U.S. Environmental Protection Agency

![](media/image1.wmf){width="0.59375in"
height="0.2708333333333333in"}Motor Vehicle and Engine Compliance
Program

Miscellaneous Payments Due Form

Date: [  /  /    ]{.underline}

Manufacturer Name:      

Check here if IMO/Annex Engine Family:

Engine Family Name:                        

Original Payment Date:   /  /     Original Check#/Wire/ACH/Pay.gov
Tracking Number:       (optional)

Original Amount Paid: \$      

Revised Engine Family Name:                         (optional)

Authorized Company Representative:

Contact Name:       Phone:      

Email Address:       Fax:       (optional)

Reason for Payment:

Incorrect/Revised engine family

Underpayment

New calendar year fee schedule change

Annual Model Year Reduced Fee Payment Report

Other

Comments:

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Annual Model Year Reduced Fee Payment Report

Only use this form if each family has fewer than 6 vehicles, and each
engine/vehicle is less than \$75,000. You must

include all certificates issued for model year.

  ---------- ------------- ------------ ------------------ ----------- ---------- -----------
             Engine Family Amount       Number of          Project     Total Fees Amount
             Name:         Previously   Engines/Vehicles   Aggregate   Due:       Owed/Due:
                           Paid:        in Family:         Retail                 
                                                           Sales                  
                                                           Amount:                

  Engine                                                                               
  Family 1                                                                        

  Engine                                                                               
  Family 2                                                                        

  Engine                                                                               
  Family 3                                                                        

  Engine                                                                               
  Family 4                                                                        

  Engine                                                                               
  Family 5                                                                        

  Engine                                                                               
  Family 6                                                                        

  Engine                                                                               
  Family 7                                                                        

  Engine                                                                               
  Family 8                                                                        

  Engine                                                                               
  Family 9                                                                        

  Engine                                                                               
  Family 10                                                                       

  Engine                                                                               
  Family 11                                                                       

  Engine                                                                               
  Family 12                                                                       

  Engine                                                                               
  Family 13                                                                       

  Engine                                                                               
  Family 14                                                                       

  Engine                                                                               
  Family 15                                                                       

                                                                                  

             Totals:                                                                   
  ---------- ------------- ------------ ------------------ ----------- ---------- -----------

Fee Payment Details Current Form Expires: 1/1/07

Amount Owed \$      

Payment Type:      

Enter the check number:      

**MVECP Miscellaneous Payments Due Form**

[Instructions:]{.underline}

**Manufacturer Name:**

**Check Here if IMO/Annex Engine Family:**

**Engine Family Name:**

For these three items, enter the manufacturer\'s name and the original
engine family or test group name. If the engine name is for an IMO/Annex
certification, check the box. If payment is being made on an engine
family older than the current model year minus one, contact your
certification representative. If you are using this form to submit an
Annual Model Year Reduced Fee Payment Report, enter any relevant engine
family name.

**Original Payment Date:**

Enter the date of the original online payment or of the offline payment
by check, wire or ACH. Use the best information available. If you are
using this form to submit an Annual Model Year Reduced Payment Report,
enter today\'s date.

**Original Amount Paid:**

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

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

Enter the original check number, or indicate \"Wire\" or \"ACH\" if the
original offline payment was by those methods. Enter the Pay.gov
Tracking ID number assigned for the original payment if it was online.
This information will help EPA confirm the original payment information.

**Revised Engine Family Name:**

Enter a revised engine family name if payment is owed because an engine
family name has been changed or corrected to a category requiring a
higher fee than originally paid. It will also be necessary to fill out a
Fees Correction Form, which is available online from Pay.gov.

**Reasons for Payment:**

Select from the following options:

\-- **Incorrect/Revised engine family:** If an underpayment was made
because the wrong engine family certification was originally applied
for, and/or the original engine family is being revised to a different
family with a different certification fee payment requirement, select
this button, enter the amount of the shortfall in the Amount Owed box at
the bottom of the form, and add any explanation in the Comments box.
Indicate that the corresponding Fee Correction Form has been filed.
Include the revised engine family name in the space provided above for
Revised Engine Family Name.

\-- **Underpayment:** If the original payment did not cover the full
required amount, select this button, enter the amount of the shortfall
in the Amount Owed box at the bottom of the form, and add any
explanation in the Comments box.

\-- **New calendar year fee schedule change:** New certification fees
are calculated for each calendar year. The fee that applies to an engine
is determined by the calendar year in which a complete application is
received. If a manufacturer or ICI owes EPA due to a fee schedule
change, select this button, enter the amount of the shortfall in the
amount due box and add any explanation in the Comments box. If EPA owes
the manufacturer or ICI due to a fee schedule change, use the Fees
Correction Form or Fee Refund Form.

