Title of Regulation: 12VAC5-620. Regulations Governing Application Fees for Construction Permits for Onsite Sewage Disposal Systems and Private Wells (amending 12VAC5-620-10, 12VAC5-620-30, 12VAC5-620-40, 12VAC5-620-50, 12VAC5-620-70 through 12VAC5-620-100; adding 12VAC5-620-75; repealing 12VAC5-620-20).

Statutory Authority: §§ 32.1-12, 32.1-164, and 32.1-176.4 of the Code of Virginia.

Public Hearing Information:

January 13, 2014 - 1 p.m. - Department of Health, 9960 Mayland Drive, Perimeter Center, Training Room #2, Richmond, VA 23233

Public Comment Deadline: February 14, 2014.

Agency Contact: Jim Bowles, Department of Health, 109 Governor Street, Richmond, VA 23219, telephone (804) 864-7475, or email jim.bowles@vdh.virginia.gov.

Basis: The authority for these regulations is found in the following sections of the Code of Virginia:

1. § 32.1-12 provides the authority to make, adopt, and promulgate regulations necessary to carry out the provisions of Title 32.1 of the Code of Virginia.

2. § 32.1-164 C provides the authority to charge a fee for filing an application for an onsite sewage system or an alternative discharging sewage system permit with the department, to waive application fees for persons whose income is below the federal poverty guidelines or whose application is for the construction of a pit privy, and to refund the application fee when the department denies a permit for land upon which the applicant proposed to construct his principle place of residence.

3. § 32.164 E provides the authority to charge fees for installation and monitoring inspections of alternative discharging systems.

4. § 32.164 G provides the authority to charge fees for letters recognizing the appropriateness of onsite sewage site conditions in lieu of issuing onsite sewage system permits (i.e., certification letters).

5. § 32.1-164.1:2 C provides the authority to charge fees for betterment loan eligibility letter requests.

6. § 32.1-166.10 provides the authority to establish a reasonable fee to be charged to the appealing party commensurate with the time and expenses related to the handling of each appeal to the Review Board.

7. § 32.1-176.4 B authorizes fees for private well construction permits, the waiver of fees for persons whose incomes are below the federal poverty guidelines or when the application is for a replacement well, and the refund of the application fee when a permit is denied for land on which the applicant seeks to construct his principle place of residence.

8. § 32.1-176.4 C authorizes a fee for geothermal well system applications that will be equal to the fee for a private well construction permit and mandates a single fee for any geothermal system.

Purpose: This action protects the public health, safety, and welfare by establishing fees that support the agency's ability to provide services that ensure that sewage is adequately treated and disposed of, reducing the risk of sewage-borne and water-borne disease.

The current regulation is out of date because applicable sections of the Code of Virginia have been amended since the regulation was written. The regulation explains to citizens the requirements for application fees, the potential right to a waiver of the fees, their potential right to obtain a refund of the fee in the event that an application is denied, and the board's procedures for refunds.

Substance: The proposed changes remove references to specific fee amounts and require that the Commissioner of Health establish a schedule of fees based on current provisions of the Code of Virginia, the appropriation act, and the cost to the agency to provide services. Additionally, the proposed regulations incorporate Code of Virginia requirements related to fees for alternative discharging sewage systems for single family homes.

The proposed changes allow district health directors to reduce fee amounts for exceptional individual circumstances on a case-by-case basis; waive the fee for an application to abandon a well at the owner's primary residence; provide for a refund of the application fee for a replacement well after the existing well is properly abandoned rather than waive the fee at the time of application; and clarify that a request for refund must be made in writing and within 12 months of final agency action on the application.

