Form 5900-535 Payment of Antidumping and Countervailing Duties

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Overview

Company Idenfification
ADCVD Documentation
Lists

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Sheet 1: Company Idenfification

							OMB Control Number: 2060-XXXX
							Expiration Date: X/XX/202X
	American Innovation and Manufacturing Act - Payment of Antidumping and Countervailing Duties
	Worksheet Instructions:
	Submit this cover sheet along with any supporting documentation to EPA through the ODS Tracking System (ODSTS). Instructions on how to report data through the ODSTS are available at <https://www.epa.gov/ods-phaseout/submitting-other-documents-epa>. Select "AD/CVD Documentation" as the document type when submitting your documentation.
	Version:
	0.1
	Updated:
	9/27/2021
	Reporting Form Navigation:
	Section 1 - Company Identification
	Section 2 - Import Summary
	Section 3 - Duties Paid Summary
	Section 4 - Antidumping and Countervailing Duties Documentation
	Section 1 - Company Identification
	Instructions: Complete the following company information.
	1	2	3	4	5	6	7
	Company Name	Contact Name	Contact Phone	Contact Email	City	State/U.S. Territory	Zip
	Section 2 - Import Summary
	Instructions: List all HFCs and HTS codes as reported to Customs that were imported by your company in each year from January 1, 2017, through May 19, 2021.
	HFCs Imported
	2017	2018	2019	2020	2021 (through May 19)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
	HTS Codes Reported to Customs
	2017	2018	2019	2020	2021 (through May 19)
1
2
3
4
5
6
7
8
9
10
	Instructions: Identify the foreign exporter(s) from which HFCs were imported in each year from January 1, 2017, through May 19, 2021.
	Foreign Exporter
	2017	2018	2019	2020	2021 (through May 19)
	This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-XXXX). Responses to this collection of information are mandatory (40 CFR 84.31). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 2 hours per response. Send comments on the Agency’s need this formation, 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, Regulatory Support Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
	EPA Form # 5900-535

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Sheet 2: ADCVD Documentation

						OMB Control Number: 2060-XXXX
						Expiration Date: X/XX/202X
American Innovation and Manufacturing Act - Payment of Antidumping and Countervailing Duties
Worksheet Instructions:
Submit this cover sheet along with any supporting documentation to EPA through the ODS Tracking System (ODSTS). Instructions on how to report data through the ODSTS are available at <https://www.epa.gov/ods-phaseout/submitting-other-documents-epa>. Select "AD/CVD Documentation" as the document type when submitting your documentation.
Version:
0.1
Updated:
9/27/2021
Reporting Form Navigation:
Section 1 - Company Identification
Section 2 - Import Summary
Section 3 - Duties Paid Summary
Section 4 - Antidumping and Countervailing Duties Documentation
Section 3 - Duties Paid Summary
Instructions: Identify the total amount of duties paid for imports in each year from January 1, 2017, through May 19, 2021.
Total or Estimated Amount of Duties Paid for Imports in Each Year (USD)
2017	2018	2019	2020	2021 (through May 19)
Instructions: Provide an explanation if no duties were owed.
Explanation if No Duties were Owed
2017	2018	2019	2020	2021 (through May 19)
Section 4 - Antidumping and Countervailing Duties Documentation
Instructions: Provide documentation of cash deposit of and final payment of antidumping and countervailing duties for the regulated substances imported from January 1, 2017, through May 19, 2021, or evidence that those imports were not subject to such duties for those years. (§84.31(c)(8))
Describe the documentation provided to EPA:
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-XXXX). Responses to this collection of information are mandatory (40 CFR 84.31). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be XX hours per response. Send comments on the Agency’s need this formation, 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, Regulatory Support Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
EPA Form # 5900-XXX

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Sheet 3: Lists

Chemical Name	[Common Name]		[State]
CHF3	HFC-23		Alabama
CH2F2	HFC-32		Alaska
CH3F	HFC-41		American Samoa
CF3CHFCHFCF2CF3	HFC-43-10mee		Arizona
CHF2CF3	HFC-125		Arkansas
CHF2CHF2	HFC-134		California
CH2FCF3	HFC-134a		Colorado
CH2FCHF2	HFC-143		Connecticut
CH3CF3	HFC-143a		Delaware
CH2FCH2F	HFC-152		District of Columbia
CH3CHF2	HFC-152a		Florida
CF3CHFCF3	HFC-227ea		Georgia
CH2FCF2CF3	HFC-236cb		Guam
CHF2CHFCF3	HFC-236ea		Hawaii
CF3CH2CF3	HFC-236fa		Idaho
CH2FCF2CHF2	HFC-245ca		Illinois
CF3CH2CF3	HFC-245fa		Indiana
CF3CH2CF2CH3	HFC-365mfc		Iowa
			Kansas
			Kentucky
			Louisiana
			Maine
			Marshall Islands
			Maryland
			Massachusetts
			Michigan
			Minnesota
			Mississippi
			Missouri
			Montana
			Nebraska
			Nevada
			New Hampshire
			New Jersey
			New Mexico
			New York
			North Carolina
			North Dakota
			Northern Mariana Islands
			Ohio
			Oklahoma
			Oregon
			Pennsylvania
			Palau
			Puerto Rico
			Rhode Island
			South Carolina
			South Dakota
			Tennessee
			Texas
			Utah
			Vermont
			Virginia
			Washington
			West Virginia
			Wisconsin
			Wyoming
			U.S. Virgin Islands