3520-29 MVECP Refund Request Form

EPA Form#:3520-29

OMB No. 2060-0104

U.S. Environmental Protection Agency

Motor Vehicle and Engine Compliance Program

Refund Request Form

Date:   /  /    

M

anufacturer Name:      

Check here if IMO/Annex Engine Family:

E

ngine Family Name:                        

O

riginal Payment Date:   /  /    

O

riginal Check#/Wire/ACH/Pay.gov Tracking Number:      

O

riginal Amount Paid:       Amount of Refund Requested:      

Authorized Company Representative:

N

ame:       Phone:      

E

mail Address:       Fax:       (optional)

Reason for Refund:

This engine family or test group failed to receive an EPA certificate (no certificate issued).

Manufacturer withdraws request for certification and no certificate will be issued.

Overpayment

Other (explain in comments box):

Comments:

     

Refund Method:

Electronic Refund (EPA will contact you for account details)

Make check payable to:

Address Line 1:      

Address Line 2:      

Address Line 3:      

City:       State/Province:      

Zip/Postal Code:       Country:      

Current Form Expires: 1/1/07

S

EPA Use Only

DT/D#:________________________________ Deposit Date: __________ Check/Wire/CC/ACH#:____________________________________________

Pay.gov Tracking #: _______________________________________________

EPA Signature:________________________________ Date: ___________

end Refund Request to:

Environmental Protection Agency- NVFEL         /  /    

Fees Team

Compliance and Innovative Strategies Division      

2565 Plymouth Road      

Ann Arbor, Michigan 48105

        /  /    

MVECP Fee Refund Request Form Instructions

Normally this form will be used to request a refund of some or all of a previous payment of a test group or engine family certification fee. Refunds can take several weeks to process. As an alternative, manufacturers with upcoming engine certification applications can use the online MVECP Fee Correction Form to apply refunds claims and overpayments to such new engine families or test groups.

Instructions:

Manufacturer's Name:

Check here if IMO/Annex Engine Family:

Engine Family Name:

For these three items, enter the manufacturer's name and the twelve-digit engine family or test group name for which the refund is being requested. If the engine is an IMO/Annex engine, check the box. If you are requesting a refund on an engine older than the current model year minus one, contact your certification representative.

Original Payment Date:

Enter the date of the online payment (if used pay.gov) or the offline payment by check, wire, or ACH. Use the best information available.

Original Check #/ Wire/ACH/Pay.gov Tracking Number:

If the original payment was made offline, enter the check number, or write in "Wire" or "ACH" for offline payments by those methods. If the original payment was made online, enter the Pay.gov Tracking ID number assigned to the payment. This information will help EPA confirm the overpayment.

Original Amount Paid:

Indicate the amount you paid for this engine or test group.

Amount of Refund Requested:

Enter the amount of refund requested in dollars.

Authorized Company Representative:

Enter the authorized company representative information including the name, email address, telephone number and fax number. The person named should be someone familiar with the refund request who can be contacted for clarification of any issues and for necessary account information if an electronic refund is being requested.

Reason for Refund:

Select one of the options given: the engine family or test group failed to receive an EPA certificate (no certificate issued), manufacturer withdraws a request for certification and no certificate will be issued or other (explain). If Other is selected, provide an explanation for the refund request in the comment box.

Comments:

Enter any comments in the box necessary or helpful in explaining the refund request.

Refund Method:

Indicate how you want the refund processed, either as an electronic refund or by check. An electronic refund requires EPA to contact the person named as Authorized Company Representative for the manufacturer's account number and other information. The check refund process requires the name and address of the manufacturer to whom the check will be payable. Please include your Address, City, State or Province, Country, and Zip or Postal Code in the spaces provided. Please make a copy of the completed form for your files.

Send Refund Request Form to:

Environmental Protection Agency- NVFEL

Fees Team

Compliance and Innovative Strategies Division

2565 Plymouth Road

Ann Arbor, Michigan 48105