# 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

Date Authorized Representative Signature 

### 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** 

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