**\-- Annual Model Year Reduced Fee Payment Report:** 40 CFR 85.2406(e)
requires some reduced fee certificate holders to submit a reduced fee
payment report annually within thirty days of the end of each model
year. Selecting this button will cause a form for such a report to
appear. This form may be used for the annual report and to pay the
difference between the initial reduced fee and the final calculation. If
the initial fee payment exceeds the final reduced fee then the
manufacturer or ICI may request a refund using the Fee Refund Form.

**\-- Other:** Select this button for any other underpayments, enter the
amount to be paid in the amount due box, and explain in the Comments
box.

**Comments:**

Enter any comments that are necessary or useful to explain the payment.

**Fee Payment Details:**

**Amount Owed:**

Enter the amount owed.

**Payment Type:**

Select one of the five payment options listed: Online ACH, Online Credit
Card, Offline ACH, Offline Wire, or Offline Check. If paying offline by
check, enter the check number.

**\-- For offline payments:**

Before submitting, please make a copy of the form for your own records
and to remember the amount to be paid, by printing from the PDF version
after selecting the PDF Preview button. (The form can also be saved as a
computer file by using the Save A Copy icon on the Adobe taskbar.) After
copying the PDF version, use the backspace button on your browser to
return to the form so that it can be submitted.

**Submit Data**

[If paying online]{.underline} has been selected, pushing this button
will take you to a plastic card or an ACH debit summary page for
submission of payment. Please make sure all information is correct
before submitting data. Once the \"Submit Data\" button is selected,
changes cannot be made. The browser\'s backspace key cannot be used to
make modifications to the form.

After payment is made, a [Payment Confirmation]{.underline} will appear
that can be copied for your records. A payment summary will also be sent
automatically to your email address. The Payment Confirmation lists the
engine family along with the other payment information; the summary sent
to your email address does not. [It is a good idea to make a copy of the
Payment Confirmation.]{.underline}

[If payment offline]{.underline} was selected, pushing the Submit Data
button will take you back to the forms list; payment will be the
responsibility of the manufacturer/ICI according to the instructions at
http://www.epa.gov/otaq/fees.htm. Those instructions are summarized
below. Before submitting, please make a copy of the form for your own
records, and to remember the amount to be paid, by printing from the PDF
version after selecting the PDF Preview button. The form can also be
saved as a computer file by using the \"Save A Copy\" icon on the Adobe
taskbar.

\- [To pay offline by check]{.underline}, after submitting the form
online: Make the check payable to \"U.S. Environmental Protection
Agency\". Write \"MVECP fee\" and the engine family or test group name
on the check, or, if the check is for multiple test groups or engine
families, write \"MVECP for \_\_\_ engine families/test groups\" (edit
number as appropriate). Mail the check to:

Environmental Protection Agency

Motor Vehicle and Engine Compliance Program

P.O. Box 954472

St. Louis, MO 63195-4472

If using a private shipping service such as Federal Express (or other
service), send checks to:

US BANK

Government Lock Box Division

Mail Station SLMOC1GL, Operations Center

1005 Convention Plaza

St. Louis, MO 63101-1200

\- [To pay offline by wire]{.underline}, after filing the form online:
Electronic Funds Transfer wire payments through the New York Federal
Reserve Bank are the only wire transactions normally accepted for
certification fee payments. Fedwire payments are not normally accepted.
EFT/wire transactions must be arranged with the manufacturer\'s bank.
The bank will need the following information:

The EPA location code is 68010099.

The ABA# is 021030004.

The manufacturer must submit the following information in the EFT/wire
message field (maximum 80 columns):

Description: \"EPA MVECP FEE\"

Standard Engine Family or Test Group Name (s)

Corporate Name.

\- [To pay offline by Automated Clearing House Electronic Funds
Transfer]{.underline} (EFT/ACH) after filing the form online: To set up
an EFT/ACH payment method, the manufacturer should contact its bank,
which will make arrangements with the US Bank. At this time, the US Bank
can only receive EFT/ACH payments from banks in the United States. The
bank will need the following EPA routing and account information:

RDFI- US Bank

Routing Transit \# 081000210

Receiving Account \# 1001091030

Account Name: U.S. Environmental Protection Agency (EPA)

The manufacturer must submit the following information:

Description: \"EPA MVECP FEE\"

Standard Engine Family or Test Group Name (s)

Corporate Name.