5900-687 DERA Eligibility Statement

OMB Control Number: 2060-New
Expiration Date: MM/DD/YYYY

EPA Office of Transportation and Air Quality
Transportation and Climate Division

Burden Statement for EPA Form 5900-687: This collection of information is approved by OMB under the Paperwork Reduction Act,
44 U.S.C. 3501 et seq. (OMB Control No. 2060-NEW). Responses to this collection of information are voluntary (2 CFR 200 at 2 CFR
1500). 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 for this information, the accuracy of the provided burden estimates and
any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, 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.

Diesel Emissions Reduction Act (DERA)
Eligibility Statement
EPA Grant ID#:
Vehicle make:

Engine make:

Vehicle model:

Engine model:

Vehicle model year:

Engine model year:

VIN:

Engine horsepower:

Odometer/usage meter reading:

Engine ID or serial number:

Vehicle registration state and number:

Equipment licensing state and number:

I certify that the following statements are true regarding the vehicle/engine/equipment
identified above:
1. The existing vehicle, engine, or equipment is fully operational.
2. I have owned and operated the vehicle during the two years prior to upgrade.
3. The existing vehicle, engine, or equipment has at least three years of remaining life at the
time of upgrade.
4. The existing highway vehicle has accumulated at least 7,000 miles/year during the two years
prior to upgrade.
Vehicle owner’s name:
______________________________________________________
Vehicle Owner (Signature)

______________
Date

Vehicle owner’s address:

EPA Form Number: 5900-687