5900-309 Cash Incentives

Control #

DRAFT CASH INCENTIVE AGREEMENT
I,

0
and/or principal driver (

(
(

0

, the owner (

) and/or joint owner (

)

), being fully advised agree to the following:

) To accept a total of $20.00 per day, in addition to the use of a loaner vehicle.
) To accept a total of $50.00 per day, in lieu of a loaner vehicle.
while the vehicle described herein,

MODEL

MAKE

YEAR

0

0

0

VIN

0

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

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, 401 M St. S.W.
Washington, DC. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

PARTICIPANT:
SIGNATURE

DATE

JACOBS REPRESENTATIVE:
SIGNATURE

DATE

EPA Form #5900-309
OMB No. 2060-0086 Expires (######)