Form 8500-27 Application for Firms to Conduct Lead-Based Paint Activi

United States
Environmental Protection
Agency

Office of Prevention,
Pesticides, and
Toxic Substances

EPA 747-B-99-001
September 2004
http://www.epa.gov/lead

Application and
Instructions for Firms
Applying for Certification to Conduct
Lead-Based Paint Activities

[This page intentionally left blank]

Form Approved OMB No. 2070-0155 Expires 02/29/08

Clear data

APPLICATION FOR FIRMS

U.S. ENVIRONMENTAL PROTECTION AGENCY

TO CONDUCT LEAD-BASED PAINT ACTIVITIES

Important: This application form is a substitute for the letter required by 40 CFR §745.226(f)(2). Consult the instructions
for firms applying for certification to conduct lead-based paint activities. Persons seeking individual certification should
use the Application for Individuals instead of this form. Please fill out all sections. Type or print responses in black
or blue ink only.
A.

General Information

Official Use Only

Select one of the following application types:

‘
‘
‘
‘

Initial certification application
Re-certification application

Adding jurisdiction(s) to certification/amending certification
Replacement of a certificate

For information on EPA and
other lead programs, see:

http://www.epa.gov/lead

The fee you must pay depends on the number of EPA-run jurisdiction(s)

in which you plan to conduct lead-based paint activities. A firm does not
receive certification by discipline and your fee is not affected by the
number of disciplines you select. See the fees schedule in the instructions
to determine your fee. The total fee listed below should include fees
calculated on any additional sheets.

Check here to be listed on EPA’s

web site for

‘ Evaluation (inspection, risk

assessment, clearance)

‘ Lead Abatement

1st EPA-run jurisdiction (pay base certification fee only):___________________

Fee: $_________

(See the definition of EPA-run jurisdiction(s) and the fee example in the instructions.

For current listing of EPA-run jurisdictions, see www.epa.gov/lead or call 1-800-424-LEAD.)

Each additional EPA-run jurisdiction: ___________________________

Fee: $_________

(List on additional sheets of paper and attach, as necessary. $35 per jurisdiction)

Total Fee: $_________
0.00
B. Applicant Information
Name of Firm: ___________________________________________________________________________________
Business Address:________________________________________________________________________________
Street Address, Suite Number (Please no P.O. Box)

City

State

Zip Code

Mailing Address: _________________________________________________________________________________
(if different from above)

Address

City

State

Zip Code

Name of Attesting Individual: _______________________________________________________________________
Last

First

Middle

Firm’s Phone #:(_____) ____-_____ ext. _____
Attesting Individual’s Phone #:(_____) ____-_____ ext. _____
Attesting Individual’s E-mail Address: ________________________________________________________________
C. Professional Certifications
Does the firm hold current permits, licenses, certifications, or registrations in the lead-based
paint activity field in any state, U.S. territory, or Indian tribal land?

‘ Yes

‘ No

If yes, please fill in the following blanks, one line for each permit, license, certification, or registration held. Attach
additional sheets of paper, as necessary.
____________________________
Type of certification held

____________________________
Type of certification held

_____________________________________
State, U.S. territory, or Indian tribal land(s) nam

_____________________________________
State, U.S. territory, or Indian tribal land(s) name

__________________________

__________

Certification/Identification Number

Date received

__________________________

__________

Certification/Identification Number

Date received

D. Lead-Based Paint Activity Violations
Does the firm have any past, present, or pending lead-based paint activity violations of EPA,
state, U.S. territory, or Indian tribal land(s) regulations?

‘ Yes

‘ No

If yes, please attach a written explanation.

EPA Form 8500-27 (Rev 09/04)

Page1 of 2

CERTIFICATION APPLICATION FOR FIRMS (CONTINUED)

