporate seal and other information in the same manner as for Surety above.] Bond premium: $ APPENDIX Form 6—Irrevocable Standby Letter of Credit The following text should be used to comply with the requirements of 10 CSR 20-11.099(2) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Irrevocable Standby Letter of Credit [Name and address of issuing institution] [Name and address of director] Dear Sir or Madam: We hereby establish our Irrevocable Standby Letter of Credit No. in your favor, at the request and for the account of [owner or operator name] of [address] up to the aggregate amount of [in words] United States dollars ($[insert dollar amount]), available upon presentation [insert, if more than one (1) state is a beneficiary, “by any one (1) of you”] of: (A) Your sight draft, bearing reference to this letter of credit, No. , and (B) Your signed statement reading as follows: ‘’I certify that the amount of the draft is payable pursuant to regulations issued under authority of Subtitle I of the Resource Conservation and Recovery Act of 1976, as amended.’’ This letter of credit may be drawn on to cover [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases’’ or “nonsudden accidental releases” or “accidental releases”] arising from operating the underground storage tank(s) identified below in the amount of [in words] $[insert dollar amount] per occurrence and [in words] $[insert dollar amount] annual aggregate: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one (1) instrument is used to assure different tanks at any one (1) facility, for each tank covered by this instrument, list the tank identification number provided by in the notification submitted pursuant to 10 CSR 20-10.022 and the name and address of the facility.] The letter of credit may not be drawn on to cover any of the following: 1. Any obligation of [insert owner or operator] under a Workers’ Compensation, disability benefits or unemployment compensation law or other similar law; 2. Bodily injury to an employee of [insert owner or operator] arising from, and in the course of, employment by [insert owner or opera- tor]; 3. Bodily injury or property damage arising from the ownership, maintenance, use or entrustment to others of any aircraft, motor vehi- cle or watercraft; 4. Property damage to any property owned, rented, loaned to, in the care, custody, or control of or occupied by [insert owner or opera- tor] that is not the direct result of a release from a petroleum underground storage tank; 5. Bodily injury or property damage for which [insert owner or operator] is obligated to pay damages by reason of the assumption of lia- bility in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. This letter of credit is effective as of [date] and shall expire on [date], but such expiration date shall be automatically extended for a period of [at least the length of the original term] on [expiration date] and on each successive expiration date unless, at least one hundred twenty (120) days before the current expiration date, we notify [owner or operator] by certified mail that we have decided not to extend this letter of credit beyond the current expiration date. In the event that [owner or operator] is so notified, any unused portion of the credit shall be available upon presentation of your sight draft for one hundred twenty (120) days after the date of receipt by [owner or operator], as shown on the signed return receipt. Whenever this letter of credit is drawn on under and in compliance with the terms of this credit, we shall duly honor such draft upon presentation to us and we shall deposit the amount of the draft directly into the standby trust fund of [owner or operator], in accordance with your instructions. We certify that the wording of this letter of credit is identical to the wording specified in 10 CSR 20-11.099(2) as such rules were constituted on the date shown immediately below. [Signature(s) and title(s) of official(s) of issuing institution] [Date] This credit is subject to [insert “the most recent edition of the Uniform Customs and Practice for Documentary Credits, published by the International Chamber of Commerce,” or the “Uniform Commercial Code”]. APPENDIX Form 7—Trust Agreement The following text should be used to comply with the requirements of 10 CSR 20-11.102(6) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Trust Agreement Trust agreement, the ‘’Agreement’’ entered into as of [date] by and between [name of the owner or operator], a [name of state] [insert “corporation,” “partnership,” “association,” or “proprietorship”], the “Grantor,” and [name of corporate trustee], [insert “Incorporated in the state of” or “a national bank”], the “Trustee.” Whereas, the Department of Natural Resources, “the department,” an agency of the state of Missouri, has established certain regulations applicable to the Grantor, requiring that an owner or operator of an underground storage tank shall provide assurance that funds will be available when needed for corrective action and third-party compensation for bodily injury and property damage caused by sudden and non-sudden accidental releases arising from the operation of the underground storage tank; Whereas, the Grantor has elected to establish [insert either “a guarantee,” “surety bond,” or “letter of credit”] to provide all or part of such financial assurance for the underground storage tanks identified herein and is required to establish a standby trust fund able to accept payments from the instrument (This paragraph is only applicable to the standby trust agreement.); Whereas, the Grantor, acting through its duly authorized officers, has selected the Trustee to be the trustee under this agreement, and the Trustee is willing to act as trustee; Now, therefore, the Grantor and the Trustee agree as follows: 1. Definitions As used in this Agreement: A. The term ‘’Grantor’’ means the owner or operator who enters into this Agreement and any successors or assigns of the Grantor. B. The term ‘’Trustee’’ means the Trustee who enters into the Agreement and any successor Trustee. 2. Identification of the Financial Assurance Mechanism. This Agreement pertains to the [identify the financial assurance mechanism, either a guarantee, surety bond, or letter of credit, from which the standby trust fund is established to receive payments] (This paragraph is only applicable to the standby trust agreement)]. 3. Establishment of Fund. The Grantor and the Trustee hereby establish a trust fund, the ‘’Fund’’ for the benefit of department. The Grantor and the Trustee intend that no third-party have access to the Fund except as herein provided. (The Fund is established initially as a standby to receive payments and shall not consist of any property.) Payments made by the provider of financial assurance pursuant to the director’s instructions are transferred to the Trustee and are referred to as the Fund, together with all earnings and profits thereon, less any payments or distributions made by the Trustee pursuant to this Agreement. The Fund shall be held by the Trustee, IN TRUST, as hereinafter provided. The Trustee shall not be responsible nor shall it undertake any responsibility for the amount or adequacy of, nor any duty to collect from the Grantor as provider of financial assurance, any payments necessary to discharge any liability of the Grantor established by the department. 