OFFICE USE ONLY

 Claim No. ____________

New Jersey Department of Environmental Protection
Environmental Claims Administration

SANITARY LANDFILL FACILITY CLOSURE AND CONTINGENCY FUND ACT
N.J.S.A. 13:1E-100 et seq and N.J.A.C. 7:1I

DAMAGE CLAIM

PLEASE NOTE:	The filing of this claim form is not to be construed that the claimant is entitled to receive compensation.  	The Department must conduct a complete review of the claim before a determination is made regarding 	compensability.

SECTION A:  GENERAL INFORMATION AND INSTRUCTIONS

1.	This claim must be based on damages proximately resulting from the improper operation or improper closure of a 	sanitary landfill.

2.	The claim must be filed on this official form not later than one year after the date of discovery of the damages. 

3.	The claim shall be mailed by certified mail, return receipt requested, or delivered by hand to:

	a.	N.J. Department of Environmental Protection
		Environmental Claims Administration
		P.O. Box 413
		Trenton, New Jersey 08625-0413
		(609) 777-0101

	b.	the owner and/or operator of the sanitary landfill and/or
	c.	any other responsible persons the claimant alleges to have caused the damage.

4.	The claim shall be signed by the claimant. Where the claimant is a minor or incompetent, as defined under New 	Jersey 	Law, or is deceased, the claim may be signed by the claimant's parent, guardian, executor, or court-appointed 	representative, as the case may be.

5.	Pursuant to N.J.A.C. 7:1I-2.1, no claim by a subrogee or assignee may be filed with or processed by the 	Department.

6.	Since the claim may be denied, or only a portion thereof may be compensated, the claimant may wish to file a civil action 	in an appropriate court to preserve his legal rights in this matter due to statutes of limitations and other restrictions 	provided by law.

7.	All information must be typewritten or printed legible in black ink. Each question or section must be completed in 	full or 	marked as not applicable. Responses requiring additional space may be continued on a separate piece of 8 1/2 x 11 	paper. Information on supplemental sheets of paper should be positively identifiable, using the appropriate form section 	letters and question numbers.

8.	Copies of all requested and applicable documents, if obtainable, must be attached to this claim. If unobtainable at this 	time, they must be submitted within the time period determined by the DEP.

	All documents submitted with this claim will be retained by the DEP and may be used in subsequent subrogation 	actions.

9.	All damages must be stated in their entirety in a single claim. Provide any other information on the losses which the 	claimant considers pertinent to the processing of the claim.

SECTION B:  PRIORITY

1.	Should your claim be granted priority in payment?    ____ Yes     ____ No

2.	State in writing the specific reasons why your claim should be accorded priority: ___________________________
	___________________________________________________________________________________________

SECTION C:  BACKGROUND INFORMATION

1.	________________________________	_______________________	_______________
	Claimant's Last Name	First	Middle

2.	____________________	__________________________
	Date of Birth	Social Security Number

3.	Claimant is:	____ individual	____ unit of local government	____ individual business
			____ partnership	____ unit of state government
			____ corporation

	If a partnership, corporation or state agency, provide full legal name, state of principal office, and Federal I.D. No.

	__________________________________________________________________________________________

	_______________________________	____________________________________

4.	Claimant's Permanent Address: ________________________________________________________________

	a.	Phone Number:  (Day) _______________________   (Evenings) ______________________

5.	Claimant's Mailing Address  (If different than Permanent Address)

	__________________________________________________________________________________________

6.	a.	If claimant is a partnership, list the name and address of general partners on a separate sheet and attach 		hereto. If claimant is a corporation, list name and address of directors and principal officers and state of 		incorporation on a separate sheet and attach hereto. If claimant is a foreign corporation, is it registered with the N.J. 	Secretary of State to do business in New Jersey?	____ Yes    ____ No

	b.	This claim is based on damages proximately resulting from the operations or closure of a sanitary landfill. 				Check the type of losses for which the claimant is seeking reimbursement from the fund.

