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Economic Hardship Application - economic hardship application

Economic Hardship Application-economic hardship application

Economic Hardship Extension
This form can be submitted online at www.IllinoisAirTeam.com
This form may be used to apply for an economic hardship extension in accordance with the Illinois Vehicle Emissions Inspection Law of 2005 (625 ILCS
5/13C-30) and 35 Ill. Adm. Code Section 276.404.
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: Phone Email U.S. Mail
(Please select only one method.)
Household(s) Income Eligibility Requirements Below
Household(s) Income Chart
Total Number of People Living Combined Income of Household(s) Members - Age 18 or Older
in Household(s) During Preceding 12 Months
1 $19,140
2 $25,860
3 $32,580
4 $39,300
5 $46,020
6 $52,740
7 $59,460
8 $66,180
For families/households with more than 8 people, add $6,720 for each additional person.
(In the case of multiple registered owners who are not part of the same household, both owners must provide income.)
Total number of people living in household(s): Total household(s) income:
Eligibility (Do I qualify?) (See reverse side for instructions)
If an economic hardship extension has been previously issued, the vehicle must have passed an emissions test prior to the
issuance of another economic hardship extension. A waiver is not acceptable.
If you answer "NO" to any of the following questions, you r application will be denied. YES NO
1) Do you meet the guidelines of the Household(s) Income chart above?
2) Did this vehicle fail an emissions test?
3) Did you attach an estimate or repair receipts related to the test failure(s) totaling at least $225?
The undersigned hereby certifies that the statements contained herein are true and correct and acknowledges that the Illinois EPA may revoke an
economic hardship extension if it is determined that any such statement is false. By affixing his/her signature hereto the undersigned further certifies that
he/she is authorized to execute this form.
By signing this form, the undersigned authorize(s) all relevant State agencies, including the Illinois Department of Revenue and the Illinois Department of
Human Services, to release to the Illinois EPA or its contractor, information regarding his/her/their Illinois tax record(s) and/or other relevant information
to verify household size and income information.
The Illinois EPA is authorized to require, and you shall disclose, the information requested on this form pursuant to 625 ILCS 5/13C and/or 35 Ill. Adm.
Code Part 276. This information shall be provided using this form or by alternative means, at your discretion. Failure to disclose the requisite information
or comply with 625 ILCS 5/13C and/or 35 Ill. Adm. Code Part 276 may result in the extension being denied 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 Registered Owner 1 Date Signature Registered Owner 2 Date
IL 532-2614
VIM 134 Rev. 1/2020
Application Instructions
Illinois State Law (625 ILCS 5/13C-30(c)) and regulations (35 Ill. Adm. Code 276.404) allow the Illinois Environmental Protection
Agency (IEPA) to grant the registered owner(s) of a vehicle a one-year extension of time from the vehicle's current registration
expiration date to allow additional time to get the vehicle repaired and pass an emissions test.
This economic hardship extension can be granted only if all of the following eligibility criteria are met:
Household(s) Income Eligibility
The registered owner(s) of the vehicle must certify that the income during the preceding 12 months of all persons who were 18
years of age and older and residing in the household(s) was not more than the applicable amount stated below.
In the case of multiple registered owners, who are not part of the same household, both owners must certify that the sum of their
household income was not more than the applicable amount stated below.
Household(s) Income Chart
Total Number of People Living Combined Income of Household(s) Members - Age 18 or Older
in Household(s) During Preceding 12 Months
1 $19,140
2 $25,860
3 $32,580
4 $39,300
5 $46,020
6 $52,740
7 $59,460
8 $66,180
For families/households with more than 8 people, add $6,720 for each additional person.
Additional Eligibility Criteria
1) If the Household(s) Income does not exceed the applicable amount in the Household(s) Income chart above, check YES for
Question 1 on the application. If not, check NO.
2) If the vehicle failed an emissions test, check YES for Question 2 on the application. If not, check NO. A reject is not a failure.
3) If estimates and/or receipts are attached, check YES for Question 3. If not, check NO. Estimates and/or receipts may not include
any costs associated with any motor vehicle emissions-related recall that has been, or is to be, paid for by a manufacturer or
dealer. All estimates and/or receipts must be prepared and dated on a company letterhead or invoice. Handwritten estimates
or receipts are not acceptable.
Attach one (1) of the following:
a) Receipts for emissions-related repairs performed no more than five (5) months prior to the expiration date of your vehicle's
Illinois registration. Receipts must be prepared on a work order dated by a recognized repair technician (someone that is:
professionally engaged in vehicle repair, employed by a going concern whose purpose is vehicle repair or has nationally
recognized certification for emissions-related diagnosis and repair) for emissions-related repairs, parts or services,
including diagnostic fees, related to the test failure(s) in the amount of at least $225; or
b) If the registered owner(s) intend(s) to perform the repairs, the estimate must include only the cost for the parts related to
the test failure(s). Brakes, exhaust systems, hoses, belts, etc., are not acceptable. The emissions-related estimate can be
either a receipt from an auto parts store or an estimate for parts from a recognized repair facility on their business invoice.
4) The registered owner has not previously received an extension for economic hardship for the identified vehicle, or, if he/she
has, the identified vehicle passed the vehicle emissions test prior to issuance of another extension for economic hardship.
Required Documentation
If your income meets the above criteria, you may complete and submit this form and attach all supporting documentation. Supporting
documentation includes copies of receipts or estimates for emissions-related repairs and/or parts.
If you have any questions on acceptable documentation, please call the Illinois Air Team at: 844.258.9071.
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: www.IllinoisAirTeam.com Email to: Waivers@IllinoisAirTeam.net Fax to: 312.327.7640
Mail to: Applus Technologies, Inc., PO Box 3266, Glen Ellyn, IL 60137-9998