4. Payment for [“Corrective Action” and/or “Third-Party Liability Claims”:]. The Trustee shall make payments from the Fund as [the director] shall direct, in writing, to provide for the payment of the costs of [insert ‘’taking corrective action’’ and/or compensating third parties for bodily injury and property damage caused by either ‘’sudden accidental releases’’ or ‘’nonsudden accidental releases’’ or ‘’accidental releases’’] arising from operating the tanks covered by the financial assurance mechanism identified in this Agreement. The Fund may not be drawn upon to cover any of the following: A. Any obligation of [insert owner or operator] under Workers’ Compensation, disability benefits, or unemployment compensation law or other similar law; B. Bodily injury to an employee of [insert owner or operator] arising from, and in the course of employment by [insert owner or opera- tor]; C. Bodily injury or property damage arising from the ownership, maintenance, use or entrustment to others of any aircraft, motor vehi- cle or watercraft; D. Property damage to any property owned, rented, loaned to, in the care, custody, or control of or occupied by [insert owner or opera- tor] that is not the direct result of a release from a petroleum underground storage tank; E. Bodily injury or property damage for which [insert owner or operator] is obligated to pay damages by reason of the assumption of lia- bility in a contract or agreement other than a contract or agreement entered into to meet the requirements of 40 CFR 280.93. The Trustee shall reimburse the Grantor, or other persons as specified by the director, from the Fund for corrective expenditures and/or third-party liability claims in such amounts as the director shall direct in writing. In addition, the Trustee shall refund to the Grantor such amounts as the director specifies in writing. Upon refund, such funds shall no longer constitute part of the Fund as defined herein. 5. Payments Comprising the Fund. Payments made to the Trustee for the Fund shall consist of cash and securities acceptable to the Trustee. 6. Trustee Management. The Trustee shall invest and reinvest the principal and income of the Fund and keep the Fund invested as a single fund, without distinction between principal and income, in accordance with general investment policies and guidelines which the Grantor may communicate in writing to the Trustee from time-to-time, subject, however, to the provisions of this Section. In investing, reinvesting, exchanging, selling, and managing the Fund, the Trustee shall discharge his/her duties with respect to the trust fund solely in the interest of the beneficiaries and with care, skill, prudence and diligence under the circumstances then prevailing which persons of prudence, acting in a like capacity and familiar with such matters, would use in the conduct of an enterprise of a like character and with like aims, except that: A. Securities or other obligations of the Grantor, or any other owner or operator of the tanks, or any of their affiliates as defined in the Investment Company Act of 1940, 15 U.S.C. 80a-2(a), shall not be acquired or held, unless they are securities or other obligations of the federal or a state government; B. The Trustee is authorized to invest the Fund in time or demand deposits of the Trustee, to the extent insured by an agency of the fed- eral or state government; and C. The Trustee is authorized to hold cash awaiting investment or distribution uninvested for a reasonable time and without liability for the payment of interest thereon. 7. Commingling and investment. The Trustee is expressly authorized in its discretion: A. To transfer from time-to-time any or all of the assets of the Fund to any common, commingled or collective trust fund created by the Trustee in which the Fund is eligible to participate, subject to all of the provisions thereof, to be commingled with the assets of other trusts participating therein; and B. To purchase shares in any investment company registered under the Investment Company Act of 1940, 15 U.S.C. 80a-1, including one which may be created, managed, underwritten, or to which investment advice is rendered or the shares of which are sold by the Trustee. The Trustee may vote such shares in its discretion. 8. Express Powers of Trustee. Without in any way limiting the powers and discretion conferred upon the Trustee by the other provisions of this Agreement or by law, the Trustee is expressly authorized and empowered: A. To sell, exchange, convey, transfer, or otherwise dispose of any property held by it, by public or private sale. No person dealing with the Trustee shall be bound to see to the application of the purchase money or to inquire into the validity or expediency of any such sale or other disposition; B. To make, execute, acknowledge and deliver any and all documents of transfer and conveyance and any and all other instruments that may be necessary or appropriate to carry out the powers herein granted; C. To register any securities held in the Fund in its own name or in the name of a nominee and to hold any security in bearer form or in book entry, or to combine certificates representing such securities with certificates of the same issue held by the Trustee in other fiduciary capacities, or to deposit or arrange for the deposit of such securities in a qualified central depository even though, when so deposited, such securities may be merged and held in bulk in the name of the nominee of such depository with other securities deposited therein by another person, or to deposit or arrange for the deposit of any securities issued by the United States Government, or any agency or instrumentality thereof, with a Federal Reserve bank, but the books and records of the Trustee shall at all times show that all such securities are part of the Fund; D. To deposit any cash in the Fund in interest-bearing accounts maintained or savings certificates issued by the Trustee, in its separate corporate capacity, or in any other banking institution affiliated with the Trustee, to the extent insured by an agency of the federal or state government; and E. To compromise or otherwise adjust all claims in favor of or against the Fund. 9. Taxes and Expenses. All taxes of any kind that may be assessed or levied against or in respect of the Fund and all brokerage commissions incurred by the Fund shall be paid from the Fund. All other expenses incurred by the Trustee in connection with the administration of this Trust, including fees for legal services rendered to the Trustee, the compensation of the Trustee to the extent not paid directly by the Grantor, and all other proper charges and disbursements of the Trustee shall be paid from the Fund. 10. Advice of Counsel. The Trustee may from time-to-time consult with counsel, who may be counsel to the Grantor with respect to any questions arising as to the construction of this Agreement or any action to be taken hereunder. The Trustee shall be fully protected, to the extent permitted by law, in acting upon the advice of legal counsel. 11. Trustee Compensation. The Trustee shall be entitled to reasonable compensation for its services as agreed upon in writing from time to time with the Grantor. 