Section NR 123.22 - Claim application(1) In order to be considered for an award or proceed notice, a claimant shall submit a completed claim in accordance with s. NR 123.05, to the department. The department shall assist claimants in completing claims and revising claims in order to fulfill the purpose of s. 281.75, Stats.(2) The claim shall contain: (a) A claim form available from the department.(b)1. Two water sample analyses results, analyzed by the state laboratory of hygiene or by a laboratory certified under s. 299.11, Stats., which show that the private water supply is contaminated as defined in s. NR 123.03(5); or2. An advisory issued by the department.(c) A description of the proposed replacement water supply. 1. The description shall include an analysis of each of the following options:a. Reconstruction of the contaminated private water supply;b. Construction of a new private water supply;c. Providing for a public water supply to replace the contaminated private water supply; or,d. Providing a connection to an existing private water supply.2. The analysis shall include a detailed description of each replacement water supply alternative or an explanation of why any of the replacement water supply alternatives are considered not feasible. The claimant shall propose the replacement water supply. If it is not feasible to remedy the problem of the contaminated private water supply with a replacement water supply, then a detailed description of the equipment to be used for treating the contaminated private water supply shall be supplied. The department shall approve the least costly feasible replacement water supply which will remedy the contamination.(d) A copy of a plat map indicating the location of the well and the legal description of the property.(e) A copy of an inspection report of the contaminated private water supply completed by the department.(f) An affidavit by the claimant verifying that the information in the claim is true to the best of his or her knowledge.(g) Evidence of annual family income of the landowner or lessee of property on which the contaminated private water supply is located. Evidence of annual family income shall consist of one of the following: 1. A copy of the landowner's or lessee's joint Wisconsin income tax return for the year prior to the year in which the claim is made; or, if filing separately, the landowner's or lessee's separate Wisconsin income tax return and the separate Wisconsin income tax return of his or her spouse, if any, for the year prior to the year in which the claim is made.2. For low income residents of Wisconsin, an affidavit by the landowner or lessee stating that he or she did not have sufficient taxable income in the prior year to be required to file a Wisconsin income tax return. The affidavit shall include the landowner's or lessee's estimate of projected gross income in the current year.3. For part-year residents or non-residents of Wisconsin, a copy of the landowner's or lessee's federal income tax return for the taxable year prior to the year in which the claim is made, the separate federal income tax return for the prior year of his or her spouse, if any, and an affidavit by the landowner or lessee including the landowner's or lessee's estimate of projected gross income in the current year.4. For landowners or lessees with a reduction of income in the current year, an affidavit by the landowner or lessee stating the reason that a reduction in adjusted gross income is expected in the current year, the estimated amount of the reduction in adjusted gross income, and a complete listing of income subject to taxation received since January 1 of the current year. In addition to this affidavit, the landowner or lessee shall provide copy of the documentation required under subd. 1. or 3. Wis. Admin. Code Department of Natural Resources NR 123.22
Cr. Register, March, 1986, No. 363, eff. 4-1-86; am. (2) (c) 2. and cr. (2) (g), Register, February, 1991, No. 422, eff. 3-1-91; correction in (1) and (2) (b) made under s. 13.93(2m) (b) 7, Stats., Register, November, 1999, No. 527.Claim forms are available from any Department of Natural Resources Region Office or from the Department of Natural Resources, Bureau of Community Financial Assistance, P.O. Box 7921, Madison, Wisconsin 53707.