5900-687 O_DERA Eligibility Statement

OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

Diesel Emissions Reduction Act (DERA)
Eligibility Statement
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. 2060-0754). 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 1.5-12 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.

Instructions: Please complete this form for each vehicle or piece of equipment that that requires
eligibility attestation as part of this project.

EPA Grant Identification:
Vehicle/Equipment make:

Engine make:

Vehicle/Equipment model:

Engine model:

Vehicle/Equipment model year:

Engine model year:

Vehicle Identification Number/Equipment
Identification or Serial Number:

Engine horsepower:

Odometer/usage meter reading:

Engine Identification or Serial Number:

Vehicle registration state and number:

Equipment licensing state and number
(when applicable):

By signing, I affirm 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.
EPA Form Number: 5900-687

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OMB Control Number: 2060-0754
Expiration Date: MM/DD/YYYY

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

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