1. Combined
  2. Application for Reimbursement of Expenses for
  3. Sewage Management Program (SMP) Administration
  4. Under the Pennsylvania Sewage Facilities Act
  5. SMP Annual Report
      1. INSTRUCTIONS FOR
      2. FILING COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES FOR
      3. SEWAGE MANAGEMENT PROGRAM (SMP) ADMINISTRATION
      4. UNDER THE PENNSYLVANIA SEWAGE FACILITIES ACT
      5. AND SMP ANNUAL REPORT
      6. Completion of Section G is Required
      7. REIMBURSEMENT APPLICATION
      8. CHECKLIST

Combined

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Application for Reimbursement of Expenses for

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Sewage Management Program (SMP) Administration

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Under the Pennsylvania Sewage Facilities Act
and

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SMP Annual Report
For more information, visit
www.dep.pa.gov
3850-FM-BCW0284
Rev. 1/2018

- 1 -
3850-FM-BCW0284
Rev. 1/2018
COMMONWEALTH OF PENNSYLVANIA
Instructions
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
INSTRUCTIONS FOR
FILING COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES FOR
SEWAGE MANAGEMENT PROGRAM (SMP) ADMINISTRATION
UNDER THE PENNSYLVANIA SEWAGE FACILITIES ACT
AND SMP ANNUAL REPORT
New SMPs, in order to gain the Department of Environmental Protection (DEP) reimbursement recognition, must be
established by the process of an update revision to the municipal or regional Official Sewage Facilities Plan (Official Plan),
including adoption of the plan by resolution of the affected municipality and approval by DEP.
Please read all instructions carefully before completing your application. If any of the information or supporting
documentation is not submitted, unsupported costs will be deducted from total expenses prior to calculating your
reimbursement.
Questions may be referred to 717.787.5017.
Municipalities that are not the local agency (LA), but which administer their own SMPs,
should use this form only to
file for reimbursement of their SMP expenses. These municipalities should not submit a
Combined Application for
Reimbursement for Enforcing the Pennsylvania Sewage Facilities Act and Onlot Sewage Disposal Program Annual Report
form (3850-FM-BCW0280). Both forms are available electronically in DEP's eLibrary online at
www.dep.pa.gov
.
Applications concerning SMP expenses
cannot be submitted directly by or on behalf of municipal authorities.
Only
LAs, or municipalities that meet the requirements of 25
Pa. Code
§71.73(d) are eligible to apply for reimbursement of SMP
expenses.
"First time" SMP reimbursement applications must include a copy of all municipal ordinances, acts, regulations or
procedures used in administrating the applicant's SMP. Subsequent submissions must include a copy of any additions,
deletions and amendments made during the preceding calendar year to municipal ordinances, acts or procedures that
affect the program.
DEADLINE:
Applications must be received by DEP no later than March 1, 2018.
Submit your application to:
Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P. O. Box 8774
Harrisburg, PA 17105-8774

3850-FM-BCW0284
Rev. 1/2018
Instructions
- 2 -
COMPLETE ALL SECTIONS AS INDICATED:
SECTION A.
a.
Item 2 - The municipal official must be an elected official or a person appointed to a responsible position with the
municipality, such as the Municipal Secretary or the Chairman of the Board of Supervisors. A Sewage Enforcement
Officer (SEO) cannot be named as the official.
b.
Item 8 - If your county has a county health department, enter its name here. If your municipality is served by a
multimunicipal agency for permitting of onlot sewage disposal systems only, enter that agency name here.
SECTION B.
Complete after Sections C and D are completed.
SECTION C.
a.
List only SMP reimbursable expenses.
Eligible costs include administrative, personnel and equipment costs
associated with SMPs. These expenses
must be itemized and completely documented
by one copy of the
Activity Record,
Section F, or
invoices
equivalent to the form. Activity records or invoices must identify the specific
person who performed each activity. Expenses under each cost category must be totaled in the right-hand column
under "Total Expenses," and this total must be entered in Section B.1.
25
Pa. Code
§72.44 contains a complete listing of eligible and ineligible costs for reimbursement of sewage facilities
permitting programs. Where applicable, these listings also apply to SMP reimbursements. Justification must be
submitted to support reimbursement requests for unlisted categories. Questions on eligibility of specific items can
be asked by calling 717.787.5017.
b.
One copy of proof of payment
(canceled checks or other records acceptable to DEP) must be submitted for
all
expenses claimed.
Expenses which are not supported by the above documentation will not be considered for reimbursement.
Your claim for expenses must be consistent with 25 Pa. Code §72.44 available electronically at
www.pacode.com
.
SECTION D.
Enter the revenue from SMP related fees, fines, other money and uncollected revenue (money owed to the
municipality). Enter the total revenue here and in Section B.2.
SECTION E.
Enter the individual fees and fines assessed to system owners under the SMP.
Do not
enter total fees, fines
or other income received.
SECTION F.
Activity Record. Submit copies of DEP activity records or invoices equivalent to the form.
SECTION G.
Completion of this section is required. This section is being used to track program activity statistics.
SECTION H.
This affidavit should be executed by the municipal official designated in Section A, who is sworn by a notary
public. The seal and signature of the notary public must be affixed. In the case of townships of the second class, the
township seal may be affixed with the certifying official's signature in lieu of notarization when this action has been approved
by the township supervisors.
SUBMIT 3 COPIES OF THE COMPLETED APPLICATION WITH ORIGINAL SIGNATURES AND EMBOSSED SEALS,
AND 1 COPY OF ACTIVITY RECORDS, INVOICES, PROOF OF PAYMENT AND MUNICIPAL ORDINANCES. KEEP
A COPY FOR YOUR RECORDS.
IF REIMBURSEMENT OF SMP EXPENSES IS NOT REQUESTED, SECTIONS A, G AND H STILL MUST BE
COMPLETED AND SUBMITTED.

