EPA Form 3520-29 OMB Control No. 2060-0545; approval expiration date: 7/31/2010

U.S. Environmental Protection Agency

Motor Vehicl e and Engi ne Compliance Program Refund Request Form

Date:

Manufac turer Name:

En g ine Family Name:

Ori gi nal Payment Date:

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

Original Amount Paid: Amount of Refund Requested:

Company Representative:

Name: Phone:

Email Address: Fax: (optional)

Reason for Refund:

This engine family or test group failed to rece ive an EPA certificate (no certificate issued).

Manufacturer withdraws request for certific ation and no certificate will be issued.

Overpayment

Other (explain in comments box):

Comments:

Refund Method:

Electronic Refund (EPA will cont act you for account details)

Make check payable to:

Name :

Address Line 2:

Address Line 3:

City: State/Province:

Zip/Postal Code : Country:

Submission: (1) Forms may be filled out and submitted online at www.Pay.gov

. (2) Forms may be submitted as email attachments to Fees@epa.gov (3) Forms may be submitted by surface mail to: EPA Use Only

DT/D#:________________________________ Deposit Date: __________

Check/Wire/CC/ACH#:____________________________________________ Environmental Protection Agency- NVFEL

Fees Team Compliance and Innovative Strategies Division

2000 Traverwood Pay. gov T racking #: _______________________________________________

EPA Signature:________________________________ Date: ___________ An n Arbor, Michigan 48105EPA Form 3520-29 OMB Control No. 2060-0545; approval expiration date: 7/31/3010 

### Instructions

This form is used to request a refund of some or all of a prev ious payment of a test group or engine family certification fee. Refunds can take several weeks to process. As an alternative, manuf acturers with upcoming engine certif ication applications can use th e Correction Form to apply refunds claims and overpayments to such new engine families or test groups . Requests for partial refunds

must be submitted no later than six months after the model year has ended (see 40 CFR §1027.125(d )). All forms can be filled

out and filed at www.Pay.gov or downloaded from www.epa.gov/otaq/fees.htm

.

Manufacturer's 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 for which the refund is being requested

Original Payment Date: Enter the date of the online payment (if Pay.gov was used) or the offline payment by check, wire, or ACH. Use the best informa tion

available.

Original Check #/ Wire/ACH/Pay.gov Tracking Number: If the original payment was made offline, enter the check number, or write in "Wire" or "ACH" . If the original payment was mad e online, enter the Pay.gov Tracking ID number assigned to the pa yment. This information will help EPA confirm the overpayment.

Original Amount Paid: Indicate the amount you paid for this engine or test group.

Amount of Refund Requested: Enter the amount in dollars of the refund requested.

Company Representative: Enter the authorized company representative information, including the name, email address, telephone number and fax number. T he person named should be someone familiar with the refund request who can be contacted for clarification of any issues and for necessary account information if an el ectronic refund is being requested.

Reason for Refund: Select one of the options given. If Other is selected, provide an explanation in the comment box.

Comments: Enter any comments in the box necessary or helpful to explain the refund request.

Refund Method: Indicate how you want the refund processed, either as an electronic refund or by check. An electronic refund requires EPA to contact the person named as Company Representative for the manufacturer's account number and other information. The check refund process requires the name and address of the manufacturer or its agent to whom the check will be payable. Please fill out all the fields: name (the company or person to whom the check is paya ble), address, city, state or pr ovince, country, and zip or postal code. Add an "attention" line if you want the check mailed to a particular person or office in your organization. Note: All refunds o n payments made by credit card w ithin the last two years will be made to that credit card, unless another method is requested. Pl ease make a copy of the completed form for your files.

Submission: (1) Forms may be filled out and submitted online at www.Pay.gov

. (2) Forms may be submitted as email attachments to Fees@epa.gov (3) Forms may be submitted by surface mail to:

Environmental Protection Agency- NVFEL

Fees Team Compliance and Innovative Strategies Division

2000 Traverwood Ann Arbor, Michigan 48105

The public reporting and recordkeeping burden for this collection of information is estimated to average 36 minutes per response. Send comments on EPA’s need for this information, the accuracy of the provided burden estimate, and any suggested methods for minim izing respondent burden, including through the use of automated collectio n techniques, to the Director, Collection Strategies Divisio n, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., N. W., Washington, D.C. 20460. Include the OMB control number i n any correspondence. Do not send the comp leted Form 3520-29 to this address.