EPA Form 3520

- 29 OMB Control No. 2060 -0 545

EPA Use Only

DT/D#:________________________________ Deposit Date: __

_ _______

Check/ Wire/CC/ACH#:____________________________________________

Pay.gov Tracking #: _______________________________________________

EPA Signature:____________

___________________ _ Date: _

__

________ U.S. Environmental Protection Agency

Motor Vehicle and Engine Compliance Program

Refund Request Form

Date:

Manufacturer Name:

Family Name:

Original 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 family failed to receive an EPA certificate (no certificate issued)

.

Manufacturer withdraws request for certification and no certificate will be issued

.

Overpayment

Other (explain in comments box):

Comments :

Refund Method:

Credit Card Refund (Note: Refunds of all credit card payments will be to the issuing card unless another

option is chosen and a valid reason given in the Comments box.)

Electronic Refund (EPA will contact 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:

Environmental Protection Agen cy - NVFEL

Fees Team

Compliance Division

2000 Traverwood

Ann Arbor, Michigan 48105EPA Form 3520

- 29 OMB Control No. 2060 -0 545



### Instructions

T his form is used to request a refund of some or all of a previous payment of a certification fee. Refunds can take several weeks to

process. For an update on our refund's status, email Fees@epa.gov

. As an alternative, manufacturers with upcoming family

certification applications can use the Correction Form to apply refunds claims and overpayments to such new families

. Requests for

partial r efunds must be submitted no later than six months after the m odel 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:

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

Family Name:

En ter the family name for which the refund is being requested

Original Payment Date:

Enter the date of the online payment (if P ay.gov was used ) or the offline payment by check, wire, or ACH. Use the best information

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 m ade

online, enter the Pay.gov Tracking ID number assigned to the payment. This information will help EPA confirm the overpayment.

Original Amount Paid:

Indicate the amount you paid for this family

.

Amount of Refund Requested:

Enter the amount in dollar s of the refund requested.

Company Representative:

Enter the company representative information

, including the name, email address, telephone number and fax n umber. The person

named should be someone familiar with the refund request who will be contacte d for clarification of any issues

, for necessary account

information if an electronic refund is being requested , or if the request is denied

.

Reason for Refund:

Select one of the options given

. If o ther is selected, provide an explanation in the C omment 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 : as credit card, electronic refund

, or by check. All refunds on payments made by credit

card wil l be made to that credit card, unless another method is requested and a valid reason given in the Comments box. An e lectronic

refund requires EPA to contact the person named as Company Representative for the manufacturer's accoun t number and other

informat ion. The c heck refund process requires the name and address of the manufacturer or its agent to whom the check will be

payable. The refund recipient should be the same as the original payer; if not, explain why in the Comments box

. Please fill out

all th e fields: name (the company or person to whom the check is payable), add ress, c ity, st ate or p rovince, c ountry, and z ip or p ostal

c ode. Add an "attention" line if you want the check mailed to a particular person or office in your organization. Please 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 minimizing

respondent burden, including through the use of automated collection techniques, to the Director, Collection Strategies Divis ion, 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.