12. Successor Trustee. The Trustee may resign or the Grantor may replace the Trustee, but such resignation or replacement shall not be effective until the Grantor has appointed a successor trustee and this successor accepts the appointment. The successor trustee shall have the same powers and duties as those conferred upon the Trustee hereunder. Upon the successor trustee’s acceptance of the appointment, the Trustee shall assign, transfer, and pay over to the successor trustee the funds and properties then constituting the Fund. If for any reason the Grantor cannot or does not act in the event of the resignation of the Trustee, the Trustee may apply to a court of competent jurisdiction for the appointment of a successor trustee or for instructions. The successor trustee shall specify the date on which it assumes administration of the trust in writing sent to the Grantor and the present Trustee by certified mail ten (10) days before such change becomes effective. Any expense incurred by the Trustee as a result of any of the acts contemplated by this section shall be paid as provided in paragraph 9 of this agreement. 13. Instructions to the Trustee. All orders, requests and instructions by the Grantor to the Trustee shall be in writing, signed by such persons as are designated in the attached Schedule B or such other designees as the Grantor may designate by amendment to Schedule B. The Trustee shall be fully protected in acting without inquiry in accordance with the Grantor’s orders, requests and instructions. All orders, requests and instructions by the director to the Trustee shall be in writing, signed by the director, and the Trustee shall act and shall be fully protected in acting in accordance with such orders, requests and instructions. The Trustee shall have the right to assume, in the absence of written notice to the contrary, that no event constituting a change or a termination of the authority of any person to act on behalf of the Grantor or the director hereunder has occurred. The Trustee shall have no duty to act in the absence of such orders, requests and instructions from the Grantor and/or the director, except as provided for herein. 14. Amendment of Agreement. This Agreement may be amended by an instrument in writing executed by the Grantor and the Trustee, or by the Trustee and [the director] if the Grantor ceases to exist. 15. Irrevocability and Termination. Subject to the right of the parties to amend this Agreement as provided in Section 14, this Trust shall be irrevocable and shall continue until terminated at the written direction of the Grantor and the Trustee, or by the Trustee and the director, if the Grantor ceases to exist. Upon termination of the Trust, all remaining trust property, less final trust administration expenses, shall be delivered to the Grantor. 16. Immunity and Indemnification. The Trustee shall not incur personal liability of any nature in connection with any act or omission, made in good faith, in the administration of this Trust, or in carrying out any directions by the Grantor or the director issued in accordance with this Agreement. The Trustee shall be indemnified and saved harmless by the Grantor, from and against any personal liability to which the Trustee may be subjected by reason of any act or conduct in its official capacity, including all expenses reasonably incurred in its defense in the event the Grantor fails to provide such defense. 17. Choice of Law. This Agreement shall be administered, construed and enforced according to the laws of the state of [insert name of state], or the Comptroller of the Currency in the case of National Association banks. 18. Interpretation. As used in this Agreement, words in the singular include the plural and words in the plural include the singular. The descriptive headings for each paragraph of this Agreement shall not affect the interpretation or the legal efficacy of this Agreement. In Witness whereof the parties have caused this Agreement to be executed by their respective officers duly authorized and their corporate seals (if applicable) to be hereunto affixed and attested as of the date first above written. The parties below certify that the wording of this Agreement is identical to the wording specified in 10 CSR 20-11.103(2)(A) as such rules were constituted on the date written above. [Signature of Grantor] [Name of the Grantor] [Title] Attest: [Signature of Trustee] [Name of the Trustee] [Title] [Seal] [Signature of Witness] [Name of the Witness] [Title] [Seal] APPENDIX Form 8—Certification of Acknowledgments The following text should be used to comply with the requirements of 10 CSR 20-11.102(3) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Certification of Acknowledgments State of County of On this [date], before me personally came [owner or operator] to me known, who, being by me duly sworn, did depose and say that s/he resides at [address], that s/he is [title] of [corporation], the corporation described in and which executed the above instrument; that s/he knows the seal of said corporation; that the seal affixed to such instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said corporation; and that s/he signed her/his name thereto by like order. [Signature of Notary Public] [Name of Notary Public] APPENDIX Form 9—Certification of Financial Responsibility The following text should be used to comply with the requirements of 10 CSR 20-11.107(2)(K) as follows, except that the instructions in brackets are to be replaced by the relevant information and the brackets deleted: Certification of Financial Responsibility [Owner or operator] hereby certifies that it is in compliance with the requirements of 10 CSR 20-11.090–10 CSR 20-11.115. The financial assurance mechanism(s) used to demonstrate financial responsibility under 10 CSR 20-11.090–10 CSR 20-11.115 is (are) as follows: [For each mechanism, list the type of mechanism, name of issuer, mechanism number (if applicable), amount of coverage, effective period of coverage and whether the mechanism covers “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases.”] [Signature of owner or operator] [Name of owner or operator] [Title] [Date] [Signature of witness or notary] [Name of witness or notary] [Date] APPENDIX Form 10—Certification of Valid Claim The certification of valid claim must be worded as follows, except that instructions in brackets are to be replaced with the relevant informa- tion and the brackets deleted: Certification of Valid Claim The undersigned, as principals and as legal representatives of [insert owner or operator] and [insert name and address of third-party claimant], hereby certify that the claim of bodily injury (and/or) property damage caused by an accidental release arising from operating [owner’s or operator’s] underground storage tank should be paid in the amount of $[ ]. [Signatures] [Owner or Operator] [Attorney for Owner or Operator] [Notary] [Date] [Signatures] [Claimant(s)] [Attorney(s) for claimants(s)] [Notary] [Date] APPENDIX Wording of Financial Assurance Instruments Form 11—General Purpose Local Government Bond Rating Test The following text should be used to comply with the requirements of 10 CSR 20-11.112(4) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Letter from Chief Financial Officer I am the