Issues: The advantage to the public and the Commonwealth is that the proposed regulation codifies current requirements of the Code of Virginia and agency policy. This action will reduce uncertainty and potential inconsistency in application of the board's and regulations. The regulatory action poses no disadvantages to the public or the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The State Board of Health proposes to 1) establish that the fees charged for construction, maintenance and repair or replacement of onsite sewage disposal systems, alternative discharge systems, and private wells will be the maximum allowed by the Code of Virginia or the 2010 Appropriation Act and that the permit fee for a minor modification of an existing system will be half of the fee for onsite sewage disposal system construction permit, 2) allow the Virginia Department of Health to charge a fee for applying to replace a private well, to refund the fee upon permanently abandoning or decommissioning the old well, and to clarify that no fee will be charged for decommissioning of a private well in cases where no replacement is planned, and 3) clarify that refunds must be requested in writing within 12 months of the denial of the permit, withdrawal of the application, or the conclusion of the appeal process.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. One of the proposed changes establishes that the fees charged for construction, maintenance, and repair or replacement of onsite sewage disposal systems, alternative discharge systems, and private wells will be the maximum allowed by the Code of Virginia or the 2010 Appropriation Act. In addition, the permit fee for a minor modification of an existing system will be half of the fee for the onsite sewage disposal system construction permit.

The current fee amounts in the regulations were established in 1988¹. Since then the fees were revised by legislation in 1994², 2003³, 2008⁴, and 2010⁵, but the specific amounts in the regulations have not been updated. Historically, the actual amounts of fees charged by the Virginia Department of Health (VDH) have been the maximum allowed by the legislation. According to VDH, updating the regulations to reflect the specific amount of fees has been impractical due to the high frequency of legislative actions affecting fees.

The proposed changes will establish that the fees are the maximum allowed by legislation except for minor modifications to existing permits where the fee would be 50% of the regular amount. However, the regulations will not contain a specific amount for the fees. This approach will allow VDH to update their fee schedule very quickly through an exempt regulatory action. Since the actual fees currently charged are the same as the maximum allowed by the legislation, no significant economic effect is expected. The main benefit of this proposed change is the elimination of potentially confusing differing amounts in the regulations and what is being charged in practice. In addition, VDH will charge lower fees for minor modification permits since they require less administrative work to process. Based on fiscal year 2011 data, VDH estimates that approximately 247 to 495 applications may be submitted for a minor modification permit which is expected to lower fee revenues between $48,893 and $97,587 per year. The main benefit of this change is to adjust the fee scale to be commensurate with the relative time it takes to process minor modification permits.

Another proposed change will allow VDH to charge a fee for applying to replace a private well and to refund the fee upon permanently abandoning or decommissioning the old well. Currently, VDH does not charge any fees at the time of the initial application for replacement wells. In addition, the proposed changes will clarify that no fee will be charged for decommissioning of a private well in cases where no replacement is planned. In 2011, VDH received 1,175 applications for private well replacements and 379 applications to abandon wells.

The main cost of this change falls on the applicants who will have to pay a fee amount to be reimbursed at a later time when the well is decommissioned. These applicants will have a reduced liquidity until they get their refund back and will have to absorb the time value associated with the fee amount being held by VDH for a period of time.

On the other hand, this change will provide additional incentives to properly close a well and to provide information to VDH about the wells that are closed. According to VDH, improperly abandoned or decommissioned wells pose fall risks, groundwater contamination risks, and improper use risks such as being used as an illegal sewage dumping place.

The proposed changes will also clarify that refunds must be requested in writing within 12 months of the denial of permit, withdrawal of the application, or the conclusion of the appeal process. According to VDH, currently there is some confusion surrounding the procedures for refunds. This proposed change is expected to clarify the conditions and time period in which a refund can be requested.

The remaining proposed changes are clarifications of other current requirements or incorporation of changes in the Code of Virginia and current policies followed in practice. Thus, no significant economic effects are expected from remaining changes other than improving the clarity of the regulations.

Businesses and Entities Affected. In 2011, VDH received approximately 20,000 sewage disposal or private well construction applications from an estimated 15,000 individuals and businesses. In addition, there are approximately 350 licensed individuals providing site evaluation or design services for onsite sewage disposal systems, single family discharge sewage systems, and installation of private wells.

Localities Particularly Affected. The proposed regulations apply throughout the Commonwealth.

Projected Impact on Employment. The proposed changes are expected to reduce the need for administrative staff time that would have been necessary to update the regulations through the standard regulatory process on a frequent basis.

