APPENDIX IV
Letter From Chief Financial Officer


A letter from the chief financial officer as specified in Chapter13, §009 of this Title must be worded as follows, except that instructions in brackets are to be replaced with the relevant information and the brackets deleted.
Letter From Chief Financial Officer

{Address to Director, Nebraska Department of Environmental Quality, Box 98922, , Lincoln, NE 68509}

I am the chief financial officer of {name and address of firm.} This letter is in support of this firm's use of a bond without surety as financial assurance and to meet the financial test in Title 122, Chapter13,§009.01.

{Fill out the following paragraph regarding injection wells and associated cost estimates. For each injection well, include its name, address, and current EPMC cost estimate.}

This firm is the operator of the following injection wells for which financial assurance for EPMC is demonstrated through the financial test specified in Title 122, Chapter13, §009.01. The current EPMC cost estimate covered by the test is shown for each injection well:

The fiscal year of this firm ends on {month, day}. The figures for the following items marked with an asterisk are derived from this firm's independently audited, year-end financial statements for the latest completed fiscal year ended {date}.

{Fill in Alternative I if the criteria of section 009.01A of Chapter 13, Title 122 are used. Fill in Alternative II if the criteria of section 009.01B of the same Chapter and Title are used}.
Alternative I
1. Current EPMC costs.$ ___________
*2. Total liabilities {If any portion of the EPMC costs is included in total liabilities, you may deduct the amount of that portion from this line and add that amount to lines 3 and 4}.$ ___________
*3. Tangible net worth$ ___________
*4. Net worth$ ___________
*5. Current assets$ ___________
*6. Current liabilities$ ___________
*7. Net working capital (line 5 minus line 6)$ ___________
*8. The sum of net income plus depreciation, depletion and amortization$ ___________
*9. Total assets in U.S. (required only if less than 90% of firm's assets are located in U.S.)$ ___________

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

YesNo
10. Is line 3 at least $10 million?__________
11. Is line 3 at least 6 times line 1? __________
12. Is line 7 at least 6 times line 1? __________
13. Are at least 90% of firm's assets located in U.S.? If not, complete line 14. __________
14. Is line 9 at least 6 times line 1? __________
15. Is line 2 divided by line 4 less than 2.0? __________
16. Is line 8 divided by line 2 greater than 0.1? __________
17. Is line 5 divided by line 6 greater than 1.5? __________
Alternative II

1. Current EPMC $ ___________


2. Current bond rating of most recent issuance of this firm and name of rating service

____________________________________________________________________

3. Date of issuance of bond ________________________________

4. Date of maturity of bond ________________________________

*5. Tangible net worth {If any portion of the EPMC cost estimate is included in "total liabilities" on your firm's financial statements, you may add the amount of that portion to this line} $ ___________

*6. Total assets in U.S. (required only if less than 90% of firm's assets are located in U.S.) $ ______

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

YesNo
7. Is line 5 at least $10 million?__________
8. Is line 5 at least 6 times line 1?__________
*9. Are at least 90% of firm's assets located in the U.S? If not, complete line 10.__________
10. Is line 6 at least 6 times line 1?__________


I hereby certify that the wording of this letter is identical to the wording specified in Title 122, Chapter 13 §009 as such regulations were constituted on the date shown immediately below.

_______________________________________
{Signature}

_______________________________________
{Name}

_______________________________________
{Title}

_______________________________________
{Date}


Nebraska Department of Environmental Quality
1200 "N" Street, Suite 400
P.O. Box 98922
Lincoln, Nebraska 68509
(402) 471-2186