New Submission

This application is for the preceding fiscal year July 1st through June 30th.
Discarded Computer Equipment and Television Management Act
In order to be eligible for funds, this application must be submitted by December 31st annually. Application submittal period begins November 1st.
Unit of Local Govenment [ULG] Name:*field type single line
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1. ULG Electronics Recycling Coordinator [Do not list recycler business contact information]:

A. Name:*field type single line
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B. Direct Phone:*field type single line
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C. Mobile Phone:field type single line
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D. E-mail Address:*field type email

2. Program Questions

Covered Device means, in part, computer equipment (including laptops, desktops, tablets, notebooks, gaming systems, monitors, printers, scanners, and virtual reality headsets) and televisions used by consumers primarily for personal or home business use.

Consumer means a covered device used for personal or home business use and for a nonprofit with fewer than 10 employees.

Other Electronics means devices that are not computer equipment or televisions.
1. Describe the ULG’s program to recycle or reuse discarded computer equipment, televisions, and other electronic devices. Include the types of electronics collected, how they are collected, and how they are handled and stored prior to recycling or reuse?*field type richtext
2. Describe the ULG’s discarded computer equipment, televisions, and other electronic devices public awareness and education program?*field type richtext
3. Does the ULG utilize a recycling information webpage?*field type checkbox
3. Does the ULG utilize a recycling information webpage?YesNo
If yes, list the web address:field type single line
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4.
Submit a copy of all recycler trailer invoices: tally electronics tons and total charges on each invoice and list the total of all electronics tons and total charges on the last invoice

OR submit an itemized list of all electronics invoices to include: destination(s), dates, invoice numbers, electronics tons and total charges for each invoice and the total electronics tons and the total charges for all invoices.
A. Invoice/Itemized List: (Submit as one document)*field type file upload
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B. Total Electronics Tons Reporting:
Amount of the TOTAL Electronics recycled that is TVs (tons)*field type number
Amount of the TOTAL TVs that is CRT (tons)*field type number
Amount of the TOTAL Electronics recycled that is Computer Equipment (tons)*field type number
Amount of the TOTAL Computer Equipment that is CRT (tons)*field type number
Amount of the TOTAL Other Electronics recycled (tons)*field type number
Total amount of electronics received that is being stored by the ULG if none were hauled to an electronics recycler during the preceding fiscal year (tons)*field type number
If not applicable, please write in 0.00
Total Electronics Tons (This number equals the total tons the ULG collected during the previous fiscal year):*field type single line
Automatically calculated.
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C. Total invoice charges:*field type currency
$
D. The average weight (in tons) of all electronics trailers hauled to the electronics recycler (total tons divided by the number of trailers):*field type single line
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E. The number of trailers hauled to the electronics recycler:*field type single line
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F. The average cost of all trailers hauled to the electronics recycler (total invoice charges divided by the number of trailers):*field type single line
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G. Does the ULG charge for the collection of computer equipment (covered devices) primarily for personal use?:*field type radio button
G. Does the ULG charge for the collection of computer equipment (covered devices) primarily for personal use?:YesNo
H. Does the ULG charge for the collection of televisions (covered devices) primarily for personal use?:*field type radio button
H. Does the ULG charge for the collection of televisions (covered devices) primarily for personal use?:YesNo
I. Does the ULG charge for the collection of computer equipment (non-covered devices) for business use?:*field type radio button
I. Does the ULG charge for the collection of computer equipment (non-covered devices) for business use?:YesNo
J. Does the ULG charge for the collection of televisions (non-covered devices) for business use?:*field type radio button
J. Does the ULG charge for the collection of televisions (non-covered devices) for business use?:YesNo
K. Does the ULG track the number of business use computer equipment and televisions received?:*field type radio button
K. Does the ULG track the number of business use computer equipment and televisions received?:YesNo
L. Does the ULG track the number of personal use computer equipment and televisions received?:*field type radio button
L. Does the ULG track the number of personal use computer equipment and televisions received?:YesNo
M. Does the ULG receive electronics from other counties within the state?:*field type radio button
M. Does the ULG receive electronics from other counties within the state?:YesNo
N. Does the ULG receive electronics from other states?:*field type radio button
N. Does the ULG receive electronics from other states?:YesNo

ULG Electronics Charges

Please add a new electronics type for each unique charge.