Effects on the Use and Value of Private Property. The proposed changes are not expected to have a significant direct effect on the use and value of private property. However, the proposed reduction in fees for minor modifications may contribute to the value of homes as it could be considered as a reduction in potential maintenance costs. Also, increased incentives to properly close wells may lead to a reduction in the number of inappropriate closures and add to the value of private property at the aggregate.

Small Businesses: Costs and Other Effects. Of the 350 licensed individuals providing site evaluation or design services for onsite sewage disposal systems, single family discharge systems, and installation of private wells who may be affected by the proposed regulations, the majority are estimated to be small businesses. While the proposed changes do not impose any direct costs on these small businesses, other effects on them are the same as discussed above.

Small Businesses: Alternative Method that Minimizes Adverse Impact. The proposed changes do not impose any significant adverse impact on the small businesses.

Real Estate Development Costs. No significant direct impact on real estate development costs is expected.

Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 14 (10). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB's best estimate of these economic impacts.

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¹ Chapter 203, 1988 Acts of Assembly.

² Chapter 747, 1994 Acts of Assembly.

³ Item 314, 2003 Appropriation Act.

⁴ Item 296, 2008 Appropriation Act.

⁵ Item 287, 2010 Appropriation Act.

Agency's Response to Economic Impact Analysis: The Virginia Department of Health concurs with the economic impact analysis that was posted to the Virginia Town Hall website on January 26, 2012.

Summary:

The proposed amendments (i) clarify that an application fee is required for an alternative discharging sewage system; (ii) clarify that an application fee is required for a letter certifying that a site is suitable for installation of an onsite sewage disposal system; (iii) clarify the application fee for closed-loop geothermal well systems; (iv) provide for fees of varying amounts based on the cost to the agency for processing the application; (v) provide authority to waive the application fee where beneficial to public health and safety; and (vi) clarify that an applicant may not receive a refund for denial of an application if the applicant is actively pursuing an administrative appeal of the denial.

CHAPTER 620
REGULATIONS GOVERNING APPLICATION FEES FOR CONSTRUCTION PERMITS FOR ONSITE SEWAGE DISPOSAL SYSTEMS, ALTERNATIVE DISCHARGE SYSTEMS, AND PRIVATE WELLS

Part I
Definitions

12VAC5-620-10. Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise:

"Agent" means a legally authorized representative of the owner.

"Alternative discharging system" means any device or system that results in a point source discharge of treated sewage for which the board may issue a permit authorizing construction and operation when the system is regulated by the State Water Control Board pursuant to a general Virginia Pollutant Discharge Elimination System permit for an individual single family dwelling with flows less than or equal to 1,000 gallons per day.

"Board" means the State Board of Health.

"Certification letter" means a letter issued by the commissioner in lieu of a construction permit, which identifies a specific site and recognizes the appropriateness of the site for an onsite wastewater disposal system.

"Commissioner" means the State Health Commissioner.

"Construction of private wells" means acts necessary to construct private wells, including the location of private wells, the boring, digging, drilling, or otherwise excavating a well hole and installing casing with or without well screens, or well curbing.

"Department" means the Virginia Department of Health.

"Dewatering well" means a driven well constructed for the sole purpose of lowering the water table and kept in operation for a period of 60 days or less. Dewatering wells are used to allow construction in areas where a high water table hinders or prohibits construction and are always temporary in nature.

"Family" means the economic unit which shall include the owner, the spouse of the owner, and any other person actually and properly dependent upon or contributing to the family's income for subsistence. A husband and wife who have been separated and are not living together, and who are not dependent on each other for support, shall be considered separate family units. The family unit, which is based on cohabitation, is considered to be a separate family unit for determining if an application fee is waiverable may be waived. The cohabitating cohabiting partners and any children shall be considered a family unit.

"Fee schedule" means a listing by item of the fees to be charged by the department for processing applications and for other services rendered by the department.

