OFFICE USE ONLY

Claim No._______________________

                     

New Jersey Department of Environmental Protection
Environmental Claims Administration
401-06J PO Box 420 Trenton, NJ 08625-0420
(609) 777-0101          Fax:  (609) 292-4401

SPILL COMPENSATION FUND
DAMAGE CLAIM

The Department must conduct a complete review of the claim and supporting documentation before any decision regarding compensation is made.  	

I.	CLAIMANT IDENTIFICATION INFORMATION

	1.	Name of Claimant(s):___________________________________________________________________________
		(Hereinafter referred to as "claimant" whether one or more.)

	2.	Claimant is: 	(   ) individual  	(   ) general partnership	(   ) unit of Federal government	
				(   ) limited partnership	(   ) unit of State government
				(   ) corporation	(   ) unit of local government

3.	If the claimant is a partnership (general or limited), state the names and addresses of all general partners.  If 
	claimant is a corporation, list the names and addresses of all director and all officers and place of incorporation.
		(Attach additional sheet if necessary)

		__________________________________________	_________________________________________

		__________________________________________	_________________________________________

		__________________________________________	_________________________________________

	4a.	Street address of claimant:_______________________________________________________________________

	4b.	Mailing address of claimant:______________________________________________________________________

	4c.	Telephone Number:   Home:______________________________   Business:______________________________
	
	4d.	Email Address: ___________________________________________________
	
	5.	Address/Location of Damaged Property:____________________________________________________________

	6	Tax Block______________  Lot___________   Municipality____________________    County:_______________

	7.	Social Security Number:________________________________________________________________________

	8.	If it is requested that notices be sent to a person other than claimant, state:

		Name of Person:______________________________________________________________________________

		Mailing Address:______________________________________________________________________________

		Tele. No.:___________________________   Relationship to Claimant:___________________________________

	9.	Have you ever filed a Spill Fund claim?   ____Yes     ____No    	If Yes, state address of damaged property 
		and Claim Number:
		___________________________________________________________________________________________

II.	DISCHARGE AND DAMAGE STATEMENT	

	10.	The discharge in connection with this claim emanated from the following precise location: 
		
		Street Address :_______________________________________________________________________________

		Municipality :____________________________________ County :______________________________________
	
		Date:  __________________________ , 19____                 Time:   ________o'clock ___M.

	11.	The person or entity believed to be responsible (if known) for the discharge is:

		Name_______________________________________________________________________________________

		Address________________________________________State___________________________Zip____________

     12.	Damage to Real and/or Personal Property:     (   ) Check if applicable.  (Personal property may be defined as property subject to ownership which is not permanently attached to the land.)  Claimant hereby claims to have suffered damages to real and/or personal property as follows:

a.	Date(s) of damage:_________________________________________________________________________

		b.	Dates damages were discovered by you_________________________________________________________

		c.	Description of damage:______________________________________________________________________
		
			_________________________________________________________________________________________

	d.	How did you discover damage:________________________________________________________________

		e.	Describe the facts regarding how the discharge caused damages to you:

			_________________________________________________________________________________________

			_________________________________________________________________________________________
			
		_________________________________________________________________________________________

		f..	Location of damaged personal property and/or real property at time the damage occurred:
	
			Street Address :____________________________________________________________________________

			Municipality :____________________________________   Tax  Lot :__________   Block:_________________	

		g.	Description of damaged property and predominant use of damaged property.  State if the damaged
			property is vacant land:

			Description:_______________________________________________________________________________

		       _________________________________________________________________________________________

			Use: _____________________________________________________________________________________

	h.	Description of any action (and cost of the action) taken to repair, restore or replace damaged real property, including, without limitation, the following and the name and address of the person who has taken such action.  (Provide 3 estimates)

			_________________________________________________________________________________________

		i.	Are you claiming property value diminution?  ____ Yes     ____ No  (If “no”, skip I through L)

		j.	Original cost of damaged property:_____________________________________________________________

	k.	Date property was acquired by claimant:_________________________________________________________
			(Attach copy of sales contract, certificate of title, bill of sale, etc., as evidence of ownership)

l.	Estimation of total damage to property:  $_______________________ .  
(The claimant shall submit all bills, invoices, receipts and other documentation in an orderly fashion.)

	m.	Name, address and qualifications of any person who prepared the estimates. 

