![](media/image1.wmf){width="0.59375in"
height="0.2708333333333333in"}**U.S. ENVIRONMENTAL PROTECTION AGENCY**

**MOTOR VEHICLE AND ENGINE COMPLIANCE PROGRAM**

**CY 2006 [ON-HIGHWAY]{.underline} FEE FILING FORM**

Applicant=s Corporate Name [     ]{.underline}

Address [     ]{.underline}

City/State/Zip Code/Country [     ]{.underline}

On-Highway Certification Request Type (check one)

**LDV/LDT/MDPV/HDV (Chassis cert) FEDERAL (\$34,724)** **HDV EVAP-ONLY
(\$839)**

**LDV/LDT/MDPV/HDV (Chassis cert) CAL-ONLY (\$18,138)** **HDE CALIF-ONLY
(\$839)**

**HDE (Engine Dyno cert) FEDERAL (\$29,201)** **MOTORCYCLE (\$2,164)**

**LD/MDPV/HDV** **ICI** **(\$16,594)**

EPA standard engine family or test group name:                        

Amount paid (U.S. Funds Only):      

**(Make checks payable to: *[\"U.S. ENVIRONMENTAL]{.underline}***
***[PROTECTION AGENCY\"]{.underline}*)**

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

**Indicate in the [EFT message field]{.underline}:**

**[Wire]{.underline}: Location Code# [\"68010099\"]{.underline}, [\"EPA
MVECP Fee\"]{.underline}, [ABA# \"021030004\"]{.underline}**

**[ACH]{.underline}: RDFI-US BANK, Routing Transit# \"081000210\",
Account#: 1001091030, Account Name: EPA**

**(Include in field: engine family/test group name, corporate name, and
\"MVECP Fees\")**

**Reduced Fee** **Section** (40 CFR 85.2406)

**Reduced Fee Calculation (minimum \$750): Total number of
vehicles/engine covered?[     ]{.underline}**

**Aggregate retail sales price of the vehicles/engines?
\$[     ]{.underline} x 1% = \$[     ]{.underline}**

**Check box if an Independent Commercial Importer?** **List the VIN of
imported vehicles/engines below:**

                 

                 

Company Representative:[     ]{.underline} Signature:[     ]{.underline}

Title:[     ]{.underline}
Phone/Fax:[     ]{.underline}/[     ]{.underline}
Date:[    ]{.underline}/[    ]{.underline}/[    ]{.underline}

**Current E-mail Address:**[     ]{.underline}

[Addresses]{.underline}: Send **checks** and all **Fee Filing Forms**
for **[checks, wires and ACH]{.underline}** payments by mail to:

**Environmental Protection Agency**

**Motor Vehicle and Engine Compliance Program**

**P.O. Box 954472**

**St. Louis, MO 63195-4472**

**See instruction page for sending checks and forms by private mail
service (e.g., Federal Express). Transmit [EFT/Wire]{.underline}
payments to the [New York Federal Reserve Bank]{.underline}.**

**Transmit [EFT/ACH]{.underline} to the [US Bank]{.underline}.**

Current Form Expires: 1/1/07

> **Fee Filing Form Instructions**
>
> Note: This form applies to complete certification applications that
> are received in Calendar Year (CY) 2006.
>
> **[Corporate Name and Address]{.underline}**
>
> List the applicant=s corporate name and corporate address which will
> appear on the Certificate of Conformity**.**
>
> **[Certification Request Type]{.underline}**
>
> Check the box that specifies the certification request type. The
> medium-duty passenger vehicles (MDPV) are included with LDV/LDT. If
> paying a reduced fee still mark the appropriate certification request
> type**.**
>
> **[EPA Standard Engine Family or Test Group Name]{.underline}**
>
> Enter the appropriate EPA standardized engine family or test group
> name that will appear on the Certificate of Conformity. For
> placeholder engine family/test group names go to
> [www.epa.gov/otaq/fees.htm]{.underline} for instructions.
>
> **[Amount Paid]{.underline}**
>
> Enter the appropriate fee amount for the designated certification
> request type. The full fee, payable in U.S. dollars, is to accompany
> the filing form. Reduced fee amount (if applicable) is also entered in
> this box.
>
> **[Check Number, EFT/ACH, or EFT/WIRE]{.underline}**
>
> Enter the number of the corporate check, money order, bank draft,
> 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. 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}
>
> [For ACH]{.underline}: RDFI- US BANK, Routing Transit# \"081000210\",
> Account#: 1001091030, Account Name: U.S. Environmental Protection
> Agency (EPA).
>
> Please include in wire or ACH message fields the following: engine
> family/test group name(s), corporate name, and MVECP Fees.
>
> **[Reduced Fee Section (if applicable)]{.underline}**
>
> Reduced fee submissions must be supported by a reduced fee calculation
> and relevant supporting information available to 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 reduced fee
> provisions under 40 CFR 85.2406**.**
>
> **[Company Representative (please include an e-mail
> address)]{.underline}**
>
> Enter the representative=s name, signature, title, phone/fax, and date
> and current e-mail address.
>
> **[Bank Address for Private Mail Shipment (other than U.S. Postal
> Service)]{.underline}**
>
> If using a private shipping service such as Federal Express (or other
> service), send checks and fee filing forms for all payment types to:
>
> **US BANK**
>
> **Government Lock Box Division**
>
> **Mail Station SLMOC1GL, Operations Center**
>
> **1005 Convention Plaza**
>
> **St. Louis, MO. 63101-1200**