		____ Real Property	____ Business Income	____ Loss of Life
		____ Personal Property	____ Personal Income	____ Other (Specify)
		____ Natural Resource(s)	____ Person Injury or Illness		_____________________

7.	If the claim is prepared and signed by someone other than the claimant pursuant to N.J.A.C. 7:1I-1.7(a)5, provide:

	a.	________________________________________	c.	______________________________________
		Name				Relationship of Claimant

	b.	________________________________________	d.	______________________________________
		Title				Address

					e.	______________________________________
						Phone

8.	Location at which the damage occurred.

	_________________________	___________________________________________________________
	Municipality		Exact Location of the Occurrence, if any (include street address and the 						lot and block number)

				___________________________________________________________

9.	Set forth in detail:  (a) When the damages for which this claim is filed occurred,  (b) When and how you first 	discovered these damages, and  (c) When and how you discovered their connection to the landfill facility.
	(Specify date or period of time.)  Attach explanation if necessary.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

10.	Describe the circumstances under which the losses occurred and how they were discovered. If a diagram or map 	will 	assist your explanation, please provide same as an attachment.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

11.	Did you know of the existence of the sanitary landfill facility and did not know, nor reasonably could have known, of 	the 	potential that property value diminution could result by virtue of purchasing the property near the particular sanitary landfill 	facility in question?     ____ Yes     ____ No

12.	If you are claiming for property value diminution, are you attempting to sell the subject property? ____Yes   ____No

13.	If the claimant is a limited partnership, list the names and addresses of all general partners.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

14.	If the claimant is a general partnership, list the names and addresses of all partners.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

15.	If the claimant is a corporation, list the names and addresses of all directors and of all officers.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

16.	Indicate any other information which the claimant believes to be relevant to the claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

17.	Indicate any other information which the Department deems necessary to process the claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

SECTION D:  LIABILITY

1.	Set forth the name, address, municipality and county of the sanitary landfill you claim to be responsible for the 	loss.  	Also list the names and addresses of the owner/operators, if known. (If owner/operator is unknown include any information 	that might assist in their identification and location.)
	
	___________________________________________________________________________________________
	___________________________________________________________________________________________

2.	Describe in detail the basis upon which it is believed that the sanitary landfill listed above is responsible for any losses you may have suffered.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

3.	Has anyone admitted liability for any of the losses set forth by you in this claim? If so, please indicate when, where, by whom, in what amount, and, if in writing, attach a copy.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

4.	Have you received or agreed to receive money, or brought suit or made claim against any fund, person or insurance company, for any losses mentioned in this claim or connected in any way to the losses incurred as a result of the operation or closure of the responsible landfill? If so, provide details and documentation.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

5.	Set forth the name and address of any other party you feel is responsible for the damage.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

SECTION E:  PROPERTY LOSSES (Personal and Real)

If no property loss is claimed, check here _______

"Personal Property" means everything that is the subject of ownership except for real property as herein defined.

"Real Property" means land, all rights to and interests in land, and those things, such as buildings and other improve-
ments, which are more or less permanently attached to the land.

Provide below all your real and personal property losses.  (If different types of real or personal property were damaged,
please make copies of this section of the form and submit as attachments.)

1.	Date(s) of damage (Explain) _____________________________________________________________________

2.	Location of property at time of damage ____________________________________________________________
	___________________________________________________________________________________________

3.	Description of property which was damaged ________________________________________________________
	___________________________________________________________________________________________
 
4.	Description of damage _________________________________________________________________________
	___________________________________________________________________________________________

5.	Original cost of damaged property (Itemize) ________________________________________________________
	Include sales agreement and settlement sheet.

6.	Date damaged property was acquired by claimant ____________________________________________________
	(Attach copy of deed, saleslip, lease, certificate of title, bill of sale, or other documentation, as applicable, evidencing ownership.)

7.	Value of property at time of damage (Itemize) _______________________________________________________

8.	Estimate or appraisal of total damage to property  $___________________________________________________
	(For multiple articles of personal property, attach a schedule.)

