National Clean Diesel Rebate Program 

Part I - Application to Reserve Funds

Applicant Information (All Applicants)

Organization Name Employer/Taxpayer Number (EIN/TIN) Organizational DUNS Code

Address City County/Parish State ZIP

Target Fleet

Original Vehicle/Equipment/Engine (All Applicants)

Vehicle Identification Number 

or Engine Serial Number

Engine 

Model 

Year

Vehicle Class Engine 

Manufacturer

Engine Family 

Name

Engine 

Tier*

Annual Miles 

or Usage 

Rate (hrs)

Annual Fuel 

Consumption

Annual 

Idling 

Hours

Horsepower*

Location of 

Operation 

County State

Rebate 

Amount**

1

2

3

4

5

I 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.

To list additional vehicles to be replaced, repowered, or retrofitted please use table below.

Eligible Entity Name Eligible Entity Location (City, State)

Eligible Entity Information (Private Fleet Owner Applicants Only) Private fleet owners are able to apply for funding from the National Clean Diesel Rebate Program if the vehicle(s) or equipment, for which funding is being requested, are currently contracted or leased to an eligible entity. An eligible entity is a federal, 

regional, State, local, or tribal agency or port authority with jurisdiction over transportation or air quality. For additional information regarding private fleet applicants and eligible entities, please refer to the rebate program's information document.

I certify the fleet of vehicle(s) or equipment, for which rebate funds are being requested, meet the requirements for private fleets as described above and in the rebate program's 

information document.

Eligible Applicant (EPA Use Only) Yes No

Total Rebate Funds Requested 

Rebate Program ID

Eligible Entity Type

Rebate Type

Date Received (EPA Use Only)

I 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.

* Non-road equipment or engines only 

**Please see the program information document for eligible rebate amounts
Additional Vehicle/Engine to be Retrofit/Replaced

Authorized Representative Name Authorized Representative Title

Authorized Representative Signature Date

Applicant Signature (All Applicants)

By signing below, I certify the statements and information provided in this application are true and accurate to the best of my knowledge. If selected for funding, I agree to provide 

the required documentation and assurances necessary for funding.

Email Phone

Funding for the National Clean Diesel Rebate is subject to continuing federal appropriations. Please see the rebate program's information document for additional funding information.

Vehicle Identification Number 

or Engine Serial Number

Engine 

Model 

Year

Vehicle Class Engine 

Manufacturer

Engine Family 

Name

Engine 

Tier*

Annual Miles 

or Usage 

Rate (hrs)

Annual Fuel 

Consumption

Annual 

Idling 

Hours

Horsepower*

Location of 

Operation 

County State

Rebate 

Amount**

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20