Form 5900-261 Payment Request

OMB No. 2060-0686
Expiration Date: [insert]

United States Environmental Protection Agency
National Clean Diesel Rebate Program
Payment Request Form
Funding Year

Target Fleet

Rebate Type

Selectee Information
Organization Name
Address
City

County/Parish

State

ZIP

Organizational DUNS Code

Employer/Taxpayer No. (EIN/TIN)

New Replacement Vehicle(s)

New Vehicle Identification
Number

New
Engine Gross Vehicle
Model Weight Rating
Year

New Engine
Manufacturer

New Engine
Family Name

New Vehicle Fuel Cost of New
Type (Select or Type)
Vehicle

Rebate
Amount

1
2
3
4
5
6
7
8
9
10
Total Replacements

I certify that:
1) The new replacement vehicle(s) is of the same type and similar gross vehicle weight rating as the
original vehicle(s) being replaced;
2) The new replacement vehicle(s) will perform the same function as the vehicle(s) being replaced;
3) Both the original vehicle(s) being replaced and the new replacement vehicle(s) meet the eligibility
requirements as defined by the Program Guide's terms and conditions;
4) The original vehicle(s) 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 Program Guide's terms and conditions; and
5) I have attached the required proof of scrappage documentation as specified in the Program Guide's
terms and conditions.

EPA Form 5900-261

OMB No. 2060-0686
Expiration Date: [insert]
Retrofits Installed - DOC + CCV
Technology
Manufacturer

VIN

Technology Model

Technology Installation
Cost
Cost

Rebate
Amount

1
2
3
4
5
6
7
8
9
10
Total Retrofits

I certify that:
1. The vehicle(s) or equipment being retrofitted meet the eligibility requirements as defined in the Program
Guide's terms and conditions; and
2. The retrofitted vehicle(s) or equipment will be used for the duration required by the Program Guide's terms
and conditions.

Selectee Signature
Number of Replacements

Number of Retrofits

Total Funds Requested

By signing below:
1. I certify the statements and information provided in this application are true and accurate to the best of my
knowledge;
2. I agree to provide the required documentation and assurances necessary for funding; and
3. I agree to comply with all terms and conditions as specified in the Program Guide.
Authorized Representative Name
Title

E-mail

Authorized Representative Signature

Phone
Date

If signing electronically, click "Submit by Email" below and attach required scrappage documentation, invoice(s), and proof of delivery. For paper signatures, please scan the signed rebate
application and submit to [email protected] with required scrappage documentation, invoice(s), proof of delivery as described this funding opportunity's Program Guide.

Submit by Email

EPA Form 5900-261

Print Form

Rebate Payment Request - Page 2

Rebate Payment Request Instructions
EPA Form 5900-261
Form Data Field Definitions
Selectee Information:
Organization Name

Enter the legal name of Selectee applying for the rebate.

Employer/Taxpayer Number
(EIN/TIN)

Enter the Employer or Taxpayer Identification Number 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 Enter the Vehicle Identification Number of the new vehicle.
New Engine Model Year

Enter the model year of the engine in the new vehicle.

Gross Vehicle Weight Rating

Enter gross vehicle weight rating for the new vehicle.

New Vehicle Class

Select the vehicle class of the new vehicle from the drop-down menu.

New Engine Manufacturer

Enter the manufacturer of the engine in the new vehicle.

New Engine Family Name

Enter the engine family name of the engine in the new vehicle. The engine family
name is a 10 to 12 character number/letter designation that can be found on the
engine nameplate.

New Vehicle Fuel Type

Enter the type of fuel the new vehicle uses.

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 Guide for eligible rebate allowances for any given program year.

Selectee Certifications

Check the box to certify that:
1) The new vehicle(s) is of the same type, similar gross vehicle weight rating as
the original vehicle(s) being replaced;
2) The new replacement vehicles(s) will perform the same function as the
vehicle(s) being replaced;
3) Both the original vehicle(s) being replaced and the new replacement
vehicle(s) meet the eligibility requirements as defined in the rebate
program's terms and conditions;
4) The original vehicle(s) have been scrapped or rendered permanently
disabled or returned to the original engine manufacturer for remanufacturing
to a certified cleaner emissions standard as required by the rebate
program's terms and conditions; and
5) The selectee has attached the required proof of scrappage documentation
as specified in the rebate program's terms and conditions.

Rebate Payment Request Instructions - Page 2

Selectee Signature

Selectee Certifications

Check the box to certify that:
1) The statements and information provided in this application are true and accurate to
the best of the Selectee's knowledge;
2) The Selectee will provide the required documentation and assurances necessary for
funding; and
3) The Selectee agrees to comply with all terms and conditions as specified in the
Program Guide (Appendix G).

Authorized Representative

Enter the name of the Selectee's authorized representative.

Title

Enter the job title of the Selectee's authorized representative.

E-mail

Enter the e-mail address of the Selectee's authorized representative.

Phone

Enter the phone number of the Selectee's authorized representative.

Signature

The form must be signed by the Selectee's authorized representative.

Date

Enter the date of the signature.

Payment Request Submission Instructions
1. Review the Program Guide, including the vehicle scrappage and documentation requirements necessary for
payment.
2. Complete and sign the Payment Request Form.
3. Ensure your application package includes the following:
1) Completed Payment Request Form
2) Proof of scrappage documentation (see Section 10 of the Program Guide)
3) A copy of the school bus invoice
4) A copy of the bill of lading (proof of delivery) for the new bus
4. E-mail payment request package as attachments to your rebate contact and [email protected].
Please use the subject line: DERA School Bus Payment Request: [your organization's name].

The public reporting and recordkeeping burden for this collection of information is estimated to average 4 hours per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested
methods for minimizing respondent burden, including through the use of automated collection techniques to the Director,
Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C.
20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.