Form Approved OMB No. 2070-0155 Expires 02/29/08

E. Certification Statement
Fill in the blanks in the following statement as indicated.
___________________________________________

attests that

_______________________________________

Name of Attesting Individual

Name of Firm

shall only employ appropriately certified individuals to conduct lead-based paint activities.
_____________________________________________ and its employees shall follow the work practice standards
Name of Firm

in 40 CFR § 745.227 for conducting lead-based paint activities at all times.
Privacy Act Statement: This statement is provided pursuant to the Privacy Act of 1974, 5 U.S.C. §552a. The authority for collecting this information is 40 C.F.R. Part 745,
and 15 U.S.C. §§2682 and 2684. The information collected on this form will be used to establish the applicant’s eligibility for certification to conduct lead-based paint
activities in target housing and child-occupied facilities. Disclosure of this information is voluntary, however, the failure to provide this information may delay or prevent an
applicant’s certification. This information may be disclosed in appropriate and limited circumstances to: EPA employees, contractors, grantees or others when performing
duties that are compatible with the purpose for which this information is collected and when this information is necessary to complete the task; a member of Congress in
response to a request made with your consent and on your behalf; to appropriate law enforcement agencies responsible for investigating, enforcing, prosecuting or
implementing specific statutes, codes or regulations and this information is relevant to that responsibility; an appropriate adjudicative body when such disclosure is
compatible with the purpose for which this information is collected and the EPA or the United States has an interest in the proceeding; and the Department of the Treasury,
the General Services Administration, the General Accounting Office and other Federal, State, and Local Agencies for authorized activities related to this information.

I hereby attest and affirm that the information included on this application, including any attachments, is true and accurate
to the best of my belief and knowledge. I acknowledge that any certification issued pursuant to this application, including
any attachments, will be subject to revocation if issuance was based on incorrect or inadequate information that materially
affected the decision to issue the certification.

Attesting Individual’s Signature

__________________________
Date Signed

(Please sign legibly within the boundaries of the box above.)

__________________________________________________________________
Attesting Individual’s Title (please print)
Before you mail your application and certification fee, make sure that you have:
Filled out all applicable sections of the application

Signed and dated the application

Made a copy of your application for your files

Enclosed the appropriate certification fees

(check or money order)

Printed “Lead Program User Fees” on the

check or money order

For more information, see the fees section in the instructions

Mail original completed application, supporting materials, and the

certification fee to:

U.S. EPA
Lead User Fees

P.O. Box 979072
St. Louis, MO 63197-9000

EPA Form 8500-27 (Rev 09/04)

Page 2 of 2

INSTRUCTIONS FOR FIRMS APPLYING FOR CERTIFICATION

TO CONDUCT LEAD-BASED PAINT ACTIVITIES

Firms must apply to the U.S. Environmental Protection Agency (EPA) to be certified or recertified to perform or offer to perform lead-based paint activities in states, U.S. territories, and
all Indian tribal land(s) in any one EPA Region where EPA implements the lead-based paint
certification program. If EPA does not administer the certification program in an area where a
firm wishes to work, the firm must apply directly to that state, territory, or Indian tribe for
certification.
These instructions supplement EPA form 8500-27 (Rev 09/04), Application for Firms to Conduct
Lead-Based Paint Activities. Please note that you must use a separate form for each
application type.
How to Apply for Initial Certification
Firms can submit their application and payment on-line or by mail. To apply for certification as a
firm, you must:
•
•

To submit an application on-line, go to the following website (http://cdx.epa.gov) and follow
the instructions for applying on-line.
To submit your application to EPA by mail:
• Complete, sign, and date EPA form 8500-27 (Rev 09/04). The form can be filled out by
hand or by using a fillable form on your computer (http://www.epa.gov/lead/firmapp.pdf).
• Calculate the appropriate fee using the fees schedule listed on the inside front cover.
• Print “Lead Program User Fees” on the check or money order for the fee and mail it with
your application to the following address:
U.S. EPA
Lead User Fees

P.O. Box 979072
St. Louis, MO 63197-9000

How to Apply for Re-certification
Firms must be re-certified every three (3) years. To ensure that your firm will be re-certified
before its current certification expires, you should submit a re-certification application well
before the expiration date. If you apply after your certification expires, you must pay
the full initial certification fee. For re-certification, complete all sections of the application and
follow the mailing instructions described in the “Initial Certification” section of these instructions.
Amended Application
Amended applications must be sent to the following address:
U.S. EPA
P.O. Box 14417
Washington, DC 20044-4417

Replacement of a Certificate
To replace a certificate, complete only sections A (General Information), B (Applicant
Information), and E (Certification Statement) of the application and follow the mailing
instructions described in the “Initial Certification” section of these instructions.
Incomplete Application
If your application is incomplete, EPA will not process your application. If any components of
your application are missing, your application will become inactive for a period not to exceed
30 days until the application is made complete. If you do not complete your application, EPA
will return the application package. You may apply again with a complete package. Please call
1-800-424-LEAD to see if your application is complete.
Firms Completing Applications for Individuals
If the firm is assisting in completing applications for individuals who are applying for certification,
please be aware of the following:
•
•
•

