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Financial Assistance Environmental Claims Administration (ECA) Forms

Guidelines for Completing a Spill Fund Claim Application for Contaminated Private Wells

Alternate Format: Adobe Acrobat [pdf 180 Kb]

This guideline is to aid homeowners and businesses in the completion of a Spill Compensation Fund Claim for damages related to contaminated potable wells. For all other types of damage claims, the application must be completed in full.

Check off box when section is completed

Section I. Claimant Identification Information
[  ]   Complete numbers 1 through 9.
Section II. Discharge and Damage Statement
[  ] Complete numbers 10 and 11 if you know or have reason to believe where the contamination is coming from and who is responsible for the discharge of the contamination.
[  ] Complete 12a through 12n.
  [  ] Must Complete 12b indicating when you discovered the damage. This space must be completed with a date. Perspective Claimants shall submit any claims to the Department no later than ONE (1) year after the date of discovery (of damages).
[  ] Complete 12k indicating when you purchased the property.
Section IV. Insurance/Other Claims
[  ] Complete 22-27. (Do not leave YES or NO questions blank, you must select either one.)
Last Page
[  ] Sign the certification and have it notarized by a Notary Public or by an Attorney at Law.

Also remember to (Check-Off):

[  ] Provide copies of INITIAL and CONFIRMING water test results from a NJ certified water-testing laboratory.
[  ] Include a copy of CURRENT TAXBILL or DEED.
[  ] Indicate if a public waterline is fronting or near your property.
[  ] If a waterline is available, provide THREE (3) ESTIMATES from plumbers to HOOK-UP and THREE (3) ESTIMATES from CERTIFIED well sealer to SEAL the well.
[  ] If no waterline is available, provide THREE (3) ESTIMATES for a Point-of-Entry Treatment (POET) system.
[  ] Keep a COPY of the application and documents for your personal records.
[  ] Submit claim by CERTIFIED MAIL, or by other means that provides a receipt showing date of mailing and date of delivery.