			_________________________________________________________________________________________

			_________________________________________________________________________________________

		n.	Place where property may be inspected:_________________________________________________________
			
			_________________________________________________________________________________________

	13.	Emergency Response:

		If this claim is being filed by a local governmental unit, please indicate whether or not the claim relates to any 	emergency response action taken by the local unit.   _____ Yes     _____ No (If Yes, please forward the following)
		
a.	A copy of the Incident Report from the NJDEP Hotline 1-877-927-6337

b.	An affidavit stating that you obtained NJDEP approval before taking the emergency response, including the name of the NJDEP employee who gave the approval, the date of the approval and the form of the approval  (i.e. telephone, mail, facsimile)

	14.	Loss of Income:

	a.	Total amount claimed:  $______________________ 

		b.	Period of time for which loss of income is claimed_________________________________________________

	c.	If more than 12 months is involved, please specifically indicate how much is claimed for each calendar quarter	commencing with the date of the discharge:
			_________________________________________________________________________________________

			_________________________________________________________________________________________

d.	Please describe in detail the precise manner in which claimant has calculated the total loss of income 
		_________________________________________________________________________________________

			_________________________________________________________________________________________

		e.	Is all income, sales and other accounting or financial information on the basis of which, in part or in whole, the 				claimant has claimed loss of income, available for inspection and audit?     ____ Yes     ____ No    
			If Yes, explain where information can be obtained. If No, explain why information is unavailable.
			_________________________________________________________________________________________

			_________________________________________________________________________________________

	f.	Has any income, sales and other accounting or financial information on the basis of which, in part or in whole, the claimant has 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.

			_________________________________________________________________________________________

	g. Specify the amount of lost income which is derived, exclusive of other sources of income, from activities related to the particular real or personal property damaged by such discharge during the 				     week, month or year for which the claim is filed:
			________________________________________________________________________________________

			________________________________________________________________________________________

	

15.	Loss of Tax Revenue:   (   ) Check here if claimant claims to have suffered a loss of tax revenue.

		a.	Total amount claimed:  $________________________ .

		b.	Period of time for which loss of tax revenue is claimed:____________________________________________

		c.	Please describe in detail the precise manner in which claimant has calculated the total loss of tax revenue :

			________________________________________________________________________________________
	
			________________________________________________________________________________________

	d.	Is all financial information on the basis of which, in part or in whole, the claimant has claimed loss of tax revenue, available for inspection and audit?     ____ Yes     ____ No  (If Yes, explain where information can be obtained. If No, explain why information is unavailable.

			________________________________________________________________________________________

			________________________________________________________________________________________

		e.	Has any  financial information on the basis of which, in part or in whole, the claimant has claimed loss of tax 				revenue been audited?    ____ Yes     ____ No
			If Yes, give name and address of auditor, date of audit and attach copies of relevant audited statements:

			________________________________________________________________________________________
			
			________________________________________________________________________________________

	16.	Submit supporting documentation which indicates the date when it was discovered that the taxing entity (Town, County, State, etc.) would lower the taxes, the appeals (if any) by affected residents from original (higher) assessments which indicates that the reduction was not initiated or encouraged by the taxing entity and all other documentation regarding the tax loss.  

