DEQ Form 410-526 "Certification of Small Entity Status for the Purposes of Annual Fees" - Oklahoma

What Is DEQ Form 410-526?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DEQ Form 410-526 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 410-526 "Certification of Small Entity Status for the Purposes of Annual Fees" - Oklahoma

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DEQ FORM #410-526 (2/18)
DEPARTMENT OF ENVIRONMENTAL QUALITY
OAC 252:410-10-111
P.O. Box 2036
Oklahoma City, OK 73101
CERTIFICATION OF SMALL ENTITY STATUS FOR THE PURPOSES OF ANNUAL FEES
DO NOT RETURN THIS FORM IF YOU DO NOT QUALIFY UNDER ONE OF THESE SIZE STANDARDS
SEE IMPORTANT INSTRUCTIONS ON THE REVERSE SIDE
NAME AND ADDRESS OF LICENSEE (as it appears
INVOICE NUMBER
BUSINESS TELEPHONE NUMBER
on the invoice)
LICENSE NUMBER
CONTACT NAME
EMAIL ADDRESS
COMPANY WEBSITE ADDRESS
STANDARD INDUSTRIAL CLASSIFICATION CODE
S I C
www.
SIZE STANDARDS (Check one box only, and pay
corresponding fee per total number
Circle the standard under which the business qualifies for
of locations listed on License)
Small Entity Status
(See Item 2 on back)
1. SMALL BUSINESS
A for-profit concern that provides a service or a concern not engaged in manufacturing with
annual gross receipts for the previous fiscal year of $5 million or less averaged over its last 3
completed fiscal years.
A. $350,000 to $5,000,000
A.
Total of Locations listed on license
B. Less than $350,000
(main facility plus additional sites)
2. MANUFACTURING INDUSTRY
1
Fee= $1,845.19
A manufacturing concern with an average number of 500 or fewer employees based upon
employment during each pay period for the preceding 12 calendar months.
2
Fee= $2,306.49
A. 35 to 500 employees
3
Fee= $2,767.79
B. Less than 35 employees
4+
Fee= $3,229.09
3. SMALL ORGANIZATION
A not-for-profit organization that is independently owned and operated and has annual
B.
gross receipts of $5 million or less.
Total of Locations listed on license
A. $350,000 to $5,000,000
(main facility plus additional sites)
B. Less than $350,000
1
Fee= $437.30
4. SMALL GOVERNMENTAL JURISDICTION (INCLUDING PUBLICLY SUPPORTED
2
Fee= $546.63
1
EDUCATIONAL INSTITUTIONS
)
3
Fee= $655.96
A government of a city, county, town, township, village, school district, or special district with
a population of less than 50,000.
4+
Fee= $765.29
A. 20,000 to 50,000 population
B. Less than 20,000 population
5. SMALL EDUCATIONAL INSTITUTION THAT IS NOT STATE OR PUBLICLY
SUPPORTED AND HAS 500 OR FEWER EMPLOYEES
A. 35 to 500 employees
B. Less than 35 employees
1
An educational institution referred to in the size standards is an entity whose primary function is education, whose programs
are accredited by a nationally recognized accrediting agency or association, who is legally authorized to provide a program of
organized instruction or study, who provides an educational program for which it awards academic degrees, and whose
educational programs are available to the public.
CERTIFICATION (Must completed by Applicant)
The applicant and any official executing this certification on the behalf of the applicant certifies under penalty of perjury that they are not a
subsidiary of a large entity and that all information contained herein is true and correct to the best of their knowledge and belief.
TYPED OR PRINTED NAME AND TITLE
SIGNATURE
DATE
DEQ FORM #410-526 Page 1
DEQ FORM #410-526 (2/18)
DEPARTMENT OF ENVIRONMENTAL QUALITY
OAC 252:410-10-111
P.O. Box 2036
Oklahoma City, OK 73101
CERTIFICATION OF SMALL ENTITY STATUS FOR THE PURPOSES OF ANNUAL FEES
DO NOT RETURN THIS FORM IF YOU DO NOT QUALIFY UNDER ONE OF THESE SIZE STANDARDS
SEE IMPORTANT INSTRUCTIONS ON THE REVERSE SIDE
NAME AND ADDRESS OF LICENSEE (as it appears
INVOICE NUMBER
BUSINESS TELEPHONE NUMBER
on the invoice)
LICENSE NUMBER
CONTACT NAME
EMAIL ADDRESS
COMPANY WEBSITE ADDRESS
STANDARD INDUSTRIAL CLASSIFICATION CODE
S I C
www.
SIZE STANDARDS (Check one box only, and pay
corresponding fee per total number
Circle the standard under which the business qualifies for
of locations listed on License)
Small Entity Status
(See Item 2 on back)
1. SMALL BUSINESS
A for-profit concern that provides a service or a concern not engaged in manufacturing with
annual gross receipts for the previous fiscal year of $5 million or less averaged over its last 3
completed fiscal years.
