Fee Review Request / Hardship Request Form
Fee Review Request
The permit categories listed under “Description” on the front of this invoice represent the formal status of your permit(s) in the
records of the Department at the beginning of the Fiscal Year on July 1, or for Environmental Results Program certifiers, the date
the facility certified, on or before the certification due date. If you believe your permit has been assigned to the wrong category
you may request a review on or before the payment due date on your original invoice. Please complete all of the required
information below. All review requests must be accompanied by payment in full of the amount of the fee due for the
category you assert is appropriate.
Hardship Request for Payment Plan
In cases of severe financial hardship, you may request a payment plan. Please complete all of the required information below and
provide us with a statement of the specific circumstances you believe constitute severe financial hardship; a proposed schedule for
making payment. All requests to extend the time for making payment must be filed in writing on or before the due date on the
front of the original invoice.
A written determination will be issued for both types of requests. Return this form along with the invoice remit slip and your
payment in the return envelope provided, or send them to: The Department of Environmental Protection, Commonwealth
Master Lock Box, P.O. Box 3982, Boston, MA 02241-3982
Before we process this form we must have your Company Federal Identification Number or
(FEIN)__________________________________
*
The following information is required for processing all requests.
- Please Print -
Information as it appears on invoice or as corrected on the reverse side of this form
Invoice Number: _____________________ Customer Number: VC__________________________
Permittee/Company Name: _______________________________Secondary Name: ___________________________________
Mailing Address: Street/P.O. Box __________________________________ City/Town ____________________Zip__________
Facility Site Address: Street __________________________________ City/Town _________________________Zip__________
Reason for Fee Review Request
Business Closed Prior to July 1, or Sept.15 of last year, for ERP Certifiers Effective Date of Closure: _____/______/_______
Incorrect Permit Fee Category
Other________________________________________________________________
Fee category and amount on invoice being contested: _________________ $__________
Fee category and amount you assert is appropriate: _________________ $__________
Please explain the reason that you believe the permit fee category change is appropriate or the specific circumstances you believe
constitute severe financial hardship. Also include payment plan information and any additional comments below. You may attach
additional pages as necessary. __________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Contact Name: _____________________________________ Telephone #___________________________
Email Address _____________________________________________
Attestation
I have examined this request and to the best of my knowledge and belief, all information supplied on this form is true, correct,
and complete. Attest:
Signature of Company Official___________________________________________ Date: ______________
Name & Title _____________________________________________
