Repair Waiver Application

1 Repair Waiver Application This form can be submitted online at IL 532-3027 VIM 170 Rev. 11/2017 This form may be used to apply for a Repair Waiver from the vehicle emissions testing requirement in accordance with the Illinois vehicle Emissions Inspection Law of 2005 (625 ILCS 5/13C-30) and 35 Ill. Adm. Code Section Please type or print legibly, and complete all fields on the Application . vehicle Information Illinois License Plate Number vehicle Identification Number (VIN) Model Year vehicle Make vehicle Owner Information Registered Owner 1 Registered Owner 2 Street Address Street Address City State Zip Code City State Zip Code Daytime Telephone Number ( ) Daytime Telephone Number ( ) Email Address Email Address Preferred Method of Contact: (Please select only one method.)

2 Phone Email Mail Waiver Requirements Illinois law provides that a vehicle that has failed a vehicle emissions retest qualifies for a Waiver of the emissions inspection standards if the following requirements are met: 1. The vehicle has received all repairs and adjustments for which it is eligible under any emissions performance warranty provisions pursuant to Section 207 of the Federal Clean Air Act. 2. The Illinois Environmental Protection Agency (IEPA) determines by normal inspection procedures that the vehicle 's emissions control devices are present and appear to be properly connected and operating. Note: The Malfunction Indicator Lamp/Light (MIL) must be operative in order to qualify for a Repair Waiver .

3 3. Pursuant to 35 Ill. Adm. Code Section , a minimum expenditure of at least $450 in emissions-related repairs, exclusive of tampering-related repairs, have been made. Note: Repairs made must be consistent with the diagnostic trouble codes (DTCs) present at the time of the initial failure. Evidence of the Repair (s) performed must be presented and consist of: signed receipts dated not more than 30 days prior to the test eligibility date that identify the vehicle by VIN, describe the diagnostic procedures utilized in determining the repairs, provide justification that repairs performed were appropriate and necessary for the failure and provide the amount charged for eligible emissions-related repairs.

4 4. Repairs for vehicles of model year 1996 and newer must have been conducted by a recognized Repair technician. If you have any questions on acceptable documentation, please call the Illinois Air Team at: The undersigned hereby certifies that the statements contained herein are true and correct. By affixing his/her signature hereto the undersigned further certifies that he/she is authorized to execute this form. I hereby designate _____ to request and/or receive a Repair Waiver on my behalf. The Illinois EPA is authorized to require, and you shall disclose, the information requested on this form pursuant to 625 ILCS 5/13C-30 and 35 Ill. Adm.

5 Code Section This information may be provided using this form or by alternative means at your discretion. Failure to disclose the requisite information or to comply with 625 ILCS 5/13C and 35 Ill. Adm. Code may result in the denial of your Application and/or penalties being imposed as provided for by applicable law. Any person who knowingly makes a false, fictitious or fraudulent material statement, orally or in writing, to the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony (415 ILCS 5/44(h)). Signature _____ Date _____ Application Instructions This form may be used to apply for a Repair Waiver from the vehicle emissions testing requirement in accordance with the Illinois vehicle Emissions Inspection Law of 2005 (625 ILCS 5/13C-30) and 35 Ill.

6 Adm. Code Section Please type or print legibly, and complete all fields on the Application . Failure to complete all fields may result in the denial of your Waiver . Along with this completed Application , pursuant to 35 Ill. Adm. Code Section , you must submit proof that a minimum expenditure of at least $450 in emissions-related repairs, exclusive of tampering-related repairs, have been made. Repairs made must be consistent with the diagnostic trouble codes (DTCs) present at the time of the initial failure. Evidence of the Repair (s) performed must be presented and consist of: signed receipts dated not more than 30 days prior to the test eligibility date that identify the vehicle by VIN, describe the diagnostic procedures utilized in determining the repairs, provide justification that repairs performed were appropriate and necessary for the failure and provide the amount charged for eligible emissions-related repairs.

7 The vehicle s Malfunction Indicator Lamp/Light (MIL) must be operative in order to qualify for a Repair Waiver . If you have any questions on acceptable documentation, please call the Illinois Air Team at: Information submitted on this form must be legible. Please include the license plate number and your telephone number on all documentation. Submit this form and all documents by one (1) of the following methods: Web: Email to: Fax to: Mail to: Applus Technologies, Inc., PO Box 3266, Glen Ellyn, IL 60137-9998