3520-29 Refund Request Form

EPA Form 3520-29

OMB Control No. 2060-0545; approval expiration date: 7/31/2010

U.S. Environmental Protection Agency
Motor Vehicle and Engine Compliance Program
Refund Request Form
Date:
Manufacturer Name:
Engine 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 engine family or test group 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:
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 [email protected]
(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

EPA Use Only

DT/D#:________________________________ Deposit Date: __________
Check/Wire/CC/ACH#:____________________________________________
Pay.gov Tracking #: _______________________________________________
EPA Signature:________________________________ Date: ___________

EPA Form 3520-29

OMB Control No. 2060-0545; approval expiration date: 7/31/3010

Instructions
This form is used to request a refund of some or all of a previous payment of a test group or engine family certification fee. Refunds
can take several weeks to process. As an alternative, manufacturers with upcoming engine certification applications can use the
Correction Form to apply refunds claims and overpayments to such new engine families or test groups. Requests for partial refunds
must be submitted no later than six months after the model 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:
List the corporate name as it appears on the application or the Certificate of Conformity.
Engine Family Name:
Enter the engine family or test group name for which the refund is being requested
Original Payment Date:
Enter the date of the online payment (if Pay.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 made
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 engine or test group.
Amount of Refund Requested:
Enter the amount in dollars of the refund requested.
Company Representative:
Enter the authorized company representative information, including the name, email address, telephone number and fax number. The
person named should be someone familiar with the refund request who can be contacted for clarification of any issues and for
necessary account information if an electronic refund is being requested.
Reason for Refund:
Select one of the options given. If Other is selected, provide an explanation in the comment 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, either as an electronic refund or by check. An electronic refund requires EPA to contact
the person named as Company Representative for the manufacturer's account number and other information. The check refund
process requires the name and address of the manufacturer or its agent to whom the check will be payable. Please fill out all the
fields: name (the company or person to whom the check is payable), address, city, state or province, country, and zip or postal code.
Add an "attention" line if you want the check mailed to a particular person or office in your organization. Note: All refunds on
payments made by credit card within the last two years will be made to that credit card, unless another method is requested. 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 [email protected]
(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 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.