9.	Estimate or appraisal made by ______________________________________________ whose address and title is
					(Name)
	___________________________________________________________________________________________

10.	Present location of the damaged property and time when it may be inspected.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

11.	Has the damage been repaired?  ____ Yes    ____No     If "Yes", indicate the name and address of repairer,  date and cost of repairs.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

12.	Attach each estimate or appraisal of damages or bill for repair costs to this form.

13.	Description of the use of the damaged real property (residential commercial, etc.) by you before and after your losses occurred.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

14.	State the name and address of every person or company who has a legal interest or claim in the property for which this claim is made. Describe the nature of this interest, such as mortgage, legal title, etc. Attach evidence of such interest or claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

15.	Describe in detail any other claim you have due to property losses resulting from the operation or closure of the sanitary landfill which you have not yet listed or described in this section.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

16.	Did you file a claim against the sanitary landfill facility's Environmental Impairment Liability Fund established pursuant to N.J.S.A. 13:1E-109?     ____ Yes     ____ No

17.	Provide a detailed description of the facts known to the claimant which support the claim, such as facts which lead you to believe that the improper operation or improper closure of the sanitary landfill facility caused the damages suffered by you.

	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________

18.	State the names and addresses of any witnesses known who may have knowledge concerning the improper operation or  improper closure, threatened damage, or damaged caused by the sanitary landfill facility.

	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________

19.	State the names of any public agencies (including, without limitation, any local or state police or any other local, county, state, interstate or federal agencies) who have investigated the improper operation or improper closure activities and, if known to the claimant, the names of the persons who conducted the investigations on behalf of such agencies. 

	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________

SECTION F:  LOSS OF BUSINESS INCOME

If no loss of business income is claimed, check here __________ .

1.	Set forth the total amount of business income loss claimed; describe in detail how this loss was calculated.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

2.	Set forth the period of time for which you have claimed a loss. __________________________________________
	___________________________________________________________________________________________

3.	Specifically indicate how much loss is claimed for each calendar quarter commencing with the date of the damage/ occurrence.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

4.	Describe in detail the precise manner in which you have calculated the amount of lost income.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

5.	Attach copies of tax returns for the three year period just prior to the commencement of loss for which this claim is filed. Attach sales and/or other fiscal documentation, for inspection and audit, which is the basis, in part or in whole, or your claimed loss of income.

6.	Has any income, sales and other accounting or financial information on the basis of which, in part or whole, you have claimed loss of income been audited?     ____ Yes     ____ No
	
	If "Yes", give name and address of auditor, date of audit and attach copies of relevant audited statements.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

7.	Describe in detail any other claim you have due to loss of business income resulting from the operation or closure of the sanitary landfill which has not yet been listed or described in this section.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

SECTION G:  PERSONAL INJURY OR ILLNESS

If no personal injury is claimed, check here ____________ .

Complete this section if claiming personal injury or illness.

1.	Describe in detail all illnesses or injuries for which this claim is made.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

2.	Is the injury or illness considered to be permanent?     ____ Yes     ____ No

3.	Set forth in detail a description of all symptoms and diagnoses concerning your injuries or illness of which you are aware, and when you first became aware of the symptoms. Also, describe the extent and personal effect of your injuries or illnesses.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

4.	For each hospital or facility, doctor or practitioner who has provided you with treatment, examination or diagnostic services for the injury or illness which is the subject of this claim, provide the following information:

	a.	Name and address of doctor or practitioner, hospital, or other facility

		________________________________________________________________________________________
		________________________________________________________________________________________

	b.	Date(s) of treatment or service _______________________________________________________________

	c.	Amount of charges to date __________________________________________________________________

	d.	Amount paid or payable by other sources as insurance ____________________________________________

	e.	Attach all written reports prepared by any doctors, hospitals, etc., which describe your illness, injury or any 	treatment received.

5.	Is the claimant eligible to receive any other payments or compensation for the injuries or losses for which this claim is made; including those from insurance companies, government agencies, and any other persons?
							____Yes     ____No

	If "Yes", continue to complete the remaining portions of this question, setting forth all benefits received for the injuries or losses claimed.

