INSTRUCTIONS: All reported information must be legible (print/type) and complete. The completed application, along with a copy of Mohave Electric Cooperative's "adjustment to actual costs," must be sent to: Mohave County Attorney, Valle Vista Redress Program, P.O. Box 7000, Kingman, Arizona 86402-7000.

This application is to be used when Mohave Electric Cooperative issues an "adjustment to actual cost" and advises the lot owner that a further payment is due because the actual cost of electric utility installation is greater than the estimate set forth in the "actual cost contract." If the Mohave County Attorney confirms that the initial payment to Mohave Electric Cooperative from the Utility Account on behalf of the lot owner was less than $8,000, the Mohave County Attorney will authorize a second transfer of monies from the Utility Account to Mohave Electric Cooperative, provided however, that the total payments from the Utility Account for the specified lot may not exceed $8,000 or total reimbursable costs, whichever is less.

Date of Application for Additional Payment: ____________________________

Valle Vista Lot Description: Lot No. ______ Parcel: _______________ Unit:________

Date of Application for Reimbursable Costs: _______________________

Name of lot owner(s): _____________________________________________________


Current address: __________________________________________________________


Telephone Numbers: Home: ___________________ Work: _____________________

Fax: _______________ Cellular Phone: ____________________

IMPORTANT: Attach copy of "adjustment to actual cost" to this application.

I (We), ________________________________________________(print names), acknowledge and attest that the information contained in this application is truthful and complete and that this application has been submitted under penalty of perjury.

By: ____________________________________ Date: _____________________

By: ____________________________________ Date: _____________________