5900-306 Reply Form

REPLY FORM

1 . Owner's Name ^{2. Control No.}

THIS INFORMATION REQUEST IS AUTHORIZED BY LAW. WHILE YOU ARE NOT REQUIRED TO RESPOND, YOUR COOPERATION IS NEEDED TO MAKE THE RESULTS OF THIS INVESTIGATION VALID

^{3. Do you own/lease a vehicle with the vehicle identification number}

_{(VIN) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___}? _____yes ______no

^4. If so, list the Make Model

5. ^{Current odometer reading miles.}

_6. ^{Are you the original owner/lessee? yes _____no}

7. Is your vehicle ______ automatic ______ manual

8. Are you interested in participating in this program?

^{yes _____ n}o _______ ^{need more information.}

9. May we contact you at your convenience:

Home Phone: (_____) - _____________________ Best time to call: a.m. ______p.m.

Work Phone: (_____) - _____________________ Best time to call: a.m. ______p.m.

Cell Phone: ( ) - _____________________ Best time to call: _______ a.m. p.m.

IF YOU HAVE ANY QUESTIONS, PLEASE CALL US TOLL FREE AT (855)665-1228.

WHETHER OR NOT YOU PLAN TO PARTICIPATE, PLEASE RETURN THIS FORM IN THE _{POSTAGE PAID ENVELOPE.}

OMB No. 2060-0086 Form No. 5900-306 Expires 09/30/14

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 on information, including suggestions for reducing this burden, to Chief, Information Policy Branch, PM-223, U.S. Environmental Protection Agency, 401 M St., S.W. Washington, DC. 20460: and to the Office of Information and Regulatory Affairs, Office Of Management and Budget, Washington, DC. 20503.