3850-FM-BCW0284
Rev. 1/2018
COMMONWEALTH OF PENNSYLVANIA
Form
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF CLEAN WATER
- 1 -
COMBINED APPLICATION FOR REIMBURSEMENT OF EXPENSES
FOR SEWAGE MANAGEMENT PROGRAM (SMP) ADMINISTRATION
UNDER THE PENNSYLVANIA SEWAGE FACILITIES ACT
AND SMP ANNUAL REPORT
FOR APPLICATION YEAR ENDING December 31, 20
READ ALL INSTRUCTIONS BEFORE COMPLETING. APPLICATION MUST BE RECEIVED BY THE DEPARTMENT OF
ENVIRONMENTAL PROTECTION (DEP) NO LATER THAN
MARCH 1
FOR ALL DUTIES PERFORMED FROM JANUARY 1
THROUGH DECEMBER 31 OF PRECEDING YEAR.
SECTION A
1.
Applicant (Municipality)
2.
Name and Title of Municipal Official
E-Mail Address (Optional)
3. Daytime Telephone Number
4.
County
5.
Federal I.D. No.
6.
Address
7
City
Zip
8. Name of Authorized Local Agency (LA) or County Health Department
SECTION B - REIMBURSEMENT REQUEST
1. TOTAL EXPENSES
$
2. NET REVENUE
$
3. PROGRAM DEFICIT
(subtract 2 from 1)
$
4. REIMBURSEMENT REQUESTED
(This is the program deficit, shown on
Line 3, but not more than 50% or 85% of
the total expenses shown on Line 1,
according to the LA's reimbursement level,
Item 8, above.)
$
DEP USE ONLY
5. Reviewer's Initials and Approval Date
/
/
Submit your application in triplicate, 1 copy of supporting documentation (if requesting
reimbursement) no later than March 1, 2018 to:
Pennsylvania Department of Environmental Protection
Bureau of Clean Water
Division of Municipal Facilities
P.O. Box 8774
Harrisburg, PA 17105-8774

3850-FM-BCW0284
Rev. 1/2018
Form
- 2 -
SECTION C - ITEMIZED EXPENSES
Copies of activity records or itemized invoices and proof of payment for these expenses must be submitted.
COST OBJECT
AMOUNT
OBJECT TOTAL
Municipal/LA Personnel Expenses
$
$
Administrative & Clerical Expenses
$
Inspection Services
$
Consultant Services
$
Materials & Supplies
$

3850-FM-BCW0284
Rev. 1/2018
Form
- 3 -
COST OBJECT
AMOUNT
OBJECT TOTAL
Legal Services
$
Auto Expense
miles @
¢/mile
$
Social Security and Medicare Expenses
$
Other Expenses
$
Total Expenses:
$
Enter Total Expenses in Section B.1.
NOTE: Expenses are subject to audit by DEP or its authorized representative.
SECTION D - REVENUE
1. Total Revenue from Inspection Fees
$
2.
Other Money Received - specify, i.e., assessments,
money from other agencies or departments
$
3.
Fines, interest, etc.
$
4.
Uncollected Revenue - specify, i.e., Accounts Receivable,
to include unpaid fines and assessments
$
Total Revenue
$
Less Refunds
$
Net Revenue
$
Enter Net Revenue in Section B.2.

3850-FM-BCW0284
Rev. 1/2018
Form
- 4 -
SECTION E - SCHEDULE OF INSPECTION FEES AND FINES
Standard Fees/Charges to
Municipality or LA by
Contracted Inspectors (If
Applicable)
Standard Fees/Fines
to Property Owners
(Municipal or LA
Income)*
Residential
Other
Residential
Other
Type of Activity:
Pumping/Inspection Notice Sent
Fine for Failure to Report
Liens Placed
Eviction Notices Served
Cesspools
Inspection
Inground Gravity Bed
Inspection
Inground Pressure Dosed Bed
Inspection
Sand Mound Non-Pressure Dosed Inspection
Sand Mound Pressure Dosed
Inspection
Individual Residential Spray
Irrigation System (IRSIS)
Inspection
Small Flow Spray Pre-IRSIS
Inspection
Small Flow Stream Discharge
Inspection
Large Volume Community Onlot
Inspection
Spray > 2000 gallons per day (gpd) Inspection
Other Non-Municipally Owned
Sewage Treatment Plants
Inspection
Non-Municipally Owned Pump
Stations, Lift Stations, etc.
Inspection
Other (List & Identify)
* This section must be consistent with the LA's current fee schedule.

