STATE REVOLVING FUND DOCUMENTATION OF SUFFICIENT FUNDS FORM MINNESOTA

STATE OF CALIFORNIA C THE RESOURCES AGENCY PRIMARY
EMPLOYEES’ COMPENSATION DIVISION LABOUR DEPARTMENT STATEMENT OF
LOGO [NAME OF ORGAN OF STATE] G4(FR) ACCEPTANCE

BILL LOCKYER STATE OF CALIFORNIA ATTORNEY GENERAL DEPARTMENT OF
CHARACTERISATION OF FUEL CELL STATE USING ELECTROCHEMICAL IMPEDANCE SPECTROSCOPY
STATEMENT ON RESTITUTION

State Revolving Fund - Documentation of Sufficient Funds Form

State Revolving Fund

Documentation of Sufficient Funds Form

Minnesota Rules 7077.0288, Subp. 2.C.

Municipality Name:
Project Number:

This documentation shows that we are collecting sufficient funds to provide for operation and maintenance and equipment replacement (OM&R) costs in conformance with the approved operation and maintenance manual.

A. Record the total annual amounts spent for each of the following items during the one-year certification period for this project:

Budgeted Costs		Actual Costs
$	Total operating costs	$
$	Total maintenance costs	$
$	Total equipment replacement costs	$
$	Total OM&R costs	$

B. Record the total annual amounts collected for each of the following items during the one-year certification period for this project:

Budgeted Costs		Actual Costs
$	Total user fees collected	$
$	Total of all other sources of income collected for OM&R	$
$	Total income collected for OM&R	$

To demonstrate compliance with this performance standard, the actual total income collected for OM&R should be equal to or greater than the actual total OM&R costs.


(Total OM&R income)	(Total OM&R cost)	(Debit or credit)

Print Authorized Representative Name:				Title:
Signature:				Date:

wq-wwtp2-18

1/8/2007 Page 1 of 1

VICTIM IMPACT STATEMENT
FOR DEATH PRIOR TO 01061959 ADMINISTRATION (INTESTATE)
CONFIGURING USER STATE MANAGEMENT FEATURES 73 CHAPTER 7 IMPLEMENTING

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