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:

Manufacturer Name:      

Engine Family Name:                        

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

Original Amount Paid: \$      

Revised Engine Family Name:                         (optional)

Company Representative:

Name:       Phone:      

Email Address:       Fax:       (optional)

Reason for Payment:

Incorrect/Revised engine family

Underpayment

New calendar year fee schedule change

Other

Comments:

Fee Payment Details

Amount Paid: \$      

Enter the check number, or the statement "EFT/Wire" or "EFT/ACH":

**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)**.**

**Page 2**

**Instructions:**

**NOTE:** This form may be found and submitted with or without
associated payments online at [www.Pay.gov](http://www.Pay.gov/). Copies
of this form may also be downloaded at
[www.epa.gov/otaq/fees.htm](http://www.epa.gov/otaq/fees.htm).

**Manufacturer Name:**

List the corporate name as it appears on the application or the
Certificate of Conformity.

**Engine Family Name:**

Enter the engine family or test group name as it appears on the
application or Certificate of Conformity. If payment is being made on an
engine family older than the current model year minus one, contact your
certification representative. For payments involving more than one
engine family, or involving both overpayments and underpayments (for
example, an Annual Model Year Reduced Fee Payment Report under 40 CFR
85.1509) you may 1) submit separate Miscellaneous Payments Due forms, 2)
explain fully in the Comments box, or 3) provide a cover letter
explaining each adjustment and payment to cover the information in this
form, including the reason for each payment, whichever is best suited to
provide the information necessary to process the payment.

**Original Payment Date:**

Enter the date of the original online payment or offline payment by
check, wire or ACH. Use the best information available.

**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.

**Company Representative:**

Enter the authorized company representative information, including a
contact name, email address, telephone number and fax number. The person
named should be someone familiar with the payment who can be contacted
for clarification of any issues.

**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. If this box is selected, this form can
operate to make the correction in engine family name; a separate
Correction Form need not be filed.

**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, enter the
amount of the shortfall in the Amount Paid box at the bottom of the
form, and add any explanation in the Comments box. 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 box, enter the amount of the shortfall in
the Amount Paid 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 owes EPA due to a fee schedule change,
select this box, enter the amount of the shortfall in the amount paid
box and add any explanation in the Comments box. If EPA owes the
manufacturer due to a fee schedule change, use the Fees Correction Form
(to apply it to another certification fee) or Fee Refund Form.

**Page 3**

**\-- 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 Paid:**

Enter the amount paid with this submission.

**Enter the check number, or the statement "EFT/Wire" or "EFT/ACH":**

[To pay by check]{.underline},: 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 fee for \_\_\_ engine
families/test groups\" (edit number as appropriate). Mail this form
along with the check to:

Environmental Protection Agency

Motor Vehicle and Engine Compliance Program

P.O. Box 979032

St. Louis, MO 63197-9000

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

U.S. Bank

Government Lockbox 979032

1005 Convention Plaza

SL-MO-C2-GL

St. Louis, MO 63179

[To pay by wire]{.underline}, 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. All banking fees are the responsibility of the
manufacturer. Your bank will need the following information:

The EPA location code is 68010099.

The ABA# is 021030004. (This is the same as the "Swift code".)

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

Description: \"EPA MVECP FEE\"

Manufacturer Name

Standard Engine Family or Test Group Name(s). If space is limited, list
one name and the number of families.

\- [To pay by Automated Clearing House Electronic Funds
Transfer]{.underline} (EFT/ACH): EFT payments can be made on-line at
[www.Pay.gov](http://www.Pay.gov/) by anyone having a U.S. banking
account. For off-line EFT, 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. All
banking fees are the responsibility of the manufacturer. The bank will
need the following EPA routing and account information:

RDFI- Federal Reserve Bank

Routing Transit Number: 051036706

Receiving Account Number: 540006

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

The manufacturer must submit the following information:

Description: \"EPA MVECP FEE\"

Manufacturer Name

Standard Engine Family or Test Group Name(s). ). If space is limited,
list one name and the number of families.