(L ist Year, Make, EF# of Class here) C ontrol #_____________________ Page 1 of 6 TELEPHONE QUESTIONNAIRE OMB No. 2060

- 0086 VEHICLE CONTROL NUMBER DATE ADMINISTERED BY OWNER'S NAME STREET ADDRESS CI TY STATE ZIP (CALL NUMBER BELOW THAT I S MARKED WI TH AN "X") TEL EPHONE (Home) / / (Business) / / BEST TIME TO CALL Privacy Act Statement Authority : T itle 42, United States Code Section 754 Purpose : T he information on the Questionnaire, and y our maintenance records if y ou provide them, will be used to help determine the emissions performance of vehicles and their effect on air quality

. If you qualify

for a cash incentive of $600 or more , EPA will ask for y our social security number to report the payment to the I RS o n Form 1099. Routine Uses : The information will be used by EPA for the purpose s set forth above. If y ou approve, your questionnaire and voluntaril y provided maintenance records will be shared with the manufacturer. Your social security number will be reported to the IRS on Form 1099 for pay ments o f $600 or more . Mandatory or voluntary disclosure and the effects on the individual of not providing information: Answering the Questionnaire and providing maintenance records is voluntary

. Failure to disclose the personal information requested on the Que stionnaire or provide maintenance records may preclude your participation in this voluntary testing program. Disclosure of y our social security

number is mandatory

to receive pay

ment of $600 or more. If y ou are not willing to provide your social securit y n umber, yo u can not receive $600 or more for y our participation

. DATE OF CONTACT _______________________ TI ME OF CONTACT _
_________________ IN DI VI DUAL CONTACTED_______________________________________________________ TO BE COMPLETED ______ _____________ DATE AND TIME OF COMPL ETION___________ Public reporting burden for this collection of information is estimated to average 2 0 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. S end comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Chief, Informati on Policy Branch, PM

- 223, U.S. Environmental Protection Agency, 40l M St., S.W. , Washington, DC. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC. 20503.(L ist Year, Make, EF# of Class here) C ontrol #_____________________ Page 2 of 6
You have been selected from a list o f vehicle owners living in the Detroit/Ann Ann Arbor metropolitan area to participate in a study of vehicle emissions being conducted by the U.S. Environmental Protection Agency. EPA is authorized by law to conduct this study and to offer incentives to yo u for your cooperation should you decide to participate. Y our participation in this program is strictly voluntary. The accuracy of the information that you provide is important. T he information that you provide will be used by EPA along with emission re sults from your vehicle to determine whether the automobile manufacturer has complied with clean air standards established by Congress. T he test results from your vehicle will not be used by EPA to take action against you. Y our cooperation will help EPA' s efforts to control air pollution due to motor vehicle emissions

. These are the conditions of the program:

- we ask that you bring or allow us to pick up and deliver your vehicle into our testing facility

. Y ou will receive either a cash incentive for ea ch day we keep y our vehicle or cash incentive plus a late model loaner car which will have a full tank of gas and unlimited mileage. T his vehicle is yours to use without charge for the duration of the testing, which may take approximately

2 to 3 weeks. During this time, we will be performing a series of tests on y our vehicle to measure vehicle emissions. At the time the vehicle is delivered to us for testing, you will be required to sign an affidavit stating that the answers to the questions y ou will be asked are true and accurate to the best of y our knowledge. We will provide y ou the following incentives for participating in our program:

- If your vehicle is accepted into t he program, a full tank of gas and a cash incentive will be awarded. You will r eceive $20 per day

for each day

y our vehicle is at NVFEL, and the use of a fully

- insured loan car; or $50 per day for every day y our vehicle is at NVFEL in lieu of a loan car. However, if your vehicle is rejected after you bring it to the lab, but before y ou leave, y ou will receive a $20 pay ment. The compensation will be based on whole day s , beginning with the day y our vehicle arrives , and ending one day after y ou are notified y our vehicle is ready for return. The maintenance performed on y our vehicle will depend on program requirements. You will be given a list of an y parts that are replaced. Are you willing to participate? Y ES N O If you are not, may we ask why not ?

