STATE VATER RESOURCES CONTRO. BOARD
CALIFORNIA WATER AND WASTEWATER ARREARAGES PAYMENT PROGRAM
WATER ARREARAGES DISBURSEMENT REQUEST FORM
PWSID NO: CA3010010
WATER SYSTEM NAME:CITY OF FULLERTON
LEGAL ENTITY NAME: CITY OF FULLERTON
MAILING ADDRESS: 303 W. Commonwealth Ave. Fullerton, CA 92832 NO. OF ACCOUNTS PAYMENT AMOUNT REQUESTED
RESIDENTIAL 337 $135,466.00
COMMERCIAL 27 $10,570.54
SUBTOTAL 364 $146,036.54
ADMINISTRATIVE COSTS $4,381.10
(Maximum of 3% OF SUBTOTAL UP TO $1 MILLION)
GRAND TOTAL OF PAYMENT AMOUNT REQUESTED $150,417.64
CERTIFICATION: I have read and signed the Conditions of Payment Form and understand that this Disbursement Request Form CANNOT BE PROCESSED unless a complete and accurate Conditions of Payment Form is currently on file with the State Water Resources Control Board.
The arrearages claimed in this Disbursement Request Form have been incurred and remain unpaid by customers of the Community Water System and any payments received from the State Water Resources Control Board will be allocated as bill credits within sixty (60) days of receipt of the funds requested in accordance with the California Water and Wastewater Arrearages Payment Program Guidelines and will return any moneys not credited to the State Water Resources Control Board within six months of receipt.
AUTHORIZED REPRESENTATIVE OR DESIGNEE SIGNATURE: DATE:
Ellis Chang Jan 5, 2022
Adobe Sign Transaction Number: CBJCHBCAABAAjMdi36-9PwiwX9ozIWZ4JWlw4npxb_Y
FOLLOWING SECTION IS FOR STATE USE ONLY
PAYMENT INVOICE NO.: CA3010010-01
INVOICE DATE: 12/07/2021
Revised Oct 20, 2021
Water Arrearages Disbursement Request Form Page 1 of 2
CALIFORNIA WATER AND WASTEWATER ARREARAGES PAYMENT PROGRAM
WATER ARREARAGES DISBURSEMENT REQUEST FORM
PWSID NO: CA3010010
WATER SYSTEM NAME: CITY OF FULLERTON
LEGAL ENTITY NAME: CITY OF FULLERTON
FOLLOWING SECTION IS FOR STATE USE ONLY
PAYMENT INVOICE NO.: CA3010010-01
INVOICE DATE: 12/7/2021
PAYMENT REQUEST AMOUNT $ 150,417.64
ADJUSTMENT $0.00
AMOUNT DUE $ 150,417.64
ADJUSTMENT COMMENTS:
FI$CAL SUPPLIER ID: 0000011708 ADDRESS ID: 2
FUND TITLE ITEM FY CHAPTER STATUTE
Coronavirus Fiscal
3940-162-8506 21/22 21/21 2021
Recovery Fund of 2021
REPORTING ALT PROJECT
PROGRAM ACCOUNT PROJECT #
STRUCTURE ACCOUNT ACTIVITY #
3560000C25 39400556 5432600 5432600000 3940COVIDARREAR L/A STATUTE LANGUAGE:
Per California Health and Safety Code 116773.4, the board provides financial assistance to community water systems for the purpose of assisting customers with past-due bills accrued during the COVID-19 pandemic bill relief period from March 4, 2020 to June 15, 2021.
SIGNATURES FOR APPROVAL OF
PAYMENT
Analyst 01/06/2022
Title: Date:
Manager Dall 4/2082
Reviewed B Title:
Revised Oct 20, 2021
Water Arrearages Disbursement Request Form Page 2 of 2