"Income" means total cash receipts of the family before taxes from all sources. These include money wages and salaries before any deductions, but do not include food or rent in lieu of wages. These receipts include net receipts from nonfarm or farm self-employment (e.g., receipts from the family's own business or farm after deductions for business or farm expenses.) They include regular payments from public assistance (including Supplemental Security Income), social security or railroad retirement, unemployment and worker's compensation, strike benefits from union funds, veterans' benefits, training stipends, alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions, and regular insurance or annuity payment; and income from dividends, interest, rents, royalties, or periodic receipts from estates or trusts. These receipts further include funds obtained through college work study programs, scholarships, and grants to the extent said funds are used for current living costs. Income does not include the value of food stamps, WIC checks, fuel assistance, money borrowed, tax refunds, gifts, lump sum settlements, inheritances or insurance payments, withdrawal of bank deposits, earnings of minor children, money received from the sale of property. Income also does not include funds derived from college work study programs, scholarships, loans, or grants to the extent such funds are not used for current living costs.

"Minor modification of an existing sewage disposal system" means an alteration that is not a repair or routine maintenance, does not result in an increase in treatment level or volume of the system, and does not require evaluation of the soil conditions prior to issuance of a permit. Minor modifications include but are not limited to relocation of a system component or an additional plumbing connection to the system that does not increase the actual or estimated flow of the system.

"Onsite sewage disposal system" means a sewerage system or treatment works designed not to result in a point source discharge.

"Owner" means any person who owns, leases, or proposes to own or lease a private well or, an onsite sewage disposal system, or both an alternative discharging system.

"Person" means the Commonwealth or any of its political subdivisions, including sanitary districts, sanitation district commissions and authorities, any individual, any group of individuals acting individually or as a group, or any public or private institution, corporation, company, partnership, firm or association which owns or proposes to own a sewerage system, treatment works or private well.

"Principal place of residence" means the dwelling unit, single family dwelling, or mobile home where the owner lives.

"Private well" means any water well constructed for a person on land which is owned or leased by that person and is usually intended for household, groundwater source heat pump, agricultural use, industrial use, use as an observation or monitoring well, or other nonpublic water well. A dewatering well, for the purposes of this chapter, is not a private well.

"Repair of a failing onsite sewage disposal system" means the construction of an onsite sewage disposal system or parts thereof to correct an existing and failing sewage disposal system for an occupied structure with indoor plumbing.

"Repair" means the construction or replacement of all or parts of a sewage disposal system or private well to correct a failing, damaged, or improperly functioning system or well when such construction or replacement is required by the board's regulations.

"Replacement of a private well" means the construction of a private well to be used in lieu of an existing private well.

"Review Board" means the State Sewage Handling and Disposal Appeals Review Board.

"Sewage" means water-carried and nonwater-carried human excrement, kitchen, laundry, shower, bath or lavatory wastes separately or together with such underground, surface, storm and other water and liquid industrial wastes as may be present from residences, buildings, vehicles, industrial establishments or other places.

"Sewerage system" means pipelines or conduits, pumping stations and force mains and all other construction, devices and appliances appurtenant thereto, used for the collection and conveyance of sewage to a treatment works or point of ultimate disposal.

"Treatment works" means any device or system used in the storage, treatment, disposal or reclamation of sewage or combinations of sewage and industrial wastes, including but not limited to pumping, power and other equipment and appurtenances, septic tanks and any works, including land, that are or will be (i) an integral part of the treatment process or (ii) used for ultimate disposal of residues or effluents resulting from such treatment.

"Voluntary upgrade" means a change to or replacement of an existing nonfailing onsite or alternative discharging sewage disposal system, without an increase in the permitted volume or strength of the sewage, in accordance with the regulations for repairing failing systems.

"Well" means any artificial opening or artificially altered natural opening, however made, by which groundwater is sought or through which groundwater flows under natural pressure or is intended to be artificially drawn; provided this definition shall not include wells drilled for the purpose of exploration or production of oil or gas, for building foundation investigation and construction, elevator shafts, grounding of electrical apparatus, or the modification or development of springs.

Part II
General Information

12VAC5-620-20. Authority for regulations. (Repealed.)