III.	RESPONSIBLE PARTY INFORMATION

	17.		Please describe in detail the basis upon which you believe that the person or entity listed above in Question No. 10 is responsible for any damage or loss of income you claim to have suffered.  Also indicate, if known, whether each such person or entity is an individual, general partnership, limited partnership, corporation or governmental entity:
		___________________________________________________________________________________________

		___________________________________________________________________________________________

		___________________________________________________________________________________________

     18.	State the names and addresses of witnesses or other persons having relevant knowledge of the discharge:

		___________________________________________________________________________________________

		___________________________________________________________________________________________

    

19.	Has the person or entity listed in Question No. 10 admitted responsibility for the discharge or threatened discharge from which the claim arose, or liability for the amount of damages for which the claim is being made in connection with which this claim is filed?     ____ Yes     ____ No     If Yes, please indicate when, where, by whom and if in writing.
		__________________________________________________________________________________________
		
		__________________________________________________________________________________________

20.	Has the person or entity listed in Question 10 admitted liability for the amount of damages and loss of income for which this claim is filed?   ____ Yes   ____ No    If Yes, indicate when, where by whom and if in writing.
	_____________________________________________________________________________________
	
	________________________________________________________________________

      21.	State the names of any public agencies (local, county, state or federal, including police) and the people involved who have investigated the discharge or damages.
	_____________________________________________________________________________________

	_____________________________________________________________________________________

IV.	INSURANCE / OTHER CLAIMS

22.	Is claimant covered by any policies of insurance which insure the real or personal property or loss of income or tax revenue for which this claim is filed?   ____ Yes   ____ No    If Yes, provide copies of any correspondence between 
		the insurance carrier and yourself or your representatives concerning the discharge or threatened discharge.

a.	Name of Insurance Company:________________________________________________________________

		b.	Address of Insurance Company:______________________________________________________________
		
		c.	Policy Number(s):_________________________________________________________________________

		d.	Phone Number:___________________________________________________________________________

	23.	Have you made a claim against anyone else for any of the losses or expenses claimed in this notice?
	____Yes ____No    If "Yes", set forth the names and addresses of all persons and insurance companies against
	whom you have made such claims:
		___________________________________________________________________________________________

		___________________________________________________________________________________________

	24.	Have you filed a lawsuit against anyone?     _____Yes     _____No           If "Yes",  attach copy of complaint.

		Give details: ________________________________________________________________________________
		
		__________________________________________________________________________________________

       25.	Have you applied for, received or agreed to receive any money from anyone including, but not limited to, a state loan or grant from the Economic Development Authority or a water supply loan from the DEP for the damages claimed herein? ____ Yes____ No         If "Yes", set forth the details:

		__________________________________________________________________________________________

		__________________________________________________________________________________________

	26.	Is there any other information that you believe to be pertinent to the merits of this claim?

		__________________________________________________________________________________________

		__________________________________________________________________________________________

	27.	State in writing the specific reasons why your claim should be accorded priority:

		___________________________________________________________________________________________

I, the undersigned claimant, hereby claim to have actually incurred damages, as defined in N.J.A.C. 7:1J-1.4, I have not received compensation, in part or in whole, from any other source for such damages and I am not a potentially responsible party in connection with the discharge, which is the subject of the claim.

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document, and that to the best of my knowledge, after diligent investigation including inquiry of those individuals immediately responsible for obtaining the information, the information contained in this claim is true, accurate and complete.  I am aware that there are significant civil and criminal penalties, including fines and/or imprisonment for submitting false information.

I state that the damage claims set forth herein represent all known damage to claimant arising out of the incident and I understand that pursuant to PL 1976, c.141, damage claims omitted from this claim are deemed waived.

Signed at    _____________________________ (Municipality), ________________________ (State),

on the ___________________ day of ________________ , 20____ .

															______________________________________

                                                                                   ______________________________________
			Signature of Claimant(s)

Sworn to and subscribed before me this

____________ day of ___________________,20___

______________________________________________
Notary Public or Attorney at Law

____________________________________
My Commission Expires

*Claims should be submitted by Certified Mail Return, Receipt Requested or by other means which provides 
a receipt of mailing and the date of delivery.