Form in process in process Application to Reserve Funds

National Clean Diesel Rebate Program

Eligible Applicant (EPA Use Only)

Part I - Application to Reserve Funds
Rebate Program ID

Target Fleet

Yes

No

Date Received (EPA Use Only)

Rebate Type

Applicant Information (All Applicants)
Organization Name

Employer/Taxpayer Number (EIN/TIN)

Address

City

Organizational DUNS Code

County/Parish

State

ZIP

Eligible Entity Information (Private Fleet Owner Applicants Only)
Private fleet owners are able to apply for funding from the National Clean Diesel Rebate Program if the vehicle(s) or equipment, for which funding is being requested, are currently contracted or leased to an eligible entity. An eligible entity is a federal,
regional, State, local, or tribal agency or port authority with jurisdiction over transportation or air quality. For additional information regarding private fleet applicants and eligible entities, please refer to the rebate program's information document.

Eligible Entity Type

Eligible Entity Name

Eligible Entity Location (City, State)

I certify the fleet of vehicle(s) or equipment, for which rebate funds are being requested, meet the requirements for private fleets as described above and in the rebate program's
information document.

Original Vehicle/Equipment/Engine (All Applicants)
Vehicle Identification Number
or Engine Serial Number

Engine
Model
Year

Vehicle Class

Engine
Manufacturer

Engine Family Engine
Name
Tier*

Annual Miles
or Usage
Rate (hrs)

Annual Fuel
Consumption

Annual
Idling
Hours

Horsepower*

Location of
Operation
County State

Rebate
Amount**

1
2
3
4
5
To list additional vehicles to be replaced, repowered, or retrofitted please use table below.

I 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.
I 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.

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

Applicant Signature (All Applicants)
By signing below, I certify the statements and information provided in this application are true and accurate to the best of my knowledge. If selected for funding, I agree to provide
the required documentation and assurances necessary for funding.
Funding for the National Clean Diesel Rebate is subject to continuing federal appropriations. Please see the rebate program's information document for additional funding information.
Authorized Representative Name

Authorized Representative Title

Email

Phone

Authorized Representative Signature

Date

Additional Vehicle/Engine to be Retrofit/Replaced
Vehicle Identification Number
or Engine Serial Number

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Engine
Model
Year

Vehicle Class

Engine
Manufacturer

Engine Family Engine
Name
Tier*

Annual Miles
or Usage
Rate (hrs)

Annual Fuel
Consumption

Annual
Idling
Hours

Horsepower*

Location of
Operation
County State

Rebate
Amount**