EPA Form 3520

- 29 OMB Control No. 2060

- 0545

U.S. E nvironmental P rotection A gency M otor V ehicle and E ngine C ompliance P rogram O n

- H ighway F ee F iling F orm F or C ertification A pplications R eceived In C alendar Y ear 20 13

Manufacturer Name

Address

City/State/Zip Code/Country

On-Highway Certification Request Type (check one)

**LDV/LDT/MDPV/HDV (Chassis cert) FEDERAL ($29,848) HDV EVAP-ONLY ($563)** 

**LDV/LDT/MDPV/HDV (Chassis cert) CAL-ONLY ($15,704) HDE CALIF-ONLY ($563)** 

**HDE (Engine Dyno cert) FEDERAL ($44,215) MOTORCYCLE ($1,427)** 

**LD/MDPV/HDV ICI**  **($68,737)**

EPA standard family or test group:

Amount paid (U.S. Funds Only): 

### $

Enter the check number, or the statement "WIRE" or "ACH":

**Reduced Fee Section** (40 CFR §1027.120 )

**Reduced fee calculation (minimum initial payment $750): Total number of vehicles/units covered:**

**Aggregate retail sales price of the vehicles/units: $ x 1% = $** 

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

Company Representative: Signature:

Title: Phone/Fax: / Date: / /

**E-mail Address:**
**Submission of payments and forms:**
(1) Online: **Forms** may be found and submitted with or without **payments** online at www.Pay.gov

. (2) By mail: For check payments only, 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 Wire **payments** to the New York Federal Reserve Bank .(See Instructions, p.2)
(4) Transmit offline ACH **payments** to the Federal Reserve Bank of Cleveland . (Instructions, p.2)

(5) **Forms** not submitted under (1) and (2) above can be sent as email 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)

**.**

Th is form expires: 1/1/ 201 4 The public reporting and recordkeeping burden for this collection of information is estimated to average 18 minutes per response. Send

comments on EPA’s need for this information, the accuracy of the provided burden estimate, and any suggested methods for minimizing respondent burden, including through the us e of automated collection techniques, to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., N.W., Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Form 3520

- 29 to this address.EPA Form 3520

- 29 OMB Control No. 2060

- 0545 

### Page 2

Instructions

NOTE : This form applies to complete certification applications that are received in Calendar Year (CY) 20 13.

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 or www.Pay.gov . Forms and payments may be submitted online at www.Pay.gov

.

Manufacturer Name and Address List the applicant ' s corporate name and corporate address as it will appear on the Certificate of Conformity

.
Certification Request Type Check the box that specifies the certification request type. If you are paying a reduced fe e, still mark the appropriate certification request type

. EPA Family Name Enter the appropriate EPA standardized family, test group, or HD evaporative name as it will appear on the Certificate of Conformity. Forms and payments for Mod ification and Test vehicles under 40 CFR §85.1509 must list the engine family for the currently valid C ertificate of Conformity under which the vehicles are being imported.

Amount Paid 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 r educed fee amount (if applicable) is also entered in this box.

Check Number, ACH, or WIRE (for off line payments)

T he check number is mandatory for check, money order, bank draft, or certified check ; or enter the letters "WIRE"

or "ACH" if sending an electronic funds transfer. Indicate the family name on the check. Make checks payable to “U.S. Environmental Protection Agency”.

Indicate in the message field the information : For Wire : Receiver FI: TREAS NYC (this is the short name for the US Treasury's routing number). Routing Number (ABA number or Swift Code for participating banks. For further information, email Fees@EPA.gov ): 021030004

. Beneficiar y (Agency Location Code [ALC] or EPA Account Number): 868010099000

. Beneficiary Name: US Environmental Protection Agency. Originator Information: MVECP Fees, manufacturer name, family name(s). If space is limited, list one family and the number of families.

For ACH : Standard Entry Class: CCD; Transaction Code: 22; Receiv ing DFI ID (ABA number): 051036706;

Account Number: 868010099000 ; Receiving Company Name: US Environmental Protection Agency. Payment Related Information: family name(s).

Reduced Fee Section (if applicable) Reduced fee submissions must be supported by the reduced fee calculation on Page 1 of this form and any re levant supporting information requested by EPA at the time of application review. Enter the number of vehicles/ units projected for sale under the family

. Enter the aggregate projected retail sales price of the vehicles or units and multiply that value by 1% (.01). Enter and pay the reduce fee amount ( first payment minimum $750 , later

refundable ). If you are an ICI, please enter the VIN for any vehicles/en gines 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 §1027.120

.

Company Representative Enter the representative 's name, signature, title, phone/fax, date

, an d an e- mail address. The person named should be someone familiar with the payment who can be contacted for clarification of any issues. Note: A n 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) If using a private shipping service such as Federal Express (or other service), send checks with fee filing forms to:

U.S. Bank

Government Lockbox 9 79032

1005 Convention Plaza

SL

- MO

- C2

- GL St. Louis, MO 63101