5900-261 Clean School Bus Payment Request Form

13
EPA CLEAN
.... ~SCHOOLBUS
2022 EPA Clean School Bus Rebate Forms:
Payment Request User Guide
November 2022

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EA~United

States
Environmental Protection
Agency

EPA-420-B-22-049

Table of Contents
1. Sign In/Register................................................................................... 4
2. Create/Edit a New Payment Request Form ...................................... 4
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15

Start a New Payment Request Form.......................................................... 5
Welcome Screen........................................................................................ 6
Information Icons ...................................................................................... 7
Application Information ............................................................................. 7
Saving and Editing Your Information .......................................................... 9
Add Purchase Orders ................................................................................. 8
Purchase Order Information .................................................................... 11
Complete a Purchase Order .................................................................... 12
New Bus Information .............................................................................. 13
Add New Bus Information ....................................................................... 14
Exclude a Bus .......................................................................................... 17
Complete Bus Information ...................................................................... 18
Infrastructure Information ....................................................................... 19
Signature ................................................................................................. 20
Next Steps ............................................................................................... 21

Appendix A. Glossary ............................................................................ 22
Appendix B. List of Fields in Payment Request Form ........................ 26

•-------------2

Before You Begin
This guide will walk you through the steps needed to create, edit, submit, and view an online payment request
form for a Clean School Bus rebate application when you have been selected for an award. This guide also
includes detailed defnitions of key felds found in the online form and a printable list of all felds required in
the form. Plan to spend approximately an hour completing the payment request form, depending on the
number of buses and purchase orders you need to enter.
Follow these steps to prepare for completing the payment request form:
1.

Review the glossary of terms used in the payment request form (see Appendix A).

2. Compile all required data. Appendix B provides a printable list of all necessary data felds.
3. Confrm the Point of Contact. Confrm the email of the person completing the payment request form
is registered as a designated Primary or Alternate Government Point of Contact, or Primary or Alternate
Electronic Point of Contact in your entity’s SAM.gov account by logging on to SAM.gov. Otherwise, the
person will not be able to log into the payment request form from the system.
4. Check your browser version. Before flling out the payment request form, make sure your web
browser version meets or exceeds the following versions:
— Chrome 38
— Safari 7.1
— Internet Explorer 11
— Firefox 13
Note: The following pages correspond to the payment request form screen sequence.

--------------•
3

1. Sign In/Register
Use your existing SAM.gov credentials to log in to your applicant dashboard. If you are unable to sign in,
please click here to refer to the instructions in the rebate application User Guide.

2. Create/Edit a New Payment Request Form
If you plan to replace old buses other than those identifed in your original application, you will need to ask EPA
to re-open your application before starting your payment request form. EPA will only allow this on a case-bycase basis, as changes can impact funding level and eligibility. To re-open your application, contact the help
desk at cleanschoolbus@epa.gov detailing the request. Be sure to provide the Rebate ID, applicant name, and
school district name. Once you have edited the application, please resubmit and EPA will re-review for errors
and completeness. Once EPA has re-approved the edited application, you can start the payment request form.
Note: Your connection to the payment request form system will time out unless you interact with the screen
at least once every 15 minutes. “Interacting” can mean entering or deleting information, or even moving your
cursor on the screen. If your connection times out, you risk losing data entered since the last save.

•-------------4

2.1

Start a New Payment Request Form

After signing in using your Login.gov account, you will see the Clean School Bus Rebate Forms screen.
An official website ol the United State1 government

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EPA development environment: The content on this page 1s not production data a nd this site 1s being used for development and/ or testing purposes only

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I Search EPA.gov

Environmental Protection
Agency

Environmental Topics

Laws & Regulations

Report a Violation

About EPA

Clean School Bus

CONTACT US

Clean School Bus Rebate Forms
Clean School Bus Rebate Prog(a_[Il
Online Rebate Application Information

EIH@E

csb-test@erg.com

M·tiWIM

Your Rebate Forms
Select a button below to Edit or View an existing rebate form.