chief financial officer of [insert: name and address of local government owner or operator, or guarantor]. This letter is in support of the use of the bond rating test to demonstrate financial responsibility for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage”] caused by [insert: “sudden accidental releases” and/or “nonsudden accidental releases”] in the amount of at least [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate arising from operating (an) underground storage tank(s). Underground storage tanks at the following facilities are assured by this bond rating test: [List for each facility: the name and address of the facility where tanks are assured by the bond rating test]. The details of the issue date, maturity, outstanding amount, bond rating, and bond rating agency of all outstanding bond issues that are being used by [name of local government owner or operator, or guarantor] to demonstrate financial responsibility are as follows: [complete table] Issue Date Maturity Date Outstanding Amount Bond Rating Rating Agency [Moody’s or Standard & Poor’s] The total outstanding obligation of [insert amount], excluding refunded bond issues, exceeds the minimum amount of one (1) million dollars. All outstanding general obligation bonds issued by this government that have been rated by Moody’s or Standard & Poor’s are rated as at least investment grade (Moody’s Baa or Standard & Poor’s BBB) based on the most recent ratings published within the last twelve (12) months. Neither rating service has provided notification within the last twelve (12) months of downgrading of bond ratings below investment grade or of withdrawal of bond rating other than for repayment of outstanding bond issues. I hereby certify that the wording of this letter is identical to the wording specified in 10 CSR 20-11.112(4) as the regulations were constituted on the date shown immediately below. [Signature] [Name] [Title] [Date] APPENDIX Form 12—Local Government Bond Rating Test The following text should be used to comply with the requirements of 10 CSR 20-11.112(5) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Letter from Chief Financial Officer I am the chief financial officer of [insert: name and address of local government owner or operator, or guarantor]. This letter is in support of the use of the bond rating test to demonstrate financial responsibility for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage”] caused by [insert: “sudden accidental releases” and/or “nonsudden accidental releases”] in the amount of at least [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate arising from operating (an) underground storage tank(s). This local government is not organized to provide general governmental services and does not have the legal authority under state law or constitutional provisions to issue general obligation debt. Underground storage tanks at the following facilities are assured by this bond rating test: [List for each facility: the name and address of the facility where tanks are assured by the bond rating test]. The details of the issue date, maturity, outstanding amount, bond rating, and bond rating agency of all outstanding revenue bond issues that are being used by [name of local government owner or operator, or guarantor] to demonstrate financial responsibility are as follows: [complete table]. Issue Date Maturity Date Outstanding Amount Bond Rating Rating Agency [Moody’s or Standard & Poor’s] The total outstanding obligation of [insert amount], excluding refunded bond issues, exceeds the minimum amount of one (1) million dollars. All outstanding revenue bonds issued by this government that have been rated by Moody’s or Standard & Poor’s are rated as at least investment grade (Moody’s Baa or Standard & Poor’s BBB) based on the most recent ratings published within the last twelve (12) months. The revenue bonds listed are not backed by third-party credit enhancement or are insured by a municipal bond insurance company. Neither rating service has provided notification within the last twelve (12) months of downgrading of bond ratings below investment grade or of withdrawal of bond rating other than for repayment of outstanding bond issues. I hereby certify that the wording of this letter is identical to the wording specified in 10 CSR 20-11.112(5) as the regulations were constituted on the date shown immediately below. [Signature] [Name] [Title] [Date] APPENDIX Form 13—Local Government Financial Test The following text should be used to comply with the requirements of 10 CSR 20-11.113(3) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Letter from Chief Financial Officer I am the chief financial officer of [insert: name and address of the owner or operator]. This letter is in support of the use of the local government financial test to demonstrate financial responsibility for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage”] caused by [insert: “sudden accidental releases” and/or “nonsudden accidental releases”] in the amount of at least [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate arising from operating (an) underground storage tank(s). Underground storage tanks at the following facilities are assured by this financial test [List for each facility: the name and address of the facility where tanks assured by this financial test are located. If separate mechanisms or combinations of mechanisms are being used to assure any of the tanks at this facility, list each tank assured by this financial test by the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10.022]. This owner or operator has not received an adverse opinion, or a disclaimer of opinion from an independent auditor on its financial statements for the latest completed fiscal year. Any outstanding issues of general obligation or revenue bonds, if rated, have a Moody’s rating of Aaa, Aa, A, or Baa or a Standard and Poor’s rating of AAA, AA, A, or BBB; if rated by both firms, the bonds have a Moody’s rating of Aaa, Aa, A, or Baa and a Standard and Poor’s rating of AAA, AA, A, or BBB. WORKSHEET FOR MUNICIPAL FINANCIAL TEST Part I: Basic Information 1. Total Revenues a. Revenues (dollars) Value of revenues excludes liquidation of investments and issuance of debt. Value includes all general fund operating and nonoperating revenues, as well as all revenues from all other governmental funds including enterprise, debt service, capital projects, and special revenues, but excluding revenues to funds held in a trust or agency capacity. b. Subtract interfund transfers (dollars) c. Total Revenues (dollars) 2. Total Expenditures a. Expenditures (dollars) Value consists of the sum of general fund operating and nonoperating expenditures including interest payments on debt, payments for retire- ment of debt principal, and total expenditures from all other governmental funds including enterprise, debt service, capital projects, and special revenues. b. Subtract interfund transfers (dollars) c. Total Expenditures (dollars) 3. Local Revenues a. Total Revenues (from 1c) (dollars) b. Subtract total intergovernmental transfers (dollars) c. Local Revenues (dollars) 4. Debt Service a. Interest and fiscal charges (dollars) b. Add debt retirement (dollars) c. Total Debt Service (dollars) 5. Total Funds (dollars) (Sum of amounts held as