Application for Payment Request

Section: Entry: Guidance:

Selectee

Information

Rebate Program ID This field will be pre-populated by EPA 

Organization Name Enter the legal name of selectee 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 organization’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 Selectee is located.

City Enter the City where the Selectee is located.

County / Parish Enter the County / Parish where the Selectee is located.

State Enter the State where the Selectee is located.

Zip Enter the Zip where the Selectee is located.

New Vehicle / 

Equipment 

Replacement

New Vehicle 

Identification 

Number or Engine 

Serial Number

Enter the Vehicle Identification Number or Engine Serial 

Number of the new vehicle /equipment.

New Engine Model 

Year

Enter the model year of the engine in the new vehicle / 

equipment.

New Vehicle Class On highway vehicles only: Select the vehicle class of the 

new vehicle from the dropdown menu. 

New Engine 

Manufacturer

Enter the manufacturer of the engine in the new vehicle.

New Engine Family 

Name

Enter the family name of the engine in the new vehicle.

New Engine Tier Nonroad vehicles only: Select the new engine tier from the 

dropdown menu.

Cost of New Vehicle Enter the cost of the new vehicle. 

Rebate Amount

Enter the rebate amount requested for each replacement 

vehicle. Please see the Program Information Document for 

eligible rebate allowances for any given program year.

Total Rebate Funds 

Requested

Sum the requested rebate amounts and enter the total.

Selectee 

Certifications

Check the box to certify that:

1) The new vehicle(s)/equipment is of the same type, 

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; 
Application for Payment Request

5) Selectee has attached the required proof of scrappage 

documentation as specified in the rebate program's 

terms and conditions.

Retrofits

Technology Type Select from the dropdown menu the type of technology used 

to retrofit the vehicle / equipment.

Technology 

Manufacturer

Enter the manufacturer of the technology used to retrofit the 

vehicle / equipment. 

Technology Model Enter the model of the technology used to retrofit the vehicle 

/ equipment.

Technology Cost Enter the cost of the retrofit technology used to retrofit the 

vehicle / equipment.

Installation Cost Enter the cost of installation of the technology used to retrofit 

the vehicle / equipment.

Rebate Amount 

Requested

Enter the rebate amount requested for each retrofit. Please see 

the Program Guidance for eligible rebate allowances for any 

given program year.

Total Rebate Funds 

Requested

Sum the requested rebate amounts and enter the total.

Eligibility & Usage 

Certification

Check the box to certify that:

1) The vehicle(s) /equipment being retrofit meets the 

eligibility requirements as defined in the program's 

terms and conditions, and;

2) The retrofitted vehicle(s) /equipment will be used in 

the manner of and for the duration required by the 

program's terms and conditions.

Repowers/ 

Upgrades

Engine Serial 

Number

Enter the serial number of the new engine

New Engine Model 

Year

On highway only: Enter the model year of the new engine.

Engine Manufacturer Enter the manufacturer of the engine in the vehicle / 

equipment.

Engine Family Name Enter the family name of the engine in the vehicle / 

equipment.

New Tier Level Nonroad only: Select the tier level of the new engine from the 

dropdown menu.

Horsepower Nonroad only: Enter the horsepower of the engine (nonroad 

only).

Total 

Repower/Upgrade 

Cost

Enter the total cost of the vehicle / equipment repower or 

upgrade.

Rebate Amount

Enter the rebate amount requested. Please see the Program 

Information Document for eligible rebate allowances for any 

given program year.

Total Rebate Funds 

Requested

Sum the rebate amounts and enter the total.

Selectee 

Certifications

Check the box to certify that:

1) The new repowered/upgraded vehicle(s)/equipment 

will continue to perform the same function as before 

the repower/upgrade; 

2) The original vehicle(s)/equipment being repowered
Application for Payment Request

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) Selectee has attached the required proof of scrappage 

documentation as specified in the rebate program's 

terms and conditions.

Selectee

Signature Selectee 

Certifications 

Check the box to certify that the statements and information 

provided in this application are true and accurate to the best 

of the selectee’s knowledge, and that selectee agrees to 

provide the required documentation and assurances necessary 

for funding.

Terms and 

Conditions 

Certification

Check the box to certify that selectee agrees to comply with 

all terms and conditions as specified in the rebate program’s 

guidance document.

Authorized 

Representative

Enter the name of the Selectee’s Authorized Representative. 

Authorized 

Representative Title

Enter the job title of the Selectee’s Authorized 

Representative.

Email Enter the email address of the Selectee’s Authorized 

Representative.

Phone Enter the phone number of the Selectee’s Authorized 

Representative.

Authorized 

Representative 

Signature

Enter the signature of the Selectee’s Authorized 

Representative.

Date Enter the date of signature.