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 only: 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 county and state 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 agrees 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.