cash and investment securities from all funds, excluding amounts held for employee retirement funds, agency funds, and trust funds) 6. Population (persons) Part II: Application of Test 7. Total Revenues to Population a. Total Revenues (from 1c) b. Population (from 6) c. Divide 7a by 7b d. Subtract 417 e. Divide by 5.212 f. Multiply by 4.095 8. Total Expenses to Population a. Total Expenses (from 2c) b. Population (from 6) c. Divide 8a by 8b d. Subtract 524 e. Divide by 5401 f. Multiply by 4.095 9. Local Revenues to Total Revenues a. Local Revenues (from 3c) b. Total Revenues (from 1c) c. Divide 9a by 9b d. Subtract .695 e. Divide by .205 f. Multiply by 2.840 10. Debt Services to Population a. Debt Service (from 4d) b. Population (from 6) c. Divide 10a by 10b d. Subtract 51 e. Divide by 1038 f. Multiply by -1.866 11. Debt Service to Total Revenues a. Debt Service (from 4d) b. Total Revenues (from 1c) c. Divide 11a by 11b d. Subtract .068 e. Divide by .259 f. Multiply by -3.533 12. Total Revenues to Total Expenses a. Total Revenues (from 1c) b. Total Expenses (from 2c) c. Divide 12a by 12b d. Subtract .910 e. Divide by .899 f. Multiply by 3.458 13. Funds Balance to Total Revenues a. Total Funds (from 5) b. Total Revenues (from 1c) c. Divide 13a by 13b d. Subtract .891 e. Divide by 9.156 f. Multiply by 3.270 14. Funds Balance to Total Expenses a. Total Funds (from 5) b. Total Expenses (from 2c) c. Divide 14a by 14b d. Subtract .866 e. Divide by 6.409 f. Multiply by 3.270 15. Total Funds to Population a. Total Funds (from 5) b. Population (from 6) c. Divide 15a by 15b d. Subtract 270 e. Divide by 4548 f. Multiply by 1.866 16. Add 7f + 8f + 9f + 10f + 11f + 12f + 13f + 14f + 15f + 4.937 I hereby certify that the financial index shown on line 16 of the worksheet is greater than zero and that the wording of this letter is identical to the wording specified in 10 CSR 20-11.113(3) as the regulations were constituted on the date shown immediately below. [Signature] [Name] [Title] [Date] APPENDIX Form 14—Local Government Guarantee With Standby Trust Made by a State The following text should be used to comply with the requirements of 10 CSR 20-11.114(4) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Local Government Guarantee With Standby Trust Made by a State Guarantee made this [date] by [name of state], herein referred to as guarantor, to [the state implementing agency] and to any and all third parties, and obligees, on behalf of [local government owner or operator]. Recitals 1. Guarantor is the state. 2. [Local government owner or operator] owns or operates the following underground storage tank(s) covered by this guarantee: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10 and 11, and the name and address of the facility]. This guarantee satisfies 10 CSR 20- 11.090–10 CSR 20-11.115 requirements for assuring funding for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases”; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the above-identified underground storage tank(s) in the amount of [insert dollar amount] per occurrence and [insert dollar amount] annual aggregate. 3. Guarantor guarantees to [implementing agency] and to any and all third parties that: In the event that [local government owner or operator] fails to provide alternative coverage within sixty (60) days after receipt of a notice of cancellation of this guarantee and the [director of the implementing agency] has determined or suspects that a release has occurred at an underground storage tank covered by this guarantee, the guarantor, upon instructions from the [director] shall fund a standby trust fund in accordance with the provisions of 10 CSR 20-11.108, in an amount not to exceed the coverage limits specified above. In the event that the [director] determines that [local government owner or operator] has failed to perform corrective action for releases arising out of the operation of the above-identified tank(s) in accordance with 10 CSR 20-10.060–10 CSR 20-10.067, the guarantor upon written instructions from the [director] shall fund a standby trust fund in accordance with the provisions of 10 CSR 20-11.108, in an amount not to exceed the coverage limits specified above. If [owner or operator] fails to satisfy a judgment or award based on a determination of liability for bodily injury or property damage to third parties caused by [“sudden” and/or “nonsudden”] accidental releases arising from the operation of the above-identified tank(s), or fails to pay an amount agreed to in settlement of a claim arising from or alleged to arise from the injury or damage, the guarantor, upon written instructions from the [director], shall fund a standby trust in accordance with the provisions of 10 CSR 20-11.108 to satisfy the judgment(s), award(s), or settlement agreement(s) up to the limits of coverage specified above. 4. Guarantor agrees to notify [owner or operator] by certified mail of a voluntary or involuntary proceeding under Title 11 (Bankruptcy), United States Code naming guarantor as debtor, within ten (10) days after commencement of the proceeding. 5. Guarantor agrees to remain bound under this guarantee notwithstanding any modification or alteration of any obligation of [owner or operator] pursuant to 10 CSR 20-10 and 11. 6. Guarantor agrees to remain bound under this guarantee for so long as [local government owner or operator] must comply with the applicable financial responsibility requirements of 10 CSR 20-11.090–10 CSR 20-11.115 for the above-identified tank(s), except that guarantor may cancel this guarantee by sending notice by certified mail to [owner or operator], the cancellation to become effective no earlier than one hundred twenty (120) days after receipt of the notice by [owner or operator], as evidenced by the return receipt. 7. The guarantor’s obligation does not apply to any of the following: A. Any obligation of [local government owner or operator] under a Workers’ Compensation, disability benefits, or unemployment compensation law or other similar law; B. Bodily injury to an employee of [insert: local government owner or operator] arising from, and in the course of, employment by [insert: local government owner or operator]; C. Bodily injury or property damage arising from the ownership, maintenance, use, or entrustment to others of any aircraft, motor vehicle, or watercraft; D. Property damage to any property owned, rented, loaded to, in the care, custody, or control of, or occupied by [insert: local government owner or operator] that is not the direct result of a release from a petroleum underground storage tank; E. Bodily injury or property damage for which [insert owner or operator] is obligated to pay damages by reason of the assumption of liability in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. 