A. $350,000 to $5,000,000
A.
Total of Locations listed on license
B. Less than $350,000
(main facility plus additional sites)
2. MANUFACTURING INDUSTRY
1
Fee= $1,845.19
A manufacturing concern with an average number of 500 or fewer employees based upon
employment during each pay period for the preceding 12 calendar months.
2
Fee= $2,306.49
A. 35 to 500 employees
3
Fee= $2,767.79
B. Less than 35 employees
4+
Fee= $3,229.09
3. SMALL ORGANIZATION
A not-for-profit organization that is independently owned and operated and has annual
B.
gross receipts of $5 million or less.
Total of Locations listed on license
A. $350,000 to $5,000,000
(main facility plus additional sites)
B. Less than $350,000
1
Fee= $437.30
4. SMALL GOVERNMENTAL JURISDICTION (INCLUDING PUBLICLY SUPPORTED
2
Fee= $546.63
1
EDUCATIONAL INSTITUTIONS
)
3
Fee= $655.96
A government of a city, county, town, township, village, school district, or special district with
a population of less than 50,000.
4+
Fee= $765.29
A. 20,000 to 50,000 population
B. Less than 20,000 population
5. SMALL EDUCATIONAL INSTITUTION THAT IS NOT STATE OR PUBLICLY
SUPPORTED AND HAS 500 OR FEWER EMPLOYEES
A. 35 to 500 employees
B. Less than 35 employees
1
An educational institution referred to in the size standards is an entity whose primary function is education, whose programs
are accredited by a nationally recognized accrediting agency or association, who is legally authorized to provide a program of
organized instruction or study, who provides an educational program for which it awards academic degrees, and whose
educational programs are available to the public.
CERTIFICATION (Must completed by Applicant)
The applicant and any official executing this certification on the behalf of the applicant certifies under penalty of perjury that they are not a
subsidiary of a large entity and that all information contained herein is true and correct to the best of their knowledge and belief.
TYPED OR PRINTED NAME AND TITLE
SIGNATURE
DATE
DEQ FORM #410-526 Page 1
IMPORTANT INSTRUCTIONS FOR DEQ FORM #410-526 – PLEASE READ CAREFULLY
DO NOT COMPLETE OR RETURN THIS FORM IF YOU DO NOT QUALIFY
AS A SMALL ENTITY
CERTIFICATION OF SMALL ENTITY STATUS FOR THE PURPOSES
OF ANNUAL FEES
A licensee who qualifies as a small entity under a specific size standard established by the DEQ may pay
a reduced annual fee by filing the required certification on DEQ FORM #410-526, which is on the reverse
side of this page. A separate DEQ FORM #410-526 is required for each invoice. Licensees who do not
qualify under one of the size standards shown on DEQ FORM #410-526 should disregard this form.
1. Complete all items on DEQ FORM #410-526 as follows: (NOTE: Incomplete or improperly completed
forms will be returned as unacceptable)
Enter the licensee’s name and address exactly as they appear on the invoice. Annotate name
and/or address changes for billing purposes on the payment copy of the invoice. **Correcting the
name and/or address on DEQ FORM #410-526 or on the invoice does not constitute a request to
amend the license.**
Enter the invoice number and license number exactly as they appear on the annual fee invoice.
Enter the licensee’s business telephone number, contact name, e-mail address and company
website address. DEQ may check the status as indicated on this form.
Enter the Standard Industrial Classification (SIC) code if it is known. If it is not known, leave this
item blank.
2. Identify and circle the appropriate size standard under which the licensee qualifies as a small entity (1
through 5). Then check the box for the corresponding Number of Locations (under A or B) listed on
the license. Check only one box.
Note the following:
The size standards apply to the licensee, not the individual authorized users listed in the license.
Gross annual receipts as used in the size standards includes all revenue in whatever form
received or accrued from whatever sources, not solely receipts from licensed activities
A licensee who is a subsidiary of a large entity does not qualify as a small entity.
The owner of the entity, or an official empowered to act on behalf of the entity, must sign and date
the certification.
3. If the invoice amount is less than the reduced small entity annual fee, pay the amount on the invoice:
there is no further reduction. In this case, DEQ FORM #410-526 does not have to be filed.
4. The completed DEQ FORM #410-526 must be submitted with the required annual fee payment and the
"SEND" portion of the invoice to the address shown on the invoice.
5. Licensees should submit a new certification with its annual fee payment each year. Failure to submit
DEQ FORM #410-526 at the time the annual fee is paid will require the licensee to pay the full amount
of the invoice.
DEQ FORM #410-526 Page 2
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