Form in process in process Application for Payment Request

National Clean Diesel Rebate Program

Selectee Funded (EPA Use Only)

Part II - Application for Payment

Rebate Program ID

Yes

No

Selectee Information
Organization Name

Employer/Taxpayer Number (EIN/TIN)

Address

City

Organizational DUNS Code

County/Parish

State

ZIP

Vehicle/Equipment Replacement (Replacement Projects Only)
Vehicle Identification or
Engine Serial Number

New Engine
Model Year

Vehicle Class

New Engine
Manufacturer

New Engine
Family Name

New Engine
Tier*

Cost of New
Vehicle

Rebate Amount**

1
2
3
4
5
To list additional replacement vehicles/engines, please use table below

Total Rebate Funds Requested
* Non-road equipment or engines only
**Please see the program information document for eligible rebate amounts

I certify that:
1) The new replacement vehicle(s)/equipment is of the same type and similar gross vehicle weight rating or horsepower as the original vehicle(s)/equipment being
replaced;
2) The new replacement vehicle(s)/equipment will perform the same function as the vehicle(s)/equipment being replaced;
3) 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;
4) 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;
5) I have attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions.

Retrofits (Retrofit Projects Only)
Technology
Manufacturer

Technology Type

Technology Model

Technology Installation
Cost
Cost

Rebate Amount**

1
2
3
4
5
To list additional retrofits, please use table below

Total Rebate Funds Requested
**Please see the program information document for eligible rebate amounts

I certify that:

1) The vehicle(s) or equipment being retrofitted meet the eligibility requirements as defined in the rebate program's terms and conditions; and
2) The retrofitted vehicle(s) or equipment will be used for the duration required by the rebate program's terms and conditions.

Repowers/Upgrades (Engine Repower/Upgrade Projects Only)
Engine Serial Number

New Engine
Model Year

Engine Manufacturer

Engine Family Name

New Tier
Horsepower*
Level*

Total Repower/
Upgrade Cost

Rebate Amount**

1
2
3
4
5
To list additional repowers/upgrades, please use table below

Total Rebate Funds Requested
* Non-road equipment or engines only
**Please see the program information document for eligible rebate amounts

I certify that:
1) The repowered/upgraded vehicle(s) or equipment will continue to perform the same function as before the repower or upgrade;
2) The original vehicle(s) or equipment being repowered/upgraded and the new replacement/upgraded engine meet the eligibility requirements as defined in the rebate
program's terms and conditions;
3) 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;
4) I have attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions.

Selectee Signature
By signing below:
1) I certify the statements and information provided in this application are true and accurate to the best of my knowledge. I agree to provide the required documentation
and assurances necessary for funding, and;
2) I agree to comply with all terms and conditions as specified in the rebate program's information document.

Authorized Representative Name

Authorized Representative Title

Email

Phone

Authorized Representative Signature

Date

Additional Vehicle/Engine Replacement (Replacement Projects Only)
Vehicle Identification or
Engine Serial Number
6
7
8
9
10
11
12
13
14
15

16
17
18
19
20

New Engine
Model Year

Vehicle Class

New Engine
Manufacturer

New Engine
Family Name

New Engine
Tier*

Cost of New
Vehicle

Rebate Amount**

Additional Retrofits (Retrofit Projects Only)
Technology Type
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Technology
Manufacturer

Technology Model

Technology Installation
Cost
Cost

Rebate Amount**

Additional Repowers/Upgrades (Engine Repower/Upgrade Projects Only)
Engine Serial Number
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

New Engine
Model Year

Engine Manufacturer

Engine Family Name

New Tier
Horsepower*
Level*

Total Repower/
Upgrade Cost

Rebate Amount**