NOTICE OF ENGINE MODIFICATIO

OWNER:

CITY:

STATE/PROV:

The ENGINE MODEL information is to be recorded from the engine data plate and v
the correct model is being used.

PLEASE SELECT TYPE OF MODIFICATION BEING REPORTED FROM DROP-DOW

MODIFICATION TYPE:

FROM / BEFORE MODIFICATION

ENGINE MODEL:

CONFIGURATION NO:
CRITICAL PARTS LIST
(CPL):
 ECM CODE:

FUEL PUMP CODE:

FUEL RATING OPTION#:

HP & TORQUE:

APPLICATION:

MODIFICATION CHARGE:

RESEARCH MOD CHARGE: http://circuit.cummins.com/

FORM SUBMISSION: comm.claims@cummins.com
Note: Dealers should submit this form to their Cum

1. MULTIPLE ENGINE SERIAL NUMBERS ARE ALLOWED. MULTIPLE ENGINE SERIAL NUMBERS CAN BE LIS

2. A LISTING OF THE OPTION# FROM THE REPAIR ORDER (OTHER THAN FUEL PUMP PARTS) USED IN THIS MOD
PROVIDED BELOW.

MULTIPLE ENGINE LIST

ESN
 DEALER/DISTRIBUTOR STATEMENT

The Engine Modification Made herein incorporates a part by part match to

make the above listed engine conform to a standard model Cummins
engine currently available from Cummins Engine Company, Inc. It is
further certified that this engine, as modified, conforms to required
regulations pertaining to gaseous emissions and smoke.

OPTION LIST
Qty Option #
ENGINE MODIFICATION

ENGINE S/N:

HOURS/MILES/KM:

MODIFICATION DATE:

DATE IN SERVICE:

from the engine data plate and verified with the ECM data to ensure
rect model is being used.

CATION BEING REPORTED FROM DROP-DOWN MENU:

TO / AFTER MODIFICATION

ENGINE MODEL:

CONFIGURATION NO:
CRITICAL PARTS LIST
(CPL):
 ECM CODE:

FUEL PUMP CODE:

FUEL RATING OPTION#:

HP & TORQUE:

APPLICATION:

p://circuit.cummins.com/
m.claims@cummins.com
alers should submit this form to their Cummins Distributor

TIPLE ENGINE SERIAL NUMBERS CAN BE LISTED IN THE SECTION PROVIDED BELOW.

HAN FUEL PUMP PARTS) USED IN THIS MODIFICATION MUST BE INCLUDED IN THE SECTION
PROVIDED BELOW.

TIPLE ENGINE LIST

DATE IN SERVICE MI/HR/KM
 CUMMINS DISTRIBUTOR

DISTRIBUTOR LOCATION:

DISTRIBUTOR CODE:

SIGNATURE:

OPTION LIST
Description
HORSEPOWER UPRATE
APPLICATION CHANGE
OPTION CHANGE
DUEL FUEL
WER UPRATE
ON CHANGE