Sections 32.1-164#C and 32.1-176.4#B of the Code of Virginia provide that the State Board of Health has the power to prescribe a reasonable fee to be charged for filing an application for an onsite sewage disposal system permit and a reasonable fee to be charged for filing an application for a private well construction permit.

Part II
General Information

12VAC5-620-30. Purpose of regulations.

The board has promulgated these regulations to:

1. Establish a fee for filing an application for a permit to construct an onsite sewage disposal system or for the construction of a private well; and Establish a procedure for determining the fees for services provided by the department for onsite sewage systems, alternative discharge systems, and private wells;

2. Establish a procedure for the waiver of fees for an owner whose income of his family is at or below the federal poverty guidelines established by the United States Department of Health and Human Services, or when the application is for a pit privy, the replacement of a private well, or the repair of a failing onsite sewage disposal system.

2. Establish procedures for the refund of fees; and

3. Establish procedures for the waiver of fees.

12VAC5-620-40. Compliance with the Administrative Process Act.

The provisions of the Virginia Administrative Process Act (§ 9-6.14:l 2.2-4000 et. seq. of the Code of Virginia) shall govern the promulgation and administration of these regulations and shall be applicable to the appeal of any case decision based upon govern the decisions of cases under this chapter.

12VAC5-620-50. Powers and procedures of regulations not exclusive.

The Commissioner commissioner may enforce these regulations through any means lawfully available.

Part III
Fees

12VAC5-620-70. Application Establishing fees.

A. A fee of $50 shall be charged to the owner for filing an application for an onsite sewage disposal system permit with the department. The fee shall be paid to the Virginia Department of Health by the owner or his agent at the time of filing the application and the application shall not be processed until the fee has been collected. Applications shall be limited to one site specific proposal. When site conditions change, or the needs of an applicant change, or the applicant proposes and requests another site be evaluated, and a new site evaluation is conducted, a new application and fee is required.

B. A fee of $25 shall be charged to the owner for filing an application for the construction of a private well with the department. The fee shall be paid to the Virginia Department of Health by the owner or his agent at the time of filing the application and the application shall not be processed until the fee has been collected. Applications shall be limited to one site specific proposal. When site conditions change, or the needs of an applicant change or the applicant proposes and requests another site be evaluated, and a new site evaluation is conducted, a new application and fee is required.

C. A person seeking revalidation of a construction permit for an onsite sewage disposal system shall file a completed application and shall pay a fee of $50.

D. A person seeking revalidation of a permit for the construction of a private well shall file a completed application and shall pay a fee of $25.

A. The commissioner shall establish a schedule of fees to be charged by the department for services related to construction, maintenance, and repair or replacement of onsite sewage disposal systems, alternative discharge systems, and private wells and for appeals before the Review Board.

B. In establishing fees, the commissioner shall consider the actual or estimated average cost to the agency of delivering each service included in the schedule of fees.

C. The fees shall be the maximum allowable fees as established by the Code of Virginia or the appropriation act except that the fee for an application for a permit to make minor modifications of existing systems shall be 50% of the application fee for an onsite sewage disposal system construction permit.

D. The fee for filing an application for an administrative hearing before the Review Board shall be $135.

12VAC5-620-75. Fee remittance; application completeness.

A. Each applicant shall remit any required application fee to the department at the time of making application. In any case where an application fee is required, including requests for hearings before the Review Board, the application will be deemed to be incomplete and will not be accepted or processed until the fee is paid.

B. The owner of a newly installed alternative discharge system shall pay the installation inspection fee prior to the required department inspection.

C. The owner of an alternative discharge system shall pay the monitoring fee to the department for monitoring inspections conducted by the department that are mandated by 12VAC5-640. The department shall waive the monitoring fee when it conducts a monitoring inspection that is not mandated by 12VAC5-640.

12VAC5-620-80. Waiver of fees.

A. An owner whose income of his family income is at or below the 1988 2013 Poverty Income Guidelines For All for the 48 Contiguous States (Except Alaska and Hawaii) and The the District of Columbia established by the Department of Health and Human Services, 53 FR 4213 (1988) 78 FR 5182 (January 24, 2013), or any successor guidelines, shall not be charged a fee for filing an application for an onsite sewage disposal system permit or a private well construction permit pursuant to this chapter.

