## 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 numb er 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 pro gram'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. 

### Retrofit**s** 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 pro gram'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.