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 Owner of Authorization for Eligibility

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 doc format of Claims_Owner_Authorization.doc

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

WORD docx format of FR500.DOC

Form 500 - Monthly Delivery Fee Reporting Form 
(for fees collected on/after January 1, 2015)

WORD docx format of Form 500 After Jan-1-2015
Example of a completed Monthly Delivery Fee Report
(for fees collected on/after January 1, 2015)
PDF pdf format of Form 500 After Jan-1-2015 Example
Form 501 - Monthly Delivery Fee Report - Schedules 1-3

WORD doc format of Fr501.DOC

Form 502 - Application for Delivery Fee Abatement

WORD doc format of Fr502.DOC

Form 502 - Application for Delivery Fee Abatement 
(for fees collected on/after January 1, 2015)

WORD docx format of Form 502 After Jan-1-2015
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

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