## Application to Reserve Funds Instructions

**Section: Entry:**  **Instructions: Applicant**  **Information** Rebate Program ID This field will be pre

-populated by EPA

Target Fleet This field will be pre

-populated by EPA Rebate Type This field will be pre

-populated by EPA Organization Name Enter the legal name of applicant 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 Applicant ’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 Applicant is located. City Enter the City where the Applicant is located. County / Parish Enter the County / Parish where the Applicant is located. State Enter the State where the Applicant is located. Zip Enter the Zip where the Applicant is located.

Eligible Entity Type For Private Fleet Owner Applicants Only

- in order to be

eligible to apply for rebate funding, the applicant must be the owner of record of the vehicle, and that vehicle must be operated pursuant to a contract, license, or lease with one of the following entities: a. Federal department or agency; b. regional, state, local, or tribal government or agency, or; c. port authority with jurisdiction over transportation or air quality.
List the type of the entity with which the applicant has a current contract, license or lease for operation of the vehicle or fleet (e.g., “state agency”).
Eligible Entity Name Enter the name of the entity with which the applicant has a

current contract, license, or lease for operation of the vehicle or fleet (e.g., “Tennessee Department of Environment”). Eligible Entity Location (City, State) For Private Fleet Owner Applicants Only, enter the location

(city and state) where the Eligible Entity with which the applicant has a current contract, license, or lease is located.

Eligible Entity Certification Check the box to certify that the applicant's fleet of vehicle(s)

or equipment, for which rebate funds for retrofit or replacement are being requested , meet the requirements for private fleets as described above and in the rebate program’s information document

. 

### Original **Vehicle / Equipment** **/ Engine**  **Information** Original Vehicle

Identification Number or Engine Serial Number Enter the Vehicle Identification Number or Engine Serial

Number of the original vehicle/equipment or engine

.

Original Engine Model Year Enter the model year of the engine in the original vehicle /

equipment. Original Vehicle Class On highway vehicles o nly: Select vehicle class of the

original vehicle from the dropdown menu. Original Engine Manufacturer Enter the manufacturer of the original engine.
Original Engine Enter the family name of the original engine.

## Application to Reserve Funds Instructions

Family Name Engine Tier Nonroad equipment only: Select the original engine tier from

the dropdown menu. Original Vehicle Annual Miles/Usage Rate (hours) Enter the vehicle miles traveled per year (on highway

vehicles only) or annual usage rate (nonroad equipment only)

. Original Vehicle Annual Fuel Consumption Enter the amount of fuel used in gallons/year.

Original Annual Vehicle Idling Hours Enter the average number of hours the vehicle/equipment

idles per year. Original Horsepower Nonroad equipment only: Enter the horsepower of the

equipment. Location of Operation Enter the c ounty and s tate where the vehicle/equipment

primarily operates

.
Rebate Amount Enter the requested rebate amount. Please see the Program

Information Document for eligible rebate amounts for any given program year. Total Rebate Funds Requested Sum the requested rebate amounts for each vehicle and enter

the total.
Eligibility Certification Check the box to 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.
Scrappage Certification Check the box to 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.

Statement Certification Check to the box to certify that the statements and

information provided in this application are true and accurate to the best of the applicant’s knowledge. By checking the box, applicant agree s to provide the required documentation and assurances necessary for funding. 

### Applicant **Signature** Authorized

Representative Enter the name of the Applicant’s Authorized Representative.

Authorized Representative Title Enter the job title of the Authorized Representative.

Authorized Representative Email Enter the email address of the Applicant’s Authorized

Representative. Authorized Representative Phone Enter the phone number of the Applicant’s Authorized

Representative. Authorized Representative Signature Enter the signature of the Applicant’s Authorized

Representative.

Date Enter the date of signature.