8. Guarantor expressly waives notice of acceptance of this guarantee by [the implementing agency], by any or all third parties, or by [local government owner or operator]. I hereby certify that the wording of this guarantee is identical to the wording specified in 10 CSR 20-11.114(4) as the rules were constitut- ed on the effective date shown immediately below. Effective date: [Name of guarantor] [Authorized signature for guarantor] [Name of person signing] [Title of person signing] Signature of witness or notary: APPENDIX Form 15—Local Government Guarantee With Standby Trust Made by a Local Government The following text should be used to comply with the requirements of 10 CSR 20-11.114(5) as follows, except that the instructions in brack- ets are to be replaced by the relevant information and the brackets deleted: Local Government Guarantee With Standby Trust Made By a Local Government Guarantee made this [date] by [name of guaranteeing entity], a local government organized under the laws of [name of state], herein referred to as guarantor, to [the state implementing agency] and to any and all third parties, and obligees, on behalf of [local government owner or operator]. Recitals 1. Guarantor meets or exceeds [select one: the local government bond rating test requirements of 10 CSR 20-11.112, the local government financial test requirements of 10 CSR 20-11.113, or the local government fund under 10 CSR 20-11.115(1)(A), (B), or (C)]. 2. [Local government owner or operator] owns or operates the following underground storage tank(s) covered by this guarantee: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10 and 11, and the name and address of the facility]. This guarantee satisfies 10 CSR 20- 11.090–10 CSR 20-11.115 requirements for assuring funding for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases;” if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the above-identified underground storage tank(s) in the amount of [insert dollar amount] per occurrence and [insert: dollar amount] annual aggregate. 3. Incident to our substantial governmental relationship with [local government owner or operator], guarantor guarantees to [implementing agency] and to any and all third parties that: In the event that [local government owner or operator] fails to provide alternative coverage within sixty (60) days after receipt of a notice of cancellation of this guarantee and [the director of the implementing agency] has determined or suspects that a release has occurred at an underground storage tank covered by this guarantee, the guarantor, upon instructions from [the director] shall fund a standby trust fund in accordance with the provisions of 10 CSR 20-11.108, in an amount not to exceed the coverage limits specified above. In the event that [the director] determines that [local government owner or operator] has failed to perform corrective action for releases arising out of the operation of the above-identified tank(s) in accordance with 10 CSR 20-10.060–10 CSR 20-10.067, the guarantor upon written instructions from [the director] shall fund a standby trust fund in accordance with the provisions of 10 CSR 20-11.108, in an amount not to exceed the coverage limits specified above. If [owner or operator] fails to satisfy a judgment or award based on a determination of liability for bodily injury or property damage to third parties caused by [“sudden” and/or “nonsudden”] accidental releases arising from the operation of the above-identified tank(s), or fails to pay an amount agreed to in settlement of a claim arising from or alleged to arise from the injury or damage, the guarantor, upon written instructions from [the director], shall fund a standby trust in accordance with the provisions of 10 CSR 20-11.108 to satisfy the judgment(s), award(s), or settlement agreement(s) up to the limits of coverage specified above. 4. Guarantor agrees that, if at the end of any fiscal year before cancellation of this guarantee, the guarantor fails to meet or exceed the requirements of the financial responsibility mechanism specified in paragraph (4)(B)1., guarantor shall send within one hundred twenty (120) days of the failure, by certified mail, notice to [local government owner or operator], as evidenced by the return receipt. 5. Guarantor agrees to notify [owner or operator] by certified mail of a voluntary or involuntary proceeding under Title 11 (Bankruptcy), United States Code naming guarantor as debtor, within ten (10) days after commencement of the proceeding. 6. Guarantor agrees to remain bound under this guarantee notwithstanding any modification or alteration of any obligation of [owner or operator] pursuant to 10 CSR 20-10 and 11. 7. Guarantor agrees to remain bound under this guarantee for so long as [local government owner or operator] must comply with the applicable financial responsibility requirements of 10 CSR 20-11.090–10 CSR 20-11.115 for the above-identified tank(s), except that guarantor may cancel this guarantee by sending notice by certified mail to [owner or operator], the cancellation to become effective no earlier than one hundred twenty (120) days after receipt of the notice by [owner or operator], as evidenced by the return receipt. 8. The guarantor’s obligation does not apply to any of the following: A. Any obligation of [local government owner or operator] under a Workers’ Compensation, disability benefits, or unemployment com- pensation law or other similar law; B. Bodily injury to an employee of [insert: local government owner or operator] arising from, and in the course of, employment by [insert: local government owner or operator]; C. Bodily injury or property damage arising from the ownership, maintenance, use or entrustment to others of any aircraft, motor vehi- cle or watercraft; D. Property damage to any property owned, rented, loaned to, in the care, custody, or control of, or occupied by [insert: local govern- ment owner or operator] that is not the direct result of a release from a petroleum underground storage tank; E. Bodily injury or property damage for which [insert: owner or operator] is obligated to pay damages by reason of the assumption of liability in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. 9. Guarantor expressly waives notice of acceptance of this guarantee by [the implementing agency], by any or all third parties, or by [local government owner or operator]. I hereby certify that the wording of this guarantee is identical to the wording specified in 10 CSR 20-11.114(5) as the rules were constituted on the effective date shown immediately below. Effective date: [Name of guarantor] [Authorized signature for guarantor] [Name of person signing] [Title of person signing] Signature of witness or notary: APPENDIX Form 16—Local Government Guarantee Without Standby Trust Made by a State The following text should be used to comply with the requirements of 10 CSR 20-11.114(6) as follows, except that instructions in brackets are to be replaced with relevant information and the brackets deleted: Local Government Guarantee Without Standby Trust Made by a State Guarantee made this [date] by [name of state], herein referred to as guarantor, to [the state implementing agency] and to any and all third parties, and obligees, on behalf of [local government owner or operator]. Recitals 1. Guarantor is the state. 2. [Local government owner or operator] owns or operates the following underground storage tank(s) covered by this guarantee: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10 and 11, and the name and address of the facility.]