### Vehicle/Equipment Replacement (Replacement Projects Only) Vehicle Identification or

Engine Serial Number New Engine Model Year Vehicle Class New Engine Manufacturer New Engine Family Name New Engine Tier* Cost of New Vehicle Rebate Amount** 1 2 3 4 5 To list additional replacement vehicles/engines, please use table below Selectee Funded (EPA Use Only) Yes No 

# National Clean Diesel Rebate Program Part II - Application for Payment

Total Rebate Funds Requested Rebate Program ID

I certify that: 1) The new replacement vehicle(s)/equipment is of the same type and 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; 5) I have attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions. Organization Name Employer/Taxpayer Number (EIN/TIN) Organizational DUNS Code

Address City County/Parish State ZIP 

### Selectee Information

* Non-road equipment or engines only **Please see the program information document for eligible rebate amounts

### Retrofits (Retrofit Projects Only) Technology Type Technology Manufacturer Technology Model Technology Cost Installation Cost Rebate Amount** 1 2 3 4 5

I certify that: 1) The vehicle(s) or equipment being retrofitted meet the eligibility requirements as defined in the rebate program's terms and conditions; and 2) The retrofitted vehicle(s) or equipment will be used for the duration required by the rebate program's terms and conditions. To list additional retrofits, please use table below Total Rebate Funds Requested



### Repowers/Upgrades (Engine Repower/Upgrade Projects Only) Engine Serial Number New Engine Model Year Engine Manufacturer Engine Family Name New Tier Level* Horsepower* Total Repower/ Upgrade Cost Rebate Amount** 1 2 3 4 5 To list additional repowers/upgrades, please use table below Total Rebate Funds Requested

I certify that: 1) The repowered/upgraded vehicle(s) or equipment will continue to perform the same function as before the repower or upgrade; 2) The original vehicle(s) or equipment being repowered/upgraded 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) I have attached the required proof of scrappage documentation as specified in the rebate program's terms and conditions. * Non-road equipment or engines only **Please see the program information document for eligible rebate amounts **Please see the program information document for eligible rebate amounts

### Additional Vehicle/Engine Replacement (Replacement Projects Only) 

### Selectee Signature By signing below: 1) I certify the statements and information provided in this application are true and accurate to the best of my knowledge. I agree to provide the required documentation and assurances necessary for funding, and; 2) I agree to comply with all terms and conditions as specified in the rebate program's information document.
Authorized Representative Name Authorized Representative Title

Date Authorized Representative Signature Email Phone

Vehicle Identification or

Engine Serial Number New Engine Model Year Vehicle Class New Engine Manufacturer New Engine Family Name New Engine Tier* Cost of New Vehicle Rebate Amount** 6 7 8 9 10 11 12 13 14 15 

### 16 17 18 19 20

### Additional Retrofits (Retrofit Projects Only) Technology Type Technology Manufacturer Technology Model Technology Cost Installation Cost Rebate Amount** 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

### Additional Repowers/Upgrades (Engine Repower/Upgrade Projects Only) Engine Serial Number New Engine Model Year Engine Manufacturer Engine Family Name New Tier Level* Horsepower* Total Repower/ Upgrade Cost Rebate Amount** 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20