•
•

Individual must have an address and phone number different from the firm’s.
Individual must sign and date the application.
Individual’s name, social security number, and discipline should appear on the front of the
application fee payment (check or money order), even if it is hand-written, if the firm pays for
the individual.
EPA forwards all correspondence to individuals who have signed the application attesting to
their willingness to comply with the work practice standards found at 40 CFR §745.227.
EPA forwards copies of the individual’s approval letter and certificate to the firm upon written
request of the applicant; however, the approval letter, identification badge, and certificate
remain the property of the individual.

Fees
The fee for applying for certification, re-certification, and other requests is listed in the following
schedule. It is important that you:
•
•
•

Calculate fee based on the number of EPA-run jurisdiction(s) in which you plan to operate
(the number of disciplines you select does not affect your fee).
Write your total fee amount in section A of the application, even if you attach additional
sheets of paper listing additional EPA-run jurisdictions.
Make the check or money order payable to U.S. Environmental Protection Agency. Other
methods of payment include wire transfer, electronic funds transfer, and, for government
payers only, on-line payment agency collection (OPAC).

Fees Schedule
Description

Fee

Certification

$540

Certification Renewal
[every 3 years, see 40 CFR
745.226(f)(7) for details]

$430

Multi-jurisdictional Certification Fee*

$35 for each additional EPA-run jurisdiction**

Replacement Certificate

$15

*Multi-jurisdictional certification applies to an applicant applying in more than one EPA-run jurisdiction.

**An EPA-run jurisdiction includes an EPA-run state, a U.S. territory, or all Indian tribal land(s) in any one EPA

Region. (For current listing of EPA-run jurisdictions, see www.epa.gov/lead or call 1-800-424-LEAD.)

Fee Example
If your firm is applying for initial certification in two states and all Indian tribal land(s) in any one
EPA Region, your firm is required to pay $610:
Initial firm certification fee
One additional state fee*
All Indian tribes in one EPA Region fee*
Total Amount Due:
*Each certification request includes the fee for one EPA-run jurisdiction.

$ 540
$ 35
$ 35
$ 610

EPA’s Certification Fees Refund Policy
Firms having submitted an application and associated fees for certification or re-certification
who wish to withdraw their application prior to Agency approval will receive a fee refund based
upon the schedule listed below. Firms who request a refund more than 10 days after the
Agency receives the application will not receive a 100 percent refund.
Number of Days Following Agency Receipt of
Application

Percent Reimbursable (based upon total fees
submitted)

up to 10 days

100%

11 to 60 days

75%

61 to 120 days

50%

121 or more days

25%

Note: Refunds will only be made after EPA verifies fee receipt and deposit by the U.S.
Treasury.
Firms must notify the Agency in writing in order to qualify for a refund. The date of withdrawal is
the date on which the Agency received the withdrawal notification.
EPA will not refund fees after granting a firm certification or re-certification. If your application is
disapproved, EPA will not refund fees.
Refunds are not available for replacing a certificate.

Application Process for Firm Certification
EPA processes applications on a first-come, first-served basis. The following flowchart depicts
the application process for firm certification. EPA has up to 90 days after receiving a complete
request for certification to approve or disapprove the application.

Firm submits application and fee
to EPA

Is the
application
complete?

Firm submits missing
information

No

EPA sends letter
detailing missing
information

No

EPA returns
application with an
explanation of
deficiency

Yes
EPA sends the firm a letter indicating
that the application is complete

Is the applicant
qualified?
Yes
EPA sends
approval letter
and certificate

Paperwork Reduction Act Notice: The annual public burden for this collection of information is estimated to be 7.5
hours for firms, including the time needed for reading the instructions and completing the necessary information
contained in this form. Send comments regarding the burden estimate or any other aspect of this collection of
information, including suggestions for reducing the burden to: Director, Collection Strategies Division, Office of
Environmental Information (OEI), U.S. Environmental Protection Agency (Mail Code 2822), 1200 Pennsylvania
Avenue, N.W., Washington, D.C. 20460. Include OMB number 2070-0155 in any correspondence. Do not send the
completed form or requested information to this address. The actual information or form should be submitted in
accordance with the instructions accompanying the form, or as specified in the corresponding regulations.