EPA Form 3520

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U.S. Environmental Protection Agency Motor Vehicle and Engine Compliance Progra m Miscellaneous Payments Due Form

Date :

Manufacturer Name:

Family Name:

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

Original Amount Paid: $ (optional)

Revised Family Name: (optional)

Company Representative:

Name: Phone:

Email Address: Fax: (optional)

Reason for Payment :

Incorrect/Revised family

Underpayment

New calendar year fee schedule change

Component certification for evaporative emissions ($241)

Other

Comments:

Fee Payment Details

Amount Paid: $

Enter the check number, or the statement “Wire” or “ACH” :

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, s end checks and this form to:

Environmental Protection Agency Motor Vehicle and Engine Compliance Program
P.O. Box 979032 St. Louis, MO 6319 7

- 9000

(3) Transmit offline Wire payments to the New York Federal Reserve Bank

. (See Instructions, page 2) (4) Transmit offline ACH payments to the Federal Reserve Bank of Cleveland . (See Instructions , page 2 .) (5) Forms not submitted under (1) and (2) above can be sent as e

- mail attachments to F ees@ 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)

.

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 minimizing respondent burden, including through the use 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

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I nstructions:

NOTE: This form may be found and submitted with or without associated payments online at www.Pay.gov

. Copies of this form may also be downloaded at www.epa.gov/otaq/fees.htm

.

Manufacturer Name: List the corporate name as it appears o n the application or the Certificate of Conformity.

Family Name: Enter the family name as it appears on the application or Certificate of Conformity.

. For payments involving more than one family, or involving both overpayments and underpayments (for example, final reduced fee calculation and adjustment under 40 CFR §1027.120(d)) you may 1) submit separate M iscellaneous Payments Due forms, 2) explain fully in the Comments box, or 3) p rovide 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 family or test group.

Original Check Number / 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.

Com pany Representative:

Enter the 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. Note: An acknowledgment of payment will be sent to this e

- mail address where appropriate. No other receipts will

be sent.

Revised Family Name: Enter a revised family name if payment is owed because a family name has been changed or corrected to a category or model year requiring a higher fee than originally paid. If this box is selected, this form can operate to make the correction in family name; a separate Correction Form need not be filed.

Reasons for Payment: Select from the following options:

-- Incorrect/Revised family: If an underpayment was made because the wrong family certification was originally applied for, and/or the original family is being revised to a different family with a different certification fee payment requirement, enter the amo unt 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 family name in the space provided above for Revised Family Name.

-- Underpayment: If the original payment did not cove r 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 a family 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 the amount owed to another certification fee) or Fee R efund Form.

-- Component certification for evaporative emissions ($241) : Select this box if you are applying for certification of evaporative emission components under 40 CFR Part 1060.

-- Other : Select this box f or any other underpayments; enter the amount to be paid in the amount due box, and explain in the Comments box.EPA Form 3520

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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 “Wire” or “ACH”:

To pay by check

, : Make the check payable to "U.S. Environmental Protection Agency". Write "MVECP fee" and the family or test group name on the check, or, if the check is for multiple test groups or famil ies, write "MVECP fee for ___ families/test groups" (edit n umber 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), sen d checks to :

U.S. Bank

Government Lockbox 979032

1005 Convention Plaza

SL

- MO

- C2

- GL St. Louis, MO 63101

To pay by wire , wire payments through the New York Federal Reserve Bank are the only wire transactions normally accepted for certification fee payments . For further information, email Fees@epa.gov . W ire 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:

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

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

. Beneficiary Name: US Environmental Protection Agency. Originator In formation: MVECP Fees, manufacturer name, family name(s). If space is limited, list one family and

the number of families.

To pay by Automated Clearing House (ACH) : payments can be made on

- line at www.Pay.gov by anyone having a U.S. banking account. All banking fees are the responsibility of the manufacturer. Your bank will need the following EPA routing and account information:

Standard Entry Class: CCD

Transaction Code: 22 Receiving DFI ID (ABA number) : 051036706

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