• Rebate ID

010716

0

8 Form Type
8 Form Status

O UEI

0

EFT Indicato r

8 Applicant
8 School District

0 Updated By
0 Date Updated

Application

123456000007

CSB TESTER INC.

csb-test@erg.com

0 .5l'lffted

1234

Wounded Knee District

10/6/2022

Application

123456000011

CSB TESTER INC.

csb-test@erg.com

C, Sl'lffted

1234

Wounded Knee District

8/ 23/2022

New Payment Request

010649

010651

Payment Request

csb-test@erg.com

... Draft

11/ 4/ 2022

Application

123456000011

CSB TESTER INC.

C, Sl'lffted

1234

Winslow Residential Holl

csb-test@erg.com

8/ 23/2022

Payment Request

csb-test@erg.com

✓

11/ 4/2022

Submitted

This collection of information is approved by 0MB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (0MB Control No. 2060-0686). Responses to this collection of information
are voluntary (Title XI, Section 71101 of the Infrastructure Investment and Jobs Act (Public Law 117-58)). An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid 0MB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be
4.3 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent
burden to the Regu latory Support Division Director, U.S. Environmental Protection Agency (2821 Tl, 1200 Pennsylvania Ave., NW, Washington, O.C. 20460. Include the 0MB control
number in any correspondence. Do not send the completed form to this address.
Expiration Date: 8/31/2025

~

to ask a question, provide feedbac k, or report a problem.

Select the “New Payment Request” button to begin.
Note: If you opened a new payment request form and then asked EPA to re-open your application to make
edits, that form will be deleted from the Clean School Bus Rebate Forms screen and you will need to start a
new payment request form once the edited application has been re-approved.

•
5

2.2

Welcome Screen

Review the text on the Welcome screen and select “Next” to proceed.
Note: Use of the browser’s back, forward, or refresh buttons while in the payment request form will result in
loss of work. Please navigate using the “Next,” “Previous,” and “Save” buttons on the screen.

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E A ~ UnitedStates
Environmental Protection
Agency

EnVlronmentaJ Topics

Laws & Regulations

Report a Violation

About EPA

Clean School Bus

CONTACT US

Clean School Bus Rebate Forms
• Clf:an School Bus Rebate

ProBcam

• ~ p p licationlnformation

MMMFl::ii

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csb~test@erg.com

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Edit Your Payment Request
Rebate ID : 010716

•

0

of 6 Welcome

Payment Request Form - Basic Information
As a rebate application award selectee, you must submit an on line Payment Request Form that includes an attached scan of the purchaseorder(s) for the new school buses and eligible
charging infrastructure by April 28, 2023.
The following information will help you complete this Payment Request Form accurately and efficiently.
• In-fo rm help text is provided below the data ent ry fields and in t he u?~ next to the field names.
• For additional assistance, please refer to the Program Guide and supporting documents at School Bus Reba tes· Clean School Bus Progr_a_m, or contact the help desk at
deanschoolbus@.f'Ra.~ {include the Applican t Name, Payment Request Form ID, the Rebate ID, Unique Ent it y Identifier (UEI), Electronic Funds Transfer (EFT) Indicator, and the School
District Nam e).
To complete this form, you will need the following information:
• Review your submited application (access it fro m the Applicant Dashboard) to con firm what buses are associated with purchase orders you will add to this form.
• The primary contact information for your organization
• Purchase Order number and date
• Purchaser information including name, address and phone number
• Vehicle/equipment vendor inform ation including name, add ress and phone number
• New bus information including make, model, model year, gross vehicle weight rating (GVWR), estimated delivery date, and purchase price
• Electric bus charging infrastructure information (if applicable), including num ber of l evel 2 chargers and hardware costs, number of DC Fast chargers and hardware costs, and other
eligible charging infrastructure costs
• File(s) containing image of the purchase order on vendor letterhead. Acceptable file formats include .pelf, .png, .jpeg, and .jpg.
To save your work on the form, you must select the uSave" or ~Next" button. Vou will be able to return later to fi nish your payment request form without losing information.
To subm it your payment request form to EPA, complete all screens and then sign and submit the fo rm. Make su re to provide a complete signature and check the ~1 confirm I have provided my
signature above" box before selecting t he ~Submit Form" button. Vour payment request fo rm status will then be displayed on the dashboard.
Note: on ly Governmen t Business (and alternate) and Electronic Business (and alternate) Points of Contact from SAM.gov can access the dashboard. The Government Business (and altern ate)
and Electronic Business (and alternate) Points of Contact, and the Primary and/ or Alternate Contacts will also receive a submittal emai l confirmation.
EPA or its authorized represen tatives may contact selectees to clarify any information provided in the Payment Request Form. If, upon review, the Payment Request Form is accurate and
includes all required information, EPA will issue t he rebate payment to the bank accoun t associated with the SAM.gov Unique Entity Ident ifier (UEI) and Electronic Funds Transrer {EFT)
Indicator associated with the application. EPA anticipates disbursing funds wi t hin approximately 60 days of the submission of a com plete Payment Request Form.

