Application to Reserve Funds - State and Local Government

Application to Reserve Funds Instructions

Section:	Entry:	Instructions:
Applicant Information	Rebate Program ID	This field will be pre-populated by EPA
	Target Fleet	This field will be pre-populated by EPA
	Rebate Type	This field will be pre-populated by EPA
	Organization Name	Enter the legal name of applicant applying for the rebate.
	Employer / Taxpayer Number (EIN/TIN)	Enter the Employer or Taxpayer Identification Number (EIN or TIN) as assigned by the Internal Revenue Service.
	Organizational DUNS Code	Enter the Applicant’s DUNS or DUNS+4 number received from Dun and Bradstreet. Information on obtaining a DUNS number can be found at www.dnb.com.
	Address	Enter the Street Address where the Applicant is located.
	City	Enter the City where the Applicant is located.
	County / Parish	Enter the County / Parish where the Applicant is located.
	State	Enter the State where the Applicant is located.
	Zip	Enter the Zip where the Applicant is located.
	Eligible Entity Type	For Private Fleet Owner Applicants Only - in order to be eligible to apply for rebate funding, the applicant must be the owner of record of the vehicle, and that vehicle must be operated pursuant to a contract, license, or lease with one of the following entities: a. Federal department or agency; b. regional, state, local, or tribal government or agency, or; c. port authority with jurisdiction over transportation or air quality. List the type of the entity with which the applicant has a current contract, license or lease for operation of the vehicle or fleet (e.g., “state agency”).
	Eligible Entity Name	Enter the name of the entity with which the applicant has a current contract, license, or lease for operation of the vehicle or fleet (e.g., “Tennessee Department of Environment”).
	Eligible Entity Location (City, State)	For Private Fleet Owner Applicants Only, enter the location (city and state) where the Eligible Entity with which the applicant has a current contract, license, or lease is located.
	Eligible Entity Certification	Check the box to certify that the applicant's fleet of vehicle(s) or equipment, for which rebate funds for retrofit or replacement are being requested, meet the requirements for private fleets as described above and in the rebate program’s information document.
Original Vehicle / Equipment/ Engine Information	Original Vehicle Identification Number or Engine Serial Number	Enter the Vehicle Identification Number or Engine Serial Number of the original vehicle/equipment or engine.
	Original Engine Model Year	Enter the model year of the engine in the original vehicle / equipment.
	Original Vehicle Class	On highway vehicles only: Select vehicle class of the original vehicle from the dropdown menu.
	Original Engine Manufacturer	Enter the manufacturer of the original engine.
	Original Engine Family Name	Enter the family name of the original engine.
	Engine Tier	Nonroad equipment only: Select the original engine tier from the dropdown menu.
	Original Vehicle Annual Miles/Usage Rate (hours)	Enter the vehicle miles traveled per year (on highway vehicles only) or annual usage rate (nonroad equipment only).
	Original Vehicle Annual Fuel Consumption	Enter the amount of fuel used in gallons/year.
	Original Annual Vehicle Idling Hours	Enter the average number of hours the vehicle/equipment idles per year.
	Original Horsepower	Nonroad equipment only: Enter the horsepower of the equipment.
	Location of Operation	Enter the county and state where the vehicle/equipment primarily operates.
	Rebate Amount	Enter the requested rebate amount. Please see the Program Information Document for eligible rebate amounts for any given program year.
	Total Rebate Funds Requested	Sum the requested rebate amounts for each vehicle and enter the total.
	Eligibility Certification	Check the box to certify that the vehicle(s), equipment, or engine(s) listed for replacement, retrofit or repower are operational and meet the eligibility requirements defined in the rebate program's terms and conditions.
	Scrappage Certification	Check the box to certify that the vehicle(s), equipment, or engine(s) listed for replacement or repower will be properly disposed of according to the requirements defined in the program’s terms and conditions.
	Statement Certification	Check to the box to certify that the statements and information provided in this application are true and accurate to the best of the applicant’s knowledge. By checking the box, applicant agrees to provide the required documentation and assurances necessary for funding.
Applicant Signature	Authorized Representative	Enter the name of the Applicant’s Authorized Representative.
	Authorized Representative Title	Enter the job title of the Authorized Representative.
	Authorized Representative Email	Enter the email address of the Applicant’s Authorized Representative.
	Authorized Representative Phone	Enter the phone number of the Applicant’s Authorized Representative.
	Authorized Representative Signature	Enter the signature of the Applicant’s Authorized Representative.
	Date	Enter the date of signature.