Application for Payment Request - Private Fleets and Non-profits

Application for Payment Request

Section:	Entry:	Guidance:
Selectee Information	Rebate Program ID	This field will be pre-populated by EPA
	Organization Name	Enter the legal name of selectee 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 organization’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 Selectee is located.
	City	Enter the City where the Selectee is located.
	County / Parish	Enter the County / Parish where the Selectee is located.
	State	Enter the State where the Selectee is located.
	Zip	Enter the Zip where the Selectee is located.
New Vehicle / Equipment Replacement	New Vehicle Identification Number or Engine Serial Number	Enter the Vehicle Identification Number or Engine Serial Number of the new vehicle /equipment.
	New Engine Model Year	Enter the model year of the engine in the new vehicle / equipment.
	New Vehicle Class	On highway vehicles only: Select the vehicle class of the new vehicle from the dropdown menu.
	New Engine Manufacturer	Enter the manufacturer of the engine in the new vehicle.
	New Engine Family Name	Enter the family name of the engine in the new vehicle.
	New Engine Tier	Nonroad vehicles only: Select the new engine tier from the dropdown menu.
	Cost of New Vehicle	Enter the cost of the new vehicle.
	Rebate Amount	Enter the rebate amount requested for each replacement vehicle. Please see the Program Information Document for eligible rebate allowances for any given program year.
	Total Rebate Funds Requested	Sum the requested rebate amounts and enter the total.
	Selectee Certifications	Check the box to certify that: The new vehicle(s)/equipment is of the same type, similar gross vehicle weight rating or horsepower as the original vehicle(s)/equipment being replaced; The new replacement vehicle(s)/equipment will perform the same function as the vehicle(s)/equipment being replaced; Both the original vehicle(s)/equipment being replaced and the new replacement vehicle(s)/equipment meet the eligibility requirements as defined in the rebate program's terms and conditions; The original vehicle(s)/equipment have been scrapped or rendered permanently disabled or returned to the original engine manufacturer for remanufacturing to a certified cleaner emission standard as required by the rebate program's terms and conditions, and; Selectee has attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions.
Retrofits	Technology Type	Select from the dropdown menu the type of technology used to retrofit the vehicle / equipment.
	Technology Manufacturer	Enter the manufacturer of the technology used to retrofit the vehicle / equipment.
	Technology Model	Enter the model of the technology used to retrofit the vehicle / equipment.
	Technology Cost	Enter the cost of the retrofit technology used to retrofit the vehicle / equipment.
	Installation Cost	Enter the cost of installation of the technology used to retrofit the vehicle / equipment.
	Rebate Amount Requested	Enter the rebate amount requested for each retrofit. Please see the Program Guidance for eligible rebate allowances for any given program year.
	Total Rebate Funds Requested	Sum the requested rebate amounts and enter the total.
	Eligibility & Usage Certification	Check the box to certify that: The vehicle(s) /equipment being retrofit meets the eligibility requirements as defined in the program's terms and conditions, and; The retrofitted vehicle(s) /equipment will be used in the manner of and for the duration required by the program's terms and conditions.
Repowers/ Upgrades	Engine Serial Number	Enter the serial number of the new engine
	New Engine Model Year	On highway only: Enter the model year of the new engine.
	Engine Manufacturer	Enter the manufacturer of the engine in the vehicle / equipment.
	Engine Family Name	Enter the family name of the engine in the vehicle / equipment.
	New Tier Level	Nonroad only: Select the tier level of the new engine from the dropdown menu.
	Horsepower	Nonroad only: Enter the horsepower of the engine (nonroad only).
	Total Repower/Upgrade Cost	Enter the total cost of the vehicle / equipment repower or upgrade.
	Rebate Amount	Enter the rebate amount requested. Please see the Program Information Document for eligible rebate allowances for any given program year.
	Total Rebate Funds Requested	Sum the rebate amounts and enter the total.
	Selectee Certifications	Check the box to certify that: The new repowered/upgraded vehicle(s)/equipment will continue to perform the same function as before the repower/upgrade; The original vehicle(s)/equipment being repowered and the new replacement/upgraded engine meet the eligibility requirements as defined in the rebate program's terms and conditions; The original engine has been scrapped or rendered permanently disabled or returned to the original engine manufacturer for remanufacturing to a certified cleaner emission standard as required by the rebate program's terms and conditions, and; Selectee has attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions.
Selectee Signature	Selectee Certifications	Check the box to certify that the statements and information provided in this application are true and accurate to the best of the selectee’s knowledge, and that selectee agrees to provide the required documentation and assurances necessary for funding.
	Terms and Conditions Certification	Check the box to certify that selectee agrees to comply with all terms and conditions as specified in the rebate program’s guidance document.
	Authorized Representative	Enter the name of the Selectee’s Authorized Representative.
	Authorized Representative Title	Enter the job title of the Selectee’s Authorized Representative.
	Email	Enter the email address of the Selectee’s Authorized Representative.
	Phone	Enter the phone number of the Selectee’s Authorized Representative.
	Authorized Representative Signature	Enter the signature of the Selectee’s Authorized Representative.
	Date	Enter the date of signature.