			Name and Address of Insurance	Insurance Policy No.	Amount of
			or Government Agency	or other ID Number	Benefits Rec'd

	a.	Blue Cross	_______________________________	____________________	_______________
			_______________________________	

	b.	Blue Shield	_______________________________	____________________	_______________				_______________________________

	c.	Workmen's	_______________________________	____________________	_______________
		Compensation	_______________________________

	d.	Disability	_______________________________	____________________	_______________
		Benefits	_______________________________

	e.	Welfare	_______________________________	____________________	_______________
			_______________________________

	f.	Unemployment	_______________________________	____________________	_______________
			_______________________________

	g.	Medicare	_______________________________	____________________	_______________
			_______________________________
	
	h.	Medicaid	_______________________________	____________________	_______________
			_______________________________

	i.	Major Medical	_______________________________	____________________	_______________
		  Policies	_______________________________

	j.	Accident and	_______________________________	____________________	_______________
		  Health Policies	_______________________________

	k.	Union or Fraternal	_______________________________	____________________	_______________
		Death Benefits	_______________________________

	l.	Other	_______________________________	____________________	_______________
			_______________________________

	m.	Social Security No. ________________________  or  Railroad Retirement No. _______________________

	n.	Veterans Administration No. __________________________

	o.	Life Insurance __________________________________   ________________________   _______________
			(Name of Company)			(Policy No.)	(Amount)

	p.	Pensions ________________________________________________________________________________
				(Name of Company)

6.	a.	If loss of wages or income of any sort as a result of the injury or illness is claimed, state:

		________________________________________	____________________________________
		Name of Employer			Address of Employer

		________________________________________	____________________________________
		Claimant's Occupation			Date Employed

		________________________________________	____________________________________
		Rate of Pay or Salary			Dates of Absence from work due to injury
					or illness

		________________________________________	____________________________________
		Total Loss of Wages to Date		If still out of work, Expected Date of Return

	b.	Have you been or will you be compensated for the loss of wages/income by your employer or any other 	insurance program?     ____ Yes     ____ No        If "Yes", explain to what extent.

		________________________________________________________________________________________
		________________________________________________________________________________________

	c.	Describe in detail any other claim you have due to injury or illness resulting from the operation or closure of a 	sanitary landfill not yet listed or described in this section.

		________________________________________________________________________________________
		________________________________________________________________________________________

SECTION H:  INSURANCE / THIRD PARTY COVERAGE

1.	State the name and address of the insurance carrier which issued your insurance policy which may provide coverage for any of the damaged real or personal property or any asserted lost income.

	__________________________________________________________________________________________
	__________________________________________________________________________________________

2.	State the name and address of the insurance carrier which issued the policy, or issuer of the other financial agreement or instrument.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

3.	Give the policy number or other applicable reference number ___________________________________________

4.	Provide the name and address of any persons other than the fund against whom you asserted a claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

5.	Have you received or agreed to receive any compensation from any person in connection with the damages claimed?     ____ Yes     ____ No

	If "Yes", give details of any such compensation or agreement to receive compensation.

	___________________________________________________________________________________________
	___________________________________________________________________________________________

6.	Provide a description of any action taken to repair, restore or replace damaged real or personal property including,
	without limitation, the following:

	a.	The name and address of the person who has taken such action

		________________________________________________________________________________________
		________________________________________________________________________________________

	b.	The cost of such action _____________________________________________________________________

