Ill. Admin. Code tit. 41, pt. 270, app A
Hazardous Materials Emergency Response Reimbursement Application
SECTION 1 - APPLICANT INFORMATION
Organization Name
________________________________________________
Address Phone Number
___________________________ ________________
Tax Identification Number Fax Number
_____________________ __________________
SECTION 2 - CONTACT INFORMATION
Name
_________________________________________________
Title Work Phone
____________________________ ________________
________________________________________
Cell Phone
______________________
SECTION 3 - RESPONSIBLE PARTY
If the responsible party is unknown, please check this box[]
Name
_________________________________________________
Address Phone Number
____________________________ ________________
Fax Number
____________________________ ________________
Date Notification for Reimbursement Provided to Responsible Party __________________________
SECTION 4 - INCIDENT NARRATIVE
Incident Date ___________________________
(Application must be submitted within 90 days after the incident date)
SECTION 5 - INCIDENT EXPENSES
You may claim expenses for a mutual aid responder if you have a mutual aid agreement. Indicate expenses of mutual aid responders in the column provided below and attach a copy of the mutual aid agreement to this application.
Itemized List of Expenses | Mutual Aid Expense (Y or N) | Qty | Amount |
TOTAL (Must equal or exceed $500. If not you are not eligible to apply) |
SECTION 6 - REIMBURSEMENT CALCULATION
Line 1: Total Annual Budget* _________________
Line 2: Multiply Line 1 by 2% (Line 1 x 2% = Line 2) _________________
Line 3: Cost of Incident Response (from Section 5) _________________
If Line 3 is less than Line 2, STOP. You are not eligible to apply.
Line 4: Enter the amount from Line 3. If Line 3 is greater than $10,000, _________________
then enter $10,000. This is your reimbursement claim.
* Exclude personnel costs (i.e., salary, benefits, training expenses and any other personnel costs) and costs to acquire capital equipment (i.e., buildings, vehicles and other major capital cost items). A copy of your approved budget or appropriation ordinance must be attached to this application.
SECTION 7 - ATTESTATION AND SIGNATURES
I attest that the information contained in this application is true and accurate to the best of my knowledge. (Signature should be from the head of the organization.)
_______________ _________________ ___________
Signature Title Date
_________________________________
Print Name
You MUST attach the following documentation to your application:
Copy of an approved budget or appropriation ordinance for your agency
Copy of mutual aid agreements (if applicable)
Ill. Admin. Code tit. 41, pt. 270, app A