Local Government Financial Assurance Form

This form or an equivalent must be submitted to the landfill record and available for review no later than 180 days following the close of the fiscal year. 40 CFR 258.74(f)(3)(iii)

You can find more information on our Local Government Financial Assurance webpage.

Landfill Name*

Submitted for Fiscal Year*

The current cost estimate for closure and post-closure of the landfill is: *

The current cost estimate for corrective action for the landfill is:

Note: Corrective action costs are only required if a long term remediation project for the landfill is currently required.

The cost for closure, post-closure and corrective action is not greater than:*

43% of the local government’s total annual revenue, if the local government does not assume other environmental obligations through a financial test, or43% of the local government’s total annual revenue for the total of all environmental obligations assured through a financial test.¹

Currently, the Local Government has:*

Outstanding general obligation bonds rated no lower than Baa for Moody’s or BBB for Standard and Poor, orThe following financial ratios: 1) Cash plus marketable securities to total expenditures greater than or equal to 0.05, and 2) Annual debt service to total expenditures less than or equal to 0.20.

The signer certifies the local government’s comprehensive annual financial report was:*

1) Prepared in conformity with Generally Accepted Accounting Principles for governments, 2) Audited by an independent, certified public accountant, and 3) The auditor issued an unqualified opinion for the report.

The signer certifies the local government:*

1) Is not currently in default on any outstanding general obligation bonds, 2) Has no outstanding general obligation bonds rated lower than Baa as issued by Moody’s or BBB as issued by Standard and Poor’s, and 3) Has not operated at a deficit equal to 5% or more of total revenue in each of the past two fiscal years.

Chief Financial Officer (CFO)*

First NameLast Name

City/Borough Name*

CFO Email*

example@example.com

CFO Signature*

I certify that the local government has complied with the provisions of 18 AAC 60.398 for financial assurance by complying with the following section of 40 CFR 258.74(f) Local Government Financial Test.

Date*

Date

¹The total of all environmental obligations including landfill closure must be considered when addressing the 43% limit. This would include such things as UIC facilities under 40 CFR 144.62, petroleum underground storage facilities under 40 CFR 280, PCB storage facilities under 40 CFR 761, and hazardous waste treatment, storage, and disposal facilities under 40 CFR 264 and 265.

Local Government Financial Assurance Form

Certifications