. This guarantee satisfies 10 CSR 20- 11.090–10 CSR 20-11.115 requirements for assuring funding for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases;” if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the above-identified underground storage tank(s) in the amount of [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate. 3. Guarantor guarantees to [implementing agency] and to any and all third parties and obligees that: In the event that [local government owner or operator] fails to provide alternative coverage within sixty (60) days after receipt of a notice of cancellation of this guarantee and the [director of the implementing agency] has determined or suspects that a release has occurred at an underground storage tank covered by this guarantee, the guarantor, upon written instructions from [the director] shall make funds available to pay for corrective actions and compensate third parties for bodily injury and property damage in an amount not to exceed the coverage limits specified above. In the event that [the director] determines that [local government owner or operator] has failed to perform corrective action for releases arising out of the operation of above-identified tank(s) in accordance with 10 CS0-10.060–10 CSR 20-10.067, the guarantor upon written instructions from [the director] shall make funds available to pay for corrective actions in an amount not exceed the coverage limits specified above. If [owner or operator] fails to satisfy a judgment or award based on a determination of liability for bodily injury or property damage to third parties caused by [“sudden” and/or “nonsudden” accidental releases arising from the operation of the above-identified tank(s), or fails to pay an amount agreed to in settlement of a claim arising from or alleged to arise from the injury or damage, the guarantor, upon written instructions from [the director], shall make funds available to compensate third parties for bodily injury and property damage in an amount not to exceed the coverage limits specified above. 4. Guarantor agrees to notify [owner or operator] by certified mail of a voluntary or involuntary proceeding under Title 11 (Bankruptcy), United States Code naming guarantor as debtor, within ten (10) days after commencement of the proceeding. 5. Guarantor agrees to remain bound under this guarantee notwithstanding any modification or alteration of any obligation of [owner or operator] pursuant to 10 CSR 20-10 and 11. 6. Guarantor agrees to remain bound under this guarantee for so long as [local government owner or operator] must comply with the applicable financial responsibility requirements of 10 CSR 20-11.090–10 CSR 20-11.115 for the above-identified tank(s), except that guarantor may cancel this guarantee by sending notice by certified mail to [owner or operator], the cancellation to become effective no earlier than one hundred twenty (120) days after receipt of the notice by [owner or operator], as evidenced by the return receipt. If notified of a probable release, the guarantor agrees to remain bound to the terms of this guarantee for all charges arising from the release, up to the coverage limits specified above, notwithstanding the cancellation of the guarantee with respect to future releases. 7. The guarantor’s obligation does not apply to any of the following: A. Any obligation of [local government owner or operator] under a workers’ compensation disability benefits, or unemployment com- pensation law or other similar law; B. Bodily injury to an employee of [insert local government owner or operator] arising from, and in the course of, employment by [insert: local government owner or operator]; C. Bodily injury or property damage arising from the ownership, maintenance, use, or entrustment to others of any aircraft, motor vehi- cle or watercraft; D. Property damage to any property owned, rented, loaned to, in the care, custody, or control of, or occupied by [insert: local govern- ment owner or operator] that is not the direct result of a release from a petroleum underground storage tank; E. Bodily injury or property damage for which [insert: owner or operator] is obligated to pay damages by reason of the assumption of liability in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. 8. Guarantor expressly waives notice of acceptance of this guarantee by [the implementing agency], by any or all third parties, or by [local government owner or operator]. I hereby certify that the wording of this guarantee is identical to the wording specified in 10 CSR 20-11.114(6) as the regulations were constituted on the effective date shown immediately below. Effective date: [Name of guarantor] [Authorized signature for guarantor] [Name of person signing] [Title of person signing] Signature of witness or notary: APPENDIX Form 17—Local Government Guarantee Without Standby Trust Made by a Local Government The following text should be used to comply with the requirements of 10 CSR 20-11.114(7) as follows, except that instructions in brackets are to be replaced with relevant information and the brackets deleted: Local Government Guarantee Without Standby Trust Made by a Local Government Guarantee made this [date] by [name of guaranteeing entity], a local government organized under the laws of [name of state], herein referred to as guarantor, to [the state implementing agency] and to any and all third parties, and obligees, on behalf of [local government owner or operator]. Recitals 1. Guarantor meets or exceeds [select one: the local government bond rating test requirements of 10 CSR 20-11.112, the local government financial test requirements of 10 CSR 20-11.113, the local government fund under 10 CSR 20-11.115(1)(A), (B) or (C)]. 2. [Local government owner or operator] owns or operates the following underground storage tank(s) covered by this guarantee: [List the number of tanks at each facility and the name(s) and address(es) of the facility(ies) where the tanks are located. If more than one instrument is used to assure different tanks at any one facility, for each tank covered by this instrument, list the tank identification number provided in the notification submitted pursuant to 10 CSR 20-10 and 11, and the name and address of the facility.] This guarantee satisfies 10 CSR 20- 11.090–10 CSR 20-11.115 requirements for assuring funding for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage caused by” either “sudden accidental releases” or “nonsudden accidental releases” or “accidental releases”; if coverage is different for different tanks or locations, indicate the type of coverage applicable to each tank or location] arising from operating the above-identified underground storage tank(s) in the amount of [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate. 3. Incident to our substantial governmental relationship with [local government owner or operator], guarantor guarantees to [implementing agency] and to any and all third parties and obligees that: In the event that [local government owner or operator] fails to provide alternative coverage within sixty (60) days after receipt of a notice of cancellation of this guarantee and the [director of the implementing agency] has determined or suspects that a release has occurred at an underground storage tank covered by this guarantee, the guarantor, upon written instructions from [the director] shall make funds available to pay for corrective actions and compensate third parties for bodily injury and property damage in an amount not to exceed the coverage limits specified above. In the event that [the director] determines that [local government owner or operator] has failed to perform corrective action for releases arising out of the operation of the above-identified tank(s) in accordance with 10 CSR 20-10.060–10 CSR 20-10.067, the guarantor upon written instructions from [the director] shall make funds available to pay for corrective actions in an amount not to exceed the coverage limits specified above. If [owner or operator] fails to satisfy a judgment or award based on a determination of liability for bodily injury or property damage to third parties caused by [“sudden” and/or “nonsudden”] accidental releases arising from the operation of the above-identified tank(s), or fails to pay an amount agreed to in settlement of a claim arising from or alleged to arise from the injury or damage, the guarantor, upon written instructions from [the director], shall make funds available to compensate third parties for bodily injury and property damage in an amount not to exceed the coverage limits specified above. 