3850-FM-BCW0284
Rev. 1/2018
Form
- 5 -
SECTION F - ACTIVITY RECORD FOR ADMINISTRATION OF
PENNSYLVANIA SMPs UNDER THE ACT
Activity Report for
SEO
SECY
Other
Name
Position
Salaried
Flat Hourly Rate
Mileage Rate
¢
Date
Description of Activity
A.
Total
Time
Spent
in
Hours
B.
Fee
Charged
(Contracted
Services
Only)
C.
Personal
Auto
Miles
Claimed
D.
Description of
Equipment &
Supplies
Purchased
E.
Cost of
Equipment
& Supplies
(Invoice
Required)
TOTAL THIS PAGE
Hourly Employees – Total Hours (A) x Hourly Rate = Total Employee Cost
$
Contracted Services – Total Fees Charged (B) – Invoices Required
$
Salaried Employees – Total Hours (A) on SMP ÷ Total Annual
Hours
x Annual Salary & Benefits
= Total Employee Cost
$
All Employees – Total Personal Miles (C) x Mileage Rate = Total Vehicle Cost
$
All Employees – Total Cost of Equipment & Supplies Purchased x (E) - Invoices Required
$
TOTAL COST TO SMP
$
This activity record or its equivalent must be used to track SMP time spent by salaried employees. The municipality or LA may
also require contracted individuals to submit this activity record or its equivalent, in addition to the required invoices. Invoices
must be provided for any items purchased and services contracted.
Period Covered

3850-FM-BCW0284
Rev. 1/2018
Form
- 6 -
Completion of Section G is Required
Date of approval of the Official Plan approving the SMP (See page 1, paragraph 1)
Status of the approved SMP (choose one)
Implemented
Under active development
Not implemented
SECTION G - SUMMARY OF SMP ACTIVITY
FROM JANUARY 1 THROUGH DECEMBER 31 OF PRECEDING YEAR
A.
Number of
Systems in
Each Category
in SMP*
B.
Operation and
Maintenance
(O & M)
Educational
Materials Sent
to Property
Owners
C.
Number of
Pumping/
Maintenance
Requirement
Notices Sent
D.
Number of
Pumping
Receipts/
Maintenance
Receipts
Received
E.
Number of
Municipal
Inspections
Performed**
F.
Enforcement Actions
Taken in Response to
Inspections or to
Property Owner's
Refusal to Comply with
SMP Requirements
1.
Aerobic Treatment Tank
2.
Septic Tank
TOTAL
How many of the systems in your management area use the following means of disposal? Please enter program activity as it relates to systems having
methods of disposal listed below.
A.
B.
C.
D.
E.
F.
1.
Holding Tanks
2.
Cesspools
3.
Gravity Inground Bed/Trench
4.
Pressure Dosed Inground Bed/
Trench
5.
Non-Pressure Dosed Elevated
Sand Mound
6.
Pressure Dosed Elevated Sand
Mound/Trench
7.
IRSIS
8.
Pre-IRSIS Small Flow Spray
9.
Small Flow Stream Discharge
10.
Large Volume Community Onlot
11.
Spray > 2000 gpd
12.
Other Non-Municipally Owned
Sewage Treatment Plants
13.
Non-Municipally Owned Pump
Stations, Lift Stations, etc.
14.
Other (List & Identify)
TOTAL
*
Information requested in Column A is for the total number of systems included in the SMP. Information requested in Columns B through
F is for related SMP activity during the preceding year.
** Inspections performed by a consulting firm employed by the municipality or LA must also be included in Column E.

3850-FM-BCW0284
Rev. 1/2018
Form
- 7 -
SECTION H - AFFIDAVIT
Affidavit must be completed and signed before a notary public by the municipal/LA official named in Section A.4. In the case of townships
of the second class, the township seal may be affixed hereto with the official's signature in lieu of the seal of a notary public. Is applicant
a second class township?
Yes
No
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
I,
, being duly sworn according to law, depose and say that I am an official
of the applicant and that the information included in the application and documents submitted as a part of the application are true and
correct to the best of my knowledge and belief.
Sworn to and subscribed before me this
day of
, 20
.
Signature of Notary Public
Signature of LA Official
MY COMMISSION EXPIRES
Title
SEAL
SMP
REIMBURSEMENT APPLICATION
CHECKLIST
A completed application for SMP reimbursement consists of:
1. Three copies of this completed application with original signatures and embossed seals.
2. One copy of activity records and/or invoices for all expenses claimed.
3. One copy of cancelled checks (both sides), W-2 forms and/or payroll records for all expenses claimed.
4. One copy of report of revenue listed in Section D.
5. One copy of all municipal ordinances, acts, regulations, or procedures used in administrating the applicant's SMP, for
first time applications. Subsequent submissions must include a copy of any additions, deletions and amendments
made during the preceding year to municipal ordinances, acts or procedures that affect the SMP.

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