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NOTE: Use of the browser back, fo rward, or refresh buttons will result in loss of work. Please navigate using the buttons at the bottom of the form.

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•
6

ask a question, provide feedbac k, or report a problem .

2.3

Information Icons

pp licant Name

Hover your mouse over the information icons, found
throughout the payment request form screens, for
additional information regarding specifc felds.

Sc hoo l District Priorit ized?

Sc hool District Name 8

National Center for Education Statist ics (NCES) Dist rict ID 8

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2.4

CSB TESTER

Yes

Wound ed Knee District

BIE0013

$700,000.00

Application Information

The Primary and Alternate Contact information felds will pre-populate with information from the associated
Application. Double-check that your Primary and Alternate Contact information is correct. The information can
be edited if changes are necessary. Select “Next” to continue.
Clean School Bus Rebate Forms
• Clean School Bus Rebate Program
• ~PPlicationlnformation

Fiiflh&M

MMM

csb-test@erg.com -

Edit Your Payment Request
~ Re bat e l0: 010716

8 of

6 Application Info

' denotes required field

Applicant Name

School District Prioriti zed?

School District Name f)

National Center for Ed ucati on Statistics (NCES) District ID f)

Total Rebate Funds Req uested In Application f)

Applicant Primary Contact

cse TESTER
Yes

Wou nded Knee District

BIE0013

$700,000.00

Applicant Alternate Contact

NOTE - Update contact info rma tion if it has changed.

NOTE - Update contact information if it has changed.

Name f) '

Name f)

Joan Smith

-@ ·
Contactee

Business Phone Numberf) '
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(123) 456-7890

BusinessEmailf) '

Iprimary@email.com

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Mi ke Doe

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Business Phone Numberf)

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BusinessEmailf)
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NOTEc Use of the browser back, forward, or refresh buttous will result iu loss of work Please uavigate using the buttons at the bottom of the fonn.

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c.on.tiK1..U.s. to ask a questi on, provide feedback, or report a proble m.

•
7

2.5

Saving and Editing Your Information

You can save your work while flling out the payment request form and return to it later to fnish and submit.
Data entered on each screen will be saved automatically when the “Next” button is selected. In addition, you
can use the “Save” buttons to save information before proceeding to the next page.
Business Emai l 6

·

I primary@ema il.com

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Business Emai l 6

I altern ate@ema il.com

NOTE: Use of the browser back, forward , or refresh buttons will result in loss of work Please navigate using the buttons at the bottom of the form.

Prev ious

~

1111 ..

Ill 11111

to ask a question, provide feedback, or report a problem .

Note: Use of the browser’s back, forward, or refresh buttons while in the payment request form will result in
loss of work. Please navigate using the “Next,” “Previous,” and “Save” buttons on the screen.

