UST Petroleum Clean-Up Program

Payment Election Form for Mid-Size Station Applicants

Mid-size station applicants must use this form to submit a payment election to the Department of Energy and Environmental Protection(“the Department”) Underground Storage Tank Petroleum Clean-Up Program (“the Program”). A payment election designates what reduction, if any, in the amount that has been or will be ordered to be paid from the Program such applicant is willing to accept. Payment to mid-size station applicants will be prioritized according to those who are willing to accept the greatest reduction.

Connecticut General Statutes (“CGS”) Section 22a-449r specifies the maximum amount the Commissioner can pay to mid-size station applicants in any fiscal year. For the fiscal year beginning July 1, 2018, that amount is ninety-five cents on each dollarthat is ordered paid from the Program. A payment election at or below this amount is called a reduced payment election. The reverse auction will determine the priority for payment among those mid-size station applicants who have submitted and those who submit a reduced payment election.

A payment election must be submitted to the Department during the reverse auction, which will commence at 9:00 a.m. on July 1, 2018and will end on August 1, 2018at 4:30 p.m., pursuant to CGS Section 22a-449r.

Payment elections submitted on this form by mid-size station applicants will serve as the bids for this auction. Each bid or payment election that is less than one dollar will be posted on the Program’s webpage at Any mid-size station applicant who fails to submit a payment election by the end of the reverse auction and who previously failed to submit a reduced payment election will not be able to receive payment for any of its approved applications in the fiscal year from July 1, 2018to June 30, 2019.

Mid-size station applicants are advised to carefully review CGS Section 22a-449r before making a payment election. Mid-size station applicants are encouraged to review the notice accompanying this form, which may also be helpful (also available on the Program’s webpage at

Also, similar to bidding at an auction, a mid-size station applicant may submit more than one payment election during the time the reverse auction is taking place. Blank payment election forms are available on the Program’s webpage at Each mid-size station applicant must submit a payment election, except for those who elected to receive 85 cents or less during any previous reverse auction. If a mid-size station applicant who previously submitted a reduced payment election wants to submit a lower reduced payment election, it must be submitted before the reverse auction ends. Such applicant may not submit a reduced payment election seeking more than the amount of any previous reduced payment election.

Please ensure that Parts I through III are all completed before submitting this form.

Part I: Applicant Information

Please designate in Part I, item #2, a contact person for the Applicant whom the Department may contact regarding this form. Include an e-mail address for any such contact. The person designated should have the authority to address matters regarding this Payment Election form on behalf of the Applicant.

1.Applicant
Name:
Mailing Address:
Additional Mailing Info:
City/Town: State: Zip Code:
E-mail address for Applicant:
2.Designate a Contact Person for the Applicant Who Can Provide Information Regarding this Form:
Contact Person:
Business Phone: ext.: Cell Phone:
Contact E-Mail address:

Part II: Making a Payment Election

Each mid-size station applicant must make a payment election by checking the box for Election 1 or 2. Those checking Election 1, must also specify on the designated line an amount, up to 99 cents, but not higher than the amount specified in any previous payment election.

In making this Payment Election, and in completing Part IV below, I acknowledge my understanding that:
  • this payment election shall apply to, and shall be the same for, all applications I have submitted to, and will in the future submit to, the Program including but not limited to, applications for which payment or reimbursement has been ordered by the Commissioner but has not been made;
  • while in the future I can make a lower payment election , I cannot, at anytime, make a payment election greater than the amount specified in this payment election; and
  • for the fiscal year July 1, 2018to June 30, 2019, the Commissioner cannot make payment in excess of 95 cents on each dollar ordered paid from the Program, except for those mid-size station applicants thatagree not to submit applications as noted in Part III below. As such, any mid-size station applicant who elects, through Election 1, to receive more than 95 cents on each dollarordered paid from the Program or who elects to receive full payment (Election 2), will not be able to receive any payment in the fiscal year July 1, 2018to June 30, 2019. Each fiscal year the amount that can be paid by the Commissioner will increase by ten cents until it reaches $1.00.
Election 1:I am electing to receive (insert an amount) on each dollar that has already been ordered, or that in the future will be ordered, to be paid from the Program to the Applicant noted in Part I above.
Election 2:I am electing to receive full payment on each dollar that has already been ordered, or that in the future will be ordered, to be paid from the Program to the Applicant noted in Part I above.

Part III: Agreement to Not Submit Any Additional Applications

Each mid-size station applicant is eligible to receive an additional ten cents on the amount paid from the Program to such applicant. To receive such amount, a mid-size station applicant must nothave submitted any applications to the Program on or after October 1, 2012. Eligible mid-size station applicants electing this option must check the box in this Part of the Payment Election form.

Any mid-size station applicant exercising this option should be aware that the receipt of this additional ten cents will not be counted when determining a mid-size station applicant’s priority for payment; each mid-size station applicant’s priority for payment will be based upon the amount specified in Part II of this form. Also, regardless of whether this option is exercised, a mid-size station applicant cannot receive more than one dollar on each dollar ordered paid, or to be ordered paid, from the Program.

I am seeking an additional 10 cents on the amount of my Payment Election noted on Part II of this form. To be eligible to receive this amount I certify and agree that I have not submitted any applications to the Program on or after October 1, 2012.

Part IV: Applicant Certification

The Applicant must complete this Part. This Part cannot be completed by a consultant for an Applicant.

“I hereby certify that I am authorized to submit this form on behalf of the Applicant noted in Part I of this form. I have personally examined and am familiar with the information pre-filled on and submitted with this form. I understand that the information pre-filled on and submitted with this form will be used to implement the provisions of the Underground Storage Tank Petroleum Clean-Up Program, including, but not limited to, payment of applications submitted to the Program. I also understand that any false statement made in this form, its attachments, or any other information submitted in connection herewith may be punishable as a criminal offense, in accordance with CGS § 22a-6, pursuant to CGS § 53a-157b, and in accordance with any other applicable statutes.
I certify that this form is accurate as prescribed by the Commissioner without any alteration or addition.”
*Signature of Authorized Representative of Applicant / Date
Printed Name of Authorized Representative of Applicant / Title of Authorized Representative (if applicable)

* Note: If a mid-size station applicant submits this payment election form by e-mail, the Signature by the Authorized Representative of the Applicant does not need to be provided.

Part IV: Instruction for Submission of this Form

This payment election form must be submitted after 9:00 a.m. on July 1,2018and before 4:30 p.m. on August 1,2018. This form may be submitted in any manner noted below.

A. Personal Delivery or Mail: This form may be submitted by personal delivery or by mail to:

UST PETROLEUM CLEAN-UP PROGRAM

DEPARTMENT OF ENERGY AND ENVIRONMENTAL PROTECTION

2ndFLOOR

79 ELM STREET

HARTFORD, CT 06106-5127

B. E-mail: This form may be sent by e-mail to . Fillable forms are available at the Program’s webpage. If a mid-size station applicant submits this payment election form by e-mail, the Signature by the Authorized Representative of the Applicant, in Part III of this form does not need to be provided.

Any person with questions regarding this form may contact the UST Petroleum Clean-Up Program at 860-424-3370 or visit the Program’s webpage at

DEEP-UST-PEFM1 of 3Rev. 6/12/18