__________________________________ ____________(L ist Year, Make, EF# of Class here) C ontrol #_____________________ Page 3 of 6
FOR URS PERSONNEL ONLY SENTENCES I

N CAPITAL L ETTERS ARE INSTRUCTI ONS TO THE CL ERK AND ARE NOT INTENDED TO BE READ TO THE OWNER. IF RESPONSE I S POSITIVE : For the purpose of this study , I am going to ask yo u some questions about your vehicle's maintenance and usage history

. Please have your maintenance records in front of you for reference during the following questions. You should answer these questions t o the best of your knowledge and indicate when you are not sure of something. 1. a . What is the engine family of your vehicle? T he engine family can be found on a Vehicle Emission Control I nformation decal located underside of the hood. The engine fami ly should start with: / /O wner is unable to locate. / /O wner located. EF# ________________________________________ / /E ngine family

located when vehicle arrived at the Lab. ENGINE FAMILY

Engine Famil y must be = (will be filled in by Task Officer) b. What is the vehicle identification number?

_______________________ c. What is the model of y our vehicle? _________________ d

. What kind of transmission does y our vehicle have? : AUTOMATI C MANUAL OTHER

If other, describe :

_________________________________________________________ e. Is your vehicle air conditioned? YES N O f. What mileage is indicated on y our odometer?

____________________ Has the odometer ever not functioned properl y? YES NO If yes, approximately

how long (months/miles) was it inoperable? ________________ CONSULT EPA FOR ELIGIBILITY IF THE RESPONSE IS "YES" to f.
2. Has your vehicle ’ s cataly st ever been replaced or removed? YES / /N O / / If yes, CALL EO. 3. a) Have you kept records of the maintenance and repairs performed on your vehicle?(L ist Year, Make, EF# of Class here) C ontrol #_____________________ Page 4 of 6 YES / /N O / / b) To prepare for testing, the glove box and trunk will need to be opened b y URS and EPA personnel. Frequently , records pertaining to the vehicle's maintenance history are found in the vehicle. Will y ou allow all records (those provided by yo u and those found) to be reviewed and duplicated? YES / /N O / / 4. EPA needs to share yo ur maintenance records as well as this questionnaire and the test results with the manufacturer to correctly test the vehicle. D o y ou agree to this? YES / /N O / / IF RECORDS ARE AVAILABLE, INFORM OWNER THAT: It is important that they are brought to the lab for review and duplication. 5. Have you ever used any fuel other than that recommended by the manufacturer in your vehicle? YES / /N O / / If Yes , what have you used? ___________________________________________________________ How often have you used it? ___________________________________________________________ When was the last time you used it?_________________________________________________

_____ 6. H as your vehicle: a) Been in an accident? YES / /N O / / b) Had an y engine repairs? YES / /N O / / c) An y vehicle modifications? YES / /N O / / If “y es” to any

of the above, please describe:

__________________________________ ____________________________________________________

______________________________________________________________________________________ Has your vehicle had an y: DATE: d) Bod y work? YES / /N O / /

________________ e) Glass repair or replacement? YES / /N O / /

________________ f) Paintwork or detailing? YES / /N O / /

________________ g) Other? Y ES / /N O / /_
________________

If “y es” to d

– g above, please describe:

_______________________________ _______________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

_____________________________ _________________________________________________________(L ist Year, Make, EF# of Class here) C ontrol #_____________________ Page 5 of 6 IF “YES” TO ANY d) THROUGH f ) ABOVE AND DATE IS LESS THAN 6 MONTHS FROM THE TIME OF THIS QUESTIONNAIRE, THIS VEHICLE SHOULD BE PUT ON HOLD. g) New tires? YES / /N O / / Date and mileag e of the most recent tire installed? D ate_________ M ileage___________ HAS IT BEEN LESS THAN 6 MONTHS AND/OR 6,000 MILES SINCE A TIRE REPLACEMENT? I F YES, THIS VEHICLE SHOULD BE PUT ON HOLD . If a replacement part was installed, was it an original manu facturer part? Yes N o What was the approximate cost of the work done ? Do y ou have an y documentation of the work that was done? ( NOTE TO URS : IF THE ANSWER TO A NY OF QUESTIONS a) THRU g) IS “YES”, PLEASE CONSULT WITH EPA STAFF BEFOR E ACCEPTING THIS VEH ICLE.) 7. I s y our vehicle equipped with a trailer hitch ? Y es ____ No ____ Was the hitch installed by : d ealer o ther How much total weight has been hauled?: trailer + cargo = ____________________________

_________________ ( IF YES, CONSULT WITH EPA STAFF BEFORE ACCEPTING THIS VEHICLE.) INFORM THE OWNER THAT : All valuables should be removed from the vehicle (including those in the glove box) prior to bringin g the vehicle to the lab.