5900-309 Cash Incentives

Control No.____________

CASH INCENTIVE AGREEMENT

I, _____________________________, the owner ( ) and/or joint owner ( ), and/or principal driver ( ) being fully advised agree to the following:

( ) To accept a total of $20.00 per day, not to exceed $599, in addition to the use of a loaner

vehicle.

( ) To accept a total of $50.00 per day, not to exceed $599, in lieu of a loaner vehicle.

while the vehicle described herein, MAKE_______________________

MODEL______________YEAR_____VIN_________________________

is in possession of Jacobs, a contractor to the U.S. Environmental Protection Agency.

NOTE: It is understood that the total value of the incentive offered will be dependent upon the time the vehicle is being held for testing not to exceed $599. This means that EPA will keep your car until testing is complete but your incentive will not exceed $599.

Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information. The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA’s Light-Duty In-Use Testing Program. Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.

Providing the requested information is voluntary, but failing to do so will result in EPA’s inability to approve your participation in the Light-Duty In-Use Testing Program.

Public reporting burden for this collection of information is estimated to vary from 1 to 60 minutes per response, with an average of 30 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. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Chief, Information 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.

PARTICIPANT:

_________________________________________ ____________ Signature Date

JACOBS REPRESENTATIVE:

________________________________________ ____________ Signature Date

OMB No. 2060-0086 Expires (09/30/2014)

EPA Form #5900-309