B. Any person applying for a permit to construct a pit privy shall not be charged a fee for filing the application.

C. Any person applying for a permit to construct an onsite sewage disposal system to repair a failing an onsite sewage disposal system or alternative discharging system shall not be charged a fee for filing the application.

D. Any person applying for a construction permit for the replacement of a private well shall not may be charged a fee for filing the application. Any application fee paid for a construction permit for a replacement well shall be refunded in full upon receipt by the department of a Uniform Water Well Completion Report, pursuant to 12VAC5-630-310, indicating that the well that was replaced has been permanently and properly abandoned or decommissioned.

E. Any person applying for a permit to properly and permanently abandon or decommission an existing well on property that is his principle place of residence shall not be charged a fee for filing the application.

F. Any person who applies to renew a construction permit for an onsite sewage disposal system, alternative discharge system, or private well shall not be charged a fee for filing the application, provided that:

1. The site and soil conditions upon which the permit was issued have not changed;

2. The legal ownership of the property has not changed;

3. A building permit for the facility to be served by the sewage system or well has been obtained or construction of the facility has commenced;

4. No previous renewal of the permit has been granted; and

5. The expiration date of the renewed permit shall be the date 18 months following the expiration date of the original permit.

G. Any person whose application for a permit to construct an onsite sewage disposal system, alternative discharging system, or private well is denied may file one subsequent application for the same site-specific construction permit for which the application fee shall be waived, provided that:

1. The subsequent application is filed within 90 days of receiving the notice of denial for the first application;

2. The denial is not currently under appeal; and

3. The application fee for the first application has not been refunded.

12VAC5-620-90. Refunds of application fee.

An application fee shall be refunded to the owner (or agent, if applicable) if the department denies a permit on his land on which the owner seeks to construct his principal place of residence. Such fee shall not be refunded by the department until final resolution of any appeals made by the owner from the denial.

A. An applicant for a construction permit or certification letter whose application is denied may apply for a refund of the application fee. The application fee shall be refunded to the owner or agent, if applicable, if the department denies an application for the land upon which the owner intends to build his principal place of residence. When the application was made for both a sewage disposal system and a private well, both fees may be refunded at the owner's request.

B. An applicant for a construction permit or a certification letter may request a refund of the application fee if the applicant voluntarily withdraws his application before the department issues the requested permit. The application fee will be refunded if the application is withdrawn before the department makes a site visit for the purpose of evaluating the application.

C. An applicant who has paid an application fee for a replacement well shall be refunded the application fee in full upon receipt by the department of a Uniform Water Well Completion Report, pursuant to 12VAC5-630-310, showing that the well that was replaced has been properly and permanently abandoned or decommissioned.

D. All applications for refunds must be made to the department no later than 12 months following the date upon which the applicant receives notification that his application for a construction permit or certification letter has been denied, within 12 months following the date upon which his application was withdrawn, or within 12 months following the date upon which any appeals of the denial of the application have been concluded.

E. All applications for refunds shall be made in writing in a form approved by the department.

F. Denials of applications may be appealed only when the applicant has a currently active application before the department, including payment of any required application fee.

12VAC5-620-100. Determining eligibility for waiver based on family income.

A. An owner seeking a waiver of an application fee shall request the waiver on the application form. The department will require information as to income, family size, financial status and other related data. The department shall not process the application until final resolution of the eligibility determination for waiver.

B. It is the owner's responsibility to furnish the department with the correct financial data in order to be appropriately classified according to income level and to determine eligibility for a waiver of an application fee. The owner shall be required to provide written verification of income such as check stubs, written letter from an employer, W-2 forms, etc., in order to provide documentation for the application.

C. The proof of income must reflect current income which that is expected to be available during the next 12-month period. Proof of income must include: Name name of employer, amount of gross earnings, and pay period for stated earnings. If no pay stub is submitted, a written statement must include the name, address, telephone number, and title of person certifying the income.