**U.S. ENVIRONMENTAL PROTECTION AGENCY**

![](media/image1.wmf){width="0.59375in"
height="0.2708333333333333in"}**MOTOR VEHICLE AND ENGINE COMPLIANCE
PROGRAM**

**[ON-HIGHWAY]{.underline} FEE FILING FORM**

**FOR CERTIFICATION APPLICATIONS RECEIVED IN [CALENDAR YEAR
2007]{.underline}**

![](media/image2.wmf)Manufacturer Name      

![](media/image3.wmf)Address      

![](media/image4.wmf)City/State/Zip Code/Country      

On-Highway Certification Request Type (check one)

**LDV/LDT/MDPV/HDV (Chassis cert) FEDERAL (\$35,354)** **HDV EVAP-ONLY
(\$802)**

**LDV/LDT/MDPV/HDV (Chassis cert) CAL-ONLY (\$18,419)** **HDE CALIF-ONLY
(\$802)**

**HDE (Engine Dyno cert) FEDERAL (\$36,032)** **MOTORCYCLE (\$1,878)**

**LD/MDPV/HDV** **ICI** **(\$19,512)**

EPA standard engine family or test group or                        

HDV Evaporative family name: Number range CHAPTER

Amount paid (U.S. Funds Only): \$      

Enter the check number, or the statement AEFT/WIRE@ or AEFT/ACH@:      

+-----------------------------------------------------------------------+
| **Reduced Fee Section** (40 CFR 85.2406)                              |
|                                                                       |
| **Reduced fee calculation (minimum initial payment \$750): Total      |
| number of vehicles/engines covered:**[   ]{.underline}                |
|                                                                       |
| ![](media/image5.wmf)**Aggregate retail sales price of the            |
| vehicles/engines: \$      ** **x 1% = \$      **                      |
|                                                                       |
| **Check box if an Independent Commercial Importer:** **List the VIN   |
| of imported vehicles/engines below:**                                 |
|                                                                       |
|                                                                       |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+

![](media/image7.wmf)Company Representative:       Signature:      

![](media/image9.wmf)Title:       Phone/Fax:       /     
Date:[  ]{.underline}/[  ]{.underline}/[    ]{.underline}

![](media/image12.wmf)**E-mail Address:**      

**Submission of payments and forms:**

\(1\) Online: **Forms** may be found and/or **payments** may be
submitted online at [www.Pay.gov](http://www.Pay.gov/).

\(2\) Send **checks** and this **form** to:

**Environmental Protection Agency**

**Motor Vehicle and Engine Compliance Program**

**P.O. Box 979032**

**St. Louis, MO 63197-9000**

\(3\) Transmit offline [EFT/Wire]{.underline} **payments** to the [New
York Federal Reserve Bank]{.underline}.

\(4\) Transmit offline [EFT/ACH]{.underline} **payments** to the [US
Bank]{.underline}. (See Instructions on page 2 for EFT payments.)

\(5\) **Forms** not submitted under (1) and (2) above can be sent as
e-mail attachments to Fees@epa.gov.

Forms and payments sent in ways other than the above may be delayed or
ineffective. See the Instructions for sending checks and forms by
private mail service (e.g., Federal Express)**.**

**This form expires: 1/1/08**

> **Page 2**
>
> **Instructions**
>
> **NOTE:** **This form applies to complete certification applications
> that are received in Calendar Year (CY) 2007.** Fee amounts due are
> subject to change every year. Use of the form for the wrong calendar
> year can cause incorrect payments and delays. Get the form for the
> calendar year of your application submission at
> [www.epa.gov/otaq/fees.htm](http://www.epa.gov/otaq/fees.htm) or
> [www.Pay.gov](http://www.Pay.gov/). Forms and payments may be
> submitted online at [www.Pay.gov](http://www.Pay.gov/).
>
> **[Manufacturer Name and Address]{.underline}**
>
> List the applicant=s corporate name and corporate address as it will
> appear on the Certificate of Conformity**.**
>
> **[Certification Request Type]{.underline}**
>
> Check the box that specifies the certification request type. If you
> are paying a reduced fee, still mark the appropriate certification
> request type**.**
>
> **[EPA Standard Engine Family or Test Group or HDV Evaporative Family
> Name]{.underline}**
>
> Enter the appropriate EPA standardized engine family or test group
> name as it will appear on the Certificate of Conformity. Forms and
> payments for Modification and Test vehicles under 40 CFR 85.1509 must
> list the engine family for the currently valid Certificate of
> Conformity under which the vehicles are being imported.
>
> **[Amount Paid]{.underline}**
>
> Enter the appropriate fee amount for the designated certification
> request type. The full fee, payable in U.S. dollars, along with a
> properly completed fee filing form, must be received before
> certification review can begin. All banking fees are the
> responsibility of the manufacturer. The reduced fee amount (if
> applicable) is also entered in this box.
>
> **[Check Number, EFT/ACH, or EFT/WIRE (for offline
> payments)]{.underline}**
>
> The check number is mandatory for check, money order, bank draft, or
> certified check; or enter the letters AEFT/ACH@ or AEFT/WIRE@ if
> sending an electronic funds transfer. Indicate the standard engine
> family or test group name on the check. **Make checks payable to "U.S.
> Environmental Protection Agency".**
>
> Indicate in the [EFT message field the information]{.underline}:
>
> [For Wire]{.underline}: Location Code#: [68-01-0099]{.underline},
> [\"EPA MVECP Fee\"]{.underline}, [ABA#: 021030004.]{.underline} (ABA
> \# is same as Swift Code)
>
> [For ACH]{.underline}: RDFI- Federal Reserve Bank, Routing Transit#:
> 051036706, Account#: 540006, Account Name: U.S. Environmental
> Protection Agency (EPA).
>
> Please include in wire or ACH message fields the following: the words
> "MVECP Fees", manufacturer name, and engine family/test group/HDV
> evaporative group name(s). If space is limited, list one name and the
> number of families.
>
> **[Reduced Fee Section (if applicable)]{.underline}**
>
> Reduced fee submissions must be supported by the reduced fee
> calculation on Page 1 of this form and any relevant supporting
> information requested by EPA at the time of application review. Enter
> the number of vehicles/engines projected for sale under the engine
> family/test group. Enter the aggregate projected retail sales price of
> the vehicles or engines and multiply that value by 1% (.01). Enter and
> pay the reduce fee amount (minimum \$750). If you are an ICI, please
> enter the VIN for any vehicles/engines already (or soon to be) in your
> possession. For any additional VINs, please use a separate page. For
> further information see the reduced fee provisions under 40 CFR
> 85.2406**.**
>
> **[Company Representative]{.underline}**
>
> Enter the representative=s name, signature, title, phone/fax, date,
> and an e-mail address. **Note: an acknowledgment of fees received will
> be sent to this e-mail address. No other receipts will be sent.**
>
> **[Bank Address for Private Mail Shipment (other than U.S. Postal
> Service)]{.underline}**
>
> If you are using a private shipping service such as Federal Express
> (or other service), send checks and fee filing forms to:
>
> **U.S. Bank**
>
> **Government Lockbox 979032**
>
> **1005 Convention Plaza**
>
> **SL-MO-C2-GL**
>
> **St. Louis, MO 63179**