Appendix T. USE FEE REFUND REQUEST

EP 1130-2-550

Change 3

15 Aug 02

APPENDIX T

USE FEE REFUND REQUEST

(EP 1130-2-550)

Part 1 (TO BE COMPLETED BY APPLICANT)

Request a Use Fee Refund in the amount of $ ________________________ to:

Name

_________________________________

Address

_________________________________

Reason for request:

______________________________________________________

_____________________

_________________________________________

(Date)

(Signature of Applicant)

Original User's Copy of Permit Must be Attached to this Request

Part 2 (TO BE COMPLETED BY CORPS OF ENGINEERS REPRESENTATIVE)

The above fee relates to F&A Work Item # __________, Park Work Item # __________,

and was transmitted on CEFMS Collection Voucher # _________dated _____________.

Corps of Engineers Point of Contact is

____________________________________

Phone:______________________________

Approved by:

_______________________________________________

___________________

(Signature of Operations Manager or Representative)

(Date)

ENG FORM 6013-R, AUG 2002

(Proponent: CECW-ON)

T-1