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<br /> . . <br /> ,;:. <br /> .. OAK GROVE SANITARY LANDFILL SITE <br /> . - - <br /> INDIVlDUAL C[AIM FORM FOR REIMBURSABLE AMOUNTS FOR OAK GROVE <br /> SITE DISTRIBUTEES <br /> . <br /> . This claim form is being provided for Oak Grove Site Distributees (all parties wishing <br /> to seek reimbursement from the State, regardless of class of senior) to use in determining <br /> . how much Df the monies they ~ave contributed to the Oak Grove Sanitary Landfill clean-up <br /> . effort are reimbursable'" The purpose of the claim form is to allow each Distributee to be in <br /> a position to sign the Reimbursement Agreement, ~tuch contains a certification by the <br /> . Distributee that it is not claiming reimbursement for costs that have already been paid by <br /> . anmher source, such as insurance or. ~nder another type of indemnity agreement a Distributee <br /> may have. Please note that each Distributee claiming reimbursement will be making this <br /> .- <br /> representation under penalty of law and subject to forfeiture of the reimbursement claim if <br /> . the information is materially false or involves a material omission. For additional <br /> information, see Minn. Stat. SS 1 15B.43 and 115B.39, Subd. 2. <br /> . Each Distributee must provide this information to Gary Gengel, Oak Grove <br /> . Common Counsel, no later than 2:00 pm on October 25, 1995. You may call Gary <br /> Gengel (612-334-2795) or Waverley Eby Booth (612-334-8826) if you have any questions. <br /> . Otherwise please tUIlSmir. the original of the Individual Claim Form under authorized and <br /> . notarized signature to Gary Gengel no later than 2:00 p.m. on October 25,1995, <br /> . <br /> . <br /> .e 299f2:2095475 [0/[J/95 <br /> . <br />