OMB Control No. 2060-0086
Expires: MM/DD/YYYY
CASH INCENTIVE AGREEMENT
I, _____________________________, the owner ( ) and/or joint owner ( ), and/or principal driver ( )
being fully advised agree to the following:
( ) To accept a total of $20.00 per day, in addition to the use of a loaner
vehicle.
( ) To accept a total of $50.00 per day, in lieu of a loaner vehicle.
while the vehicle described herein, MAKE_______________________
MODEL_________________YEAR_______VIN_________________________
is in possession of Jacobs, a contractor to the U.S. Environmental Protection Agency.
Privacy Act Statement
Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information. The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA’s Light-Duty In-Use Testing Program. Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.
Providing the requested information is voluntary, but failing to do so will result in EPA’s inability to approve your participation in the Light-Duty In-Use Testing Program.
This collection of information
is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2060-0086). Responses to this collection of
information are voluntary (42 USC 7541.) An agency may not conduct
or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control
number. The public reporting and recordkeeping burden for this
collection of information is estimated to range from 1 to 60 minutes
per response, with an average of 30 minutes per response. Send
comments on the Agency’s need for this information, the
accuracy of the provided burden estimates and any suggested methods
for minimizing respondent burden to the Regulatory Support Division
Director, U.S. Environmental Protection Agency (2821T), 1200
Pennsylvania Ave., NW, Washington, DC 20460. Include the OMB
control number in any correspondence. Do not send the completed form
to this address.”
PARTICIPANT:
_________________________________________ ___________________ SIGNATURE DATE
JACOBS REPRESENTATIVE:
________________________________________ ___________________ SIGNATURE DATE
EPA Form 5900-309
Revision Date 3/18/2021
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | cash incentive mpf |
Author | Dorothy Day |
File Modified | 0000-00-00 |
File Created | 2021-05-01 |