	Electronics Typefield type single line	Corresponding Chargefield type currency
Row 1×	Electronics Typefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Corresponding Chargefield type currency $	×

Click to Add New Electronics Type and Corresponding Charge

5. Describe the ULG’s collaboration with other ULGs to provide or receive collection services for discarded computer equipment, televisions, and other electronic devices.*field type richtext
6. List the ULG's electronics management program budget account information for the preceeding fiscal year:
Beginning Balance [July 1st]:*field type currency
$
Previous fiscal year money received from the Electronics Management Fund:*field type currency
$
Revenue from Fees Collected for Computer Equipment and Televisions:*field type currency
$
Other Monies Provided to the ULG Program:*field type currency
$
Expenditures (to include total invoice charges):*field type currency
$
Ending Balance [June 30th]:*field type currency
$Automatically Calulated.
7. Describe how the ULG will use monies received from the Electronics Management Fund:*field type richtext
8. Does the ULG's discarded computer equipment, televisions, and other electronic devices recycler have Responsible Recycling (R2) or e-Stewards certification?*field type single line
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If no, the ULG is not eligible to receive funding.
9. List the ULG's discarded computer equipment, televisions, and other electronics devices recycler:
A. Electronics Devices Recycler Name:*field type single line
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Street Address:*field type single line
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Address Line 2:field type single line
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City:*field type single line
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State:*field type single line
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Zip Code:*field type single line
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B. Phone:*field type single line
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C. Company Website:*field type single line
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D. Recycler Contact Name:*field type single line
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E. Recycler Contact Phone:*field type single line
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F. Recycler Contact Email:*field type single line
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10. Does the ULG use a third-party hauler that is not an R2 or e-Stewards certified recycling company to deliver discarded computer equipment, televisions, and other electronic devices to the certified recycler? If yes, provide the third-party hauler information.*field type checkbox
10. Does the ULG use a third-party hauler that is not an R2 or e-Stewards certified recycling company to deliver discarded computer equipment, televisions, and other electronic devices to the certified recycler? If yes, provide the third-party hauler information.YesNo
Hauler Company Name:field type single line
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Hauler Street Address:field type single line
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Hauler Address Line 2:field type single line
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City:field type single line
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State:field type single line
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Zip Code:field type single line
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Hauler Contact Name:field type single line
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Hauler Contact Phone:field type single line
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If the ULG uses a third-party hauler that is not certified, the ULG is responsible to ensure that the discarded computer equipment, televisions, and other electronic devices are not dismantled and are delivered to a certified recycler in a timely manner.

3. Attachments

A. Submit the ULG’s contract or agreement with the R2 or e-Stewards certified recycler. The contract or agreement shall be current per previous fiscal year, signed, and dated; OR if the ULG does not have a contract or agreement submit recycler invoices; OR Certificate of Destruction specific to each invoice; OR a letter, on company letterhead, that is signed and dated within the preceding fiscal year or to-date from the certified recycler stating that it receives/received discarded computer equipment, televisions, and other electronic devices from the ULG (DO NOT include a copy of a Statewide Term Contract).*field type file upload
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B. Submit a copy of the R2 or e-Stewards certification for the recycler(s) used by the ULG for the preceding fiscal year. Ensure the certification is current.*field type file upload
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You have reached the maximum file limit: 3.
C. Additional Information:field type richtext

4. Applicant Certification

This application is required to be completed in full in order to be considered for a fund distribution.
I certify that by applying to the Electronics Management Fund that the information provided is an accurate description of the unit of local government's electronics management program.
A copy of this application has been received by the ULG Finance Officer.*field type checkbox
A copy of this application has been received by the ULG Finance Officer.Yes
Finance Officer Name:*field type single line
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Finance Officer Title:*field type single line
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Finance Officer Phone:*field type single line
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Finance Officer Email:*field type single line
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Applicant Signaturefield type signature
Applicant Name:*field type single line
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Applicant Title:*field type single line
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Applicant Phone:*field type single line
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Applicant Email:*field type single line
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Date*field type date

Electronics Management Fund Annual Application

1. ULG Electronics Recycling Coordinator [Do not list recycler business contact information]:

2. Program Questions

3. Attachments

4. Applicant Certification