4. Guarantor agrees that if at the end of any fiscal year before cancellation of this guarantee, the guarantor fails to meet or exceed the requirements of the financial responsibility mechanism specified in paragraph (5)(B)1., guarantor shall send within one hundred twenty (120) days of the failure, by certified mail, notice to [local government owner or operator], as evidenced by the return receipt. 5. Guarantor agrees to notify [owner or operator] by certified mail of a voluntary or involuntary proceeding under Title 11 (Bankruptcy), United States Code naming guarantor as debtor, within ten (10) days after commencement of the proceeding. 6. Guarantor agrees to remain bound under this guarantee notwithstanding any modification or alteration of any obligation of [owner or operator] pursuant to 10 CSR 20-10 and 11. 7. Guarantor agrees to remain bound under this guarantee for so long as [local government owner or operator] must comply with the applicable financial responsibility requirements of 10 CSR 20-11.090–10 CSR 20-11.115 for the above-identified tank(s), except that guarantor may cancel this guarantee by sending notice by certified mail to [owner or operator], the cancellation to become effective no earlier than one hundred twenty (120) days after receipt of the notice by [owner or operator], as evidenced by the return receipt. If notified of a probable release, the guarantor agrees to remain bound to the terms of this guarantee for all charges arising from the release, up to the coverage limits specified above, notwithstanding the cancellation of the guarantee with respect to future releases. 8. The guarantor’s obligation does not apply to any of the following: A. Any obligation of [local government owner or operator] under a workers’ compensation disability benefits, or unemployment com- pensation law or other similar law; B. Bodily injury to an employee of [insert: local government owner or operator] arising from, and in the course of, employment by [insert: local government owner or operator]; C. Bodily injury or property damage arising from the ownership, maintenance, use, or entrustment to others of any aircraft, motor vehi- cle or watercraft; D. Property damage to any property owned, rented, loaned to, in the care, custody, or control of, or occupied by [insert: local government owner or operator] that is not the direct result of a release from a petroleum underground storage tank; E. Bodily injury or property damage for which [insert: owner or operator] is obligated to pay damages by reason of the assumption of liability in a contract or agreement other than a contract or agreement entered into to meet the requirements of 10 CSR 20-11.093. 9. Guarantor expressly waives notice of acceptance of this guarantee by [the implementing agency], by any or all third parties, or by [local government owner or operator]. I hereby certify that the wording of this guarantee is identical to the wording specified in 10 CSR 20-11.114(7) as the regulations were constituted on the effective date shown immediately below. Effective date: [Name of guarantor] [Authorized signature for guarantor] [Name of person signing] [Title of person signing] Signature of witness or notary: APPENDIX Form 18—Local Government Fund The following text should be used to comply with the requirements of 10 CSR 20-11.115(1)(D) as follows, except that the instructions in brackets are to be replaced by the relevant information and the brackets deleted: Letter from Chief Financial Officer I am the chief financial officer of [insert: name and address of local government owner or operator, or guarantor]. This letter is in support of the use of the local government fund mechanism to demonstrate financial responsibility for [insert: “taking corrective action” and/or “compensating third parties for bodily injury and property damage”] caused by [insert: “sudden accidental releases” and/or “nonsudden accidental releases”] in the amount of at least [insert: dollar amount] per occurrence and [insert: dollar amount] annual aggregate arising from operating (an) underground storage tank(s). Underground storage tanks at the following facilities are assured by this local government fund mechanism: [List for each facility: the name and address of the facility where tanks are assured by the local government fund]. [Insert: “The local government fund is funded for the full amount of coverage required under 10 CSR 20-11.093, or funded for part of the required amount of coverage and used in combination with other mechanisms that provide the remaining coverage,” or “The local government fund is funded for ten (10) times the full amount of coverage required under 10 CSR 20-11.093, or funded for part of the required amount of coverage and used in combination with other mechanisms that provide the remaining coverage,” or “A payment is made to the fund once every year for seven (7) years until the fund is fully-funded] and [name of local government owner or operator] has [available bonding authority, approved through voter referendum, of an amount equal to the difference between the required amount of coverage and the amount held in the dedicated fund” or “A payment is made to the fund once every year for seven (7) years until the fund is fully-funded and I have attached a letter signed by the state attorney general stating that 1) the use of the bonding authority will not increase the local government’s debt beyond the legal debt ceilings established by the relevant state laws and 2) that prior voter approval is not necessary before use of the bonding authority”]. The details of the local government fund are as follows: Amount in Fund (market value of fund of close of last fiscal year): [If fund balance is incrementally funded as specified in 10 CSR 20-11.107(1)(C), insert: Amount added to fund in the most recently completed fiscal year: Number of years remaining in the pay-in period:] A copy of the state constitutional provision, or local government statute, charter, ordinance or order dedicating the fund is attached. I hereby certify that the wording of this letter is identical to the wording specified in 10 CSR 20-11.115(1)(D) as the regulations were constituted on the date shown immediately below. [Signature] [Name] [Title] [Date]