Claim Application Forms

These forms are necessary for completion of the claim application package.

• Form 1 Reimbursement Application
  • This form requests background information about claimant, site, insurance, financial responsibility, and cost. It also requires certifications from the claimant and consultant performing the work. This form must be filled out with each application for reimbursement. 
• Form 2 Payment Assignment Form
  • This form is used when a responsible person wishes to assign the proceeds of an application to another party. This form is most commonly used to assign payment from the claimant to the consultant they have hired to perform the work. The assignment form must be signed and notarized for each application. 
    Any check issued as a result of the reimbursement application will be issued to the assignee and mailed to the assignee's address.
• Form 3 Multiple Owners Payment Assignment Form
  • When there are multiple responsible persons (owner/operators), only one person may claim the costs submitted for the cleanup. The remaining claimants must assign the right to reimbursement over to this single claimant. Each claimant must fill out and submit a separate signed and notarized Form 3 with the first application.
• Department of Accounts Electronic Payment Forms - Descriptions for these forms are provided in the guide below and on the Department of Accounts webpage.
• Department of Accounts Electronic Data Interchange (EDI) Guide - The EDI allows for direct deposit of reimbursement funds to a bank account.
• COV Substitute W-9 - This form must be filled out and submitted with the first application for each site by the responsible person.
• Reconsideration Claim Worksheet - Use this form to contest a claim for reconsideration. Refer to Volume V of the Reimbursement Manual for information on the reconsideration process.

Calculation Tools and FAQs

These items are worksheets and guides to assist claimants and consultants with completing the claim application and claiming costs. The FAQs answer some common questions about the reimbursement process

Calculation Tools

• 2022 UCR Schedule Excel Format - This document provides the 2022 schedule UCR codes  in Excel format as a reference for filtering, searching, and export.
• 2022 Lab/Soil Cost Aid - This tool determines a reasonable reimbursement rate for laboratory analyses that exceed the applicable usual and customary rate (2022 Schedule).
• 2019 Lab/Soil Cost Aid - This tool determines a reasonable reimbursement rate for laboratory analyses that exceed the applicable usual and customary rate (2019 Schedule).
• Soil Hauling Calculation Tool - (NEW FOR 2022 SCHEDULE) This tool assists claimants and consultants with determining the correct codes to claim for hauling soil for disposal based on mileage and volume.
• Fuel Surcharge Worksheet - (NEW FOR 2022 SCHEDULE) This tool determines a reimbursable amount for fuel surcharges based on benchmark fuel prices gathered and maintained by the U.S. Energy Information Administration.

FAQs

• Claim Application FAQ - This FAQ answers questions about submitting claim applications by paper and electronically.
• Invoice Redaction FAQ - This FAQ answers questions about which invoices may have redacted information, and what information may be redacted.
• 2022 UCR Training - PDF slides from 2022 UCR Schedule Training

2022 Schedule Documents

These documents are required to complete claim applications for corrective action phases begun on or after October 1, 2022. 

2022 Schedule Templates

• 2022 AAF Template (November 2024) - Complete this electronic Activity Authorization Form to request pre-approval for work required to perform corrective action. 
• 2022 Cost Worksheet (November 2024) - Complete this worksheet to link items listed on the AAF to invoices or other cost documentation. 
• NOTE: Crossover guides from the 2019 Schedule remain in effect, since code numbers did not change from 2019 to 2022. These documents are posted with 2019 Schedule Documents.

2022 Bidding Forms

• Bid Summary Form - Use this form to assign bids for each scope of work as described in the Reimbursement Manual.
  • Lump Sum Bid Comparison Form
  • Unit Price Bid Comparison Form 
    Use the Lump Sum and Unit Price Bid Comparison Forms to establish Lump Sum and Unit Rate codes for bid items as described in the Reimbursement Manual.

2019 Schedule Documents

These documents are required to complete claim applications for corrective action phases begun on or after August 1, 2019. 

2019 Schedule Templates and Crosswalks

• 2019 eAAF Template - Complete this electronic Activity Authorization Form to request pre-approval for work required to perform corrective action. 
• 2019 Cost Worksheet - Complete this worksheet to link items listed on the AAF to invoices or other cost documentation. 
• UCR Crosswalk from 007 to 2019 - This document is a crosswalk of all material and task codes (numbers and rates) from the 007 schedule to the 2019 schedule.
• Category 1 Typical Work Authorization (007 to 2019 Crosswalk) 
• Category 2 Typical Work Authorization (007 to 2019 Crosswalk)
  • These documents are templates for typical Category 1 and Category 2 Work Authorizations, updated from the 007 schedule to the 2019 schedule.

2019 Bidding Forms

• Bid Summary Form - Use this form to assign bids for each scope of work as described in the Reimbursement Manual.
  • Lump Sum Bid Comparison Form
  • Unit Price Bid Comparison Form 
    Use the Lump Sum and Unit Price Bid Comparison Forms to establish Lump Sum and Unit Rate codes for bid items as described in the Reimbursement Manual.