3520-29 Refund Request

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General Information
Date:

06/12/2019

Process Code:

Request Fee Refund

Manufacturer Code:
Manufacturer Name:
Contact Name:
Contact Email Address:
Contact Phone:
Engine Family / Evaporative Family / Test Group:
Original Payment Information
Payment Date: (MM/DD/YYYY)
Amount Paid:
Check#/Wire/ACH/Pay.gov Tracking Number:
Reason for Refund
This family failed to receive an EPA certificate (no certificate issued)
Manufacturer withdraws request for certification and no certificate will be issued
Overpayment
No production
Other (Explain in comments box below)
Amount of Refund Requested:
Refund Method:
Engine Family/Test Group to Apply the Refund to:

Refund Check Information

Make check payable to:
Address 1:
Address 2:
City:
Country:

United States

State/Province:

Zip/Postal Code:

Comments:

EPA Form Number 3520-29
OMB Control No. 2060-0545
Approval expires 12/31/2019
The public reporting and recordkeeping burden for this collection of information is estimated to average 12 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, 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., NW, Washington, D.C.
20460. Include the OMB control number in any correspondence. Do not send the completed forms to this address.

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