Compliance

Appendix 1 - Application for Certificate of Compliance for Dispensing Facilities (with BASA)PDF pdf format of Appendix 1
Appendix 1R - Renewal Application for Certificate of Compliance for Dispensing Facilities

PDF pdf format of Appendix 1R

Eligibility

Appendix 2 - Application for EligibilityPDF pdf format of Appendix 2
Application for Eligibility Checklist

WORD doc format of Appchecklist.doc

Owner Authorization for Eligibility Form

WORD doc format of Eligibility_Owner_Authorization.doc

Reimbursement

Appendix 4 - Application for Reimbursement

Claim Filing Requirements and FAQs

PDF pdf format of Appendix 4 - Application for Reimbursement

PDF pdf format of Appendix 4 - Requirements & FAQs
Insurance QuestionnaireWORD docx format of UST Insurance Questionnaire
Appendix 4A - Listing of Costs, Expenses and ObligationsEXCEL xls format of Appendix_4A.xls
Appendix 4A - GuidanceWORD doc format of Appendix_4A_guidance.doc
Appendix 4A - Example FormEXCEL xls format of Appendix_4A_example.xls
Appendix 5 - Competitive Bidding

PDF pdf format of Appendix 5

Appendix 6 - Third Party Claims Arising from a Civil Court ActionWORD doc format of Appendix6.doc
Owner Authorization for Claims Form

WORD docx format of Owner of Authorization for Eligibility

Policy for Insurance and Subrogation Contributions

WORD doc format of Subrogation.doc

Application for Economic Hardship Status

Request for Reconsideration Form

WORD doc format of Application_Economic_Hardship_Status.doc

WORD doc format of Request for Reconsideration

Grants

City and Towns Grants ApplicationWORD doc format of USTGrant.doc
Appendix A - Cost Breakdown Worksheet

EXCEL xls format of Appendix_A_CostBreakdownWorksheet.xls

Eligible and Ineligible Costs

WORD doc format of Eligible_IneligibleCosts.doc

Commonwealth Standard Contract Form

PDF pdf format of Standard_Contract_Form.pdf

Fee Collection

Notice of Fee IncreasePDF pdf format of Notice_to_Distributors.pdf

Form 500 - Monthly Delivery Fee Reporting Form 
(for fees collected January 1, 2015 - December 31, 2015)

WORD docx format of Form 500 - 1/15 - 12/15
Form 500 - Monthly Delivery Fee Reporting Form
(for fees collected January 1, 2016 - December 31, 2016)
WORD docx format of Form 500 - 1/16 - 12/16
Form 501 - Monthly Delivery Fee Report - Schedules 1-3

WORD doc format of Fr501.DOC

Form 502 - Application for Delivery Fee Abatement

WORD docx format of Fr502.DOC

Example of a completed Monthly Delivery Fee ReportPDF pdf format of Example of Completed Monthly Delivery Free File Report

Miscellaneous Forms

Notification of Assignment Policy and Form

PDF pdf format of Notice_Assign_Policy.pdf

IRS Form W-9 (Massachusetts Substitute)

PDF pdf format of newMass_W9.pdf