7.	If the claimant asserts any personal injury damages including medical expenses incurred and income lost as a result thereof, the claim shall include the following information:

	a.	The total amount of the claimed loss of income
	b.	The period of time during which the claimant asserts that the loss of income has occurred
	c.	If the claimant asserts that the loss of income has occurred over a period exceeding 12 months, a breakdown of the 	loss of income by three-month periods, with the first such period commencing on the date of discovery
	d.	A detailed description of the method employed by the claimant in calculating the claimed loss of income
	e.	A statement of whether all income, sales and other accounting and financial information supporting the claim is 	available for inspection, copying and audit by the Department
	f.	If any of the information described in (e) above, is not available for inspection, copying and audit, an 	explanation of why such information is unavailable for such purposes 	
	g.	With respect to any of other information described in (e) above, which is available for inspection, copying and 	audit, a description of where and when the Department can obtain access to such information
	h.	If any of the information described in (a) through (g) above has been audited, certified or reviewed by a certified public 	accountant, the name, address, and telephone number of such accountant, and the date of such audit, certification 	or review. If such information has been audited, the claimant shall attach copies of all audited statements and the 	auditor's reports
	i.	A specific statement as to the nature of the health injuries and how the health injuries are related to the 	improper operation or improper closure of the sanitary landfill facility in question
	j.	Detailed records substantiating the personal injuries; effects or damaged suffered by the claimant including any 	medical records, prognosis statements, and documentation indicating the monetary value of medical attention

SECTION I:  LOSS OF LIFE

	If no loss of life is claimed, check here _______ .

	1.	Attach a copy of the claimant's death certificate.

	2.	Has a will been probated or letters of administration granted?     ____ Yes     ____ No

	3.	Give name and address of executor or administrator.

		________________________________________________________________________________________
		________________________________________________________________________________________

	4.	Give name and address of attorney for estate.

		________________________________________________________________________________________
		________________________________________________________________________________________

	5.	List  spouse, children or other persons dependent for his or her principal support upon the deceased.

		Full Name and Address		Date of Birth		Relationship
						to Deceased

		_____________________________________________	___________________	__________________
		_____________________________________________
		_____________________________________________

		_____________________________________________	___________________	__________________
		_____________________________________________
		_____________________________________________

		_____________________________________________	___________________	__________________
		_____________________________________________
		_____________________________________________

		_____________________________________________	___________________	__________________
		_____________________________________________
		_____________________________________________

		_____________________________________________	___________________	__________________
		_____________________________________________
		_____________________________________________							

	6.	State deceased's earnings for the last three years immediately preceding his/her death __________________

	7.	Itemize out of pocket costs of medical, hospital, funeral or other services, giving amount and name and address of 	person paid or to be paid in each case.

		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________

	8.	Set forth particulars of any other sums received by dependent(s) or claimed to be due as a result of the 	damages leading to loss of life.

		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________

	9.	Is any dependent identified in Question 5 eligible for any pension or Social Security benefits as a result of the 	death of the claimant?     ____ Yes     ____ No

		If "Yes", indicate the name of the dependent(s) and whether a claim has been filed for such pension or social 	security benefits.

		________________________________________________________________________________________
		________________________________________________________________________________________

	10.	Provide any other information which you believe is pertinent to the claim.

		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________
		________________________________________________________________________________________

SECTION J:  WITNESSES

1. 	State the name and address of witnesses or other persons having personal and relevant knowledge of your injury or losses for which this claim is made, and also those with knowledge of the casual relationship between the operations and closure of the landfill and the injuries or losses stated in this claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________

2.	State the names of any public agencies (local or state police and other local, state or federal agencies) who have investigated any of the matters involved in this claim.

	___________________________________________________________________________________________
	___________________________________________________________________________________________
	___________________________________________________________________________________________

STATE OF NEW JERSEY
COUNTY OF ______________________________SS:

________________________________________of full age, being duly sworn on his oath or affirmation
	(Name of Affiant)
according to law deposes and says:

I certify that the foregoing statements made by me in this Claim Application are true. I am aware that is any of the foregoing statements made by me are willfully false, I am subject to punishment.

Date: ___________________________	__________________________________________
			Print Name of Claimant or Claimant's Representative
			authorized pursuant to N.J.A.C. 7:1I-1.7

			__________________________________________
			Signature of Claimant
				or

			__________________________________________
			Signature of Claimant's Representative authorized
			pursuant to N.J.A.C. 7:1I-1.7

Sworn to and subscribed before me this
___________day of____________ , 199___.

___________________________________
Notary Public or Attorney at Law