•
8

After saving and exiting the payment request form, you can return to the Clean School Bus Rebate Forms
screen later, open the draft form by selecting the “Edit” button, and proceed by navigating to where you left
off. Selecting forms with a “Submitted” or “Selected” status will allow you to view, but not edit, your entries.
cial websi teoftheUnitedStatesgovemment

~~"

-

EPA development envi ronment: The content on this page 1s not production data and this site ,s being used for development and/ or testing purposes only.

ft E A ~ United States

.. .,
,

I Search EPA.gov

Environmental Protection
Agency

Environmental Topics

Laws & Regulations

Report a Violation

About EPA

Clean School Bus

CONTACT US

Clean School Bus Rebate Forms
Clean School Bus Rebate Progca.m
Online Rebate Application Information

EIH@E

csb-test@erg.com

HIM

Your Rebate Forms
Select a button below to Edi t or View an existing rebate form.

•

Rebate ID

010716

e Appl icant
e School District

0
0

123456000007

CSB TESTER INC.

csb-test@erg.com

$ Selected

1234

Wounded Knee District

10/ 6/ 2022

Application

123456000011

CSB TESTER INC.

csb-test@erg.com

$ Selected

1234

Wounded Knee District

8/ 23/ 2022

e Fo rm Type
e Fo rm Statu s

O UEI

Application

0

EFT Indicator

Updated By
Date Updated

0 New Payment Request

010649

csb-test@erg.com

Pai meot Rel ~st
, ... Draft

010651

11/4/2022

Application

123456000011

CSB TESTER INC.

O Selected

1234

Winslow Residential Half

r-"lll"'"""""''ll'est
✓

Submitted

csb-test@erg.com

8/ 23/ 2022
csb-test@erg.com

11/ 4/2022

Thi s collection of information is approved byOMB under the Paperwork Reduction Act,44 U.S.C. 3501 et seq. (0MB Control No. 2060-0686). Responses to this collection of information
are volunta ry (Title XI, Section 71101 of the Infrastructure Investment and Jobs Act (Public Law 117-58)). An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information un less it displays a cu rrently valid 0MB control number. The public reporting and recordkeeping bu rden for this collection of information is estimated to be
4.3 hours per response. Send comments on the Agency's need for this information, t he accuracy of the provided burden esti mates and any suggested methods for minimizing respondent
burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T) , 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the 0MB control
number in any correspondence. Do not send t he completed form to this address.
Expiration Date: 8/31/ 2025

.c.o.n.ta.c1..U to ask a question, provide feedback, or report a problem.

•
9

2.6

Add Purchase Orders

Select “+ Add a Purchase Order” to add a purchase order. A purchase order contains the information and
specifcations for bus and/or electric bus charging infrastructure procured from a single vendor. Multiple
purchase orders can be added on this screen for additional vendors, for additional buses, or for electric bus
charging infrastructure.
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An official webs ite of the Uni ted States government ~~ v

EPA development environment: The content on th is page 1s not prod uction data and t his site 1s being used for development and/or testi ng purposes only

ft

.._,.,.~
,.,.

EA~

Uni ted States
Enviro nm ental Protection
Agency

I Search EPA.gov

Environmental Topics

Laws & Regulations

Report a Violation

,.,

About EPA

Clean School Bus

CON TACT US

Clean School Bus Rebate Forms
Clean School Bus Rebate Prog:(afil
Online Rebate Application Information

MIH&ibii

EIHMI

csb-test@erg.com

FUfl•M

Edit Your Payment Request
~ Re bate ID : 010716

0

of 6 Purchase Orders

Add purchase order information and up load purchase orders for new buses and infrastructu re (if applicab le) on t his sc reen.
· denotes required field

+Adda Purchase Order

.

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NOTE: Use of the browser back, forwa rd, or refresh buttons will result in loss of wo rk Please navigate using the buttons at the bottom of the fo rm_

Previous

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10

1111

to ask a q uestion, provide fee d back, or report a problem .

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2.7

Purchase Order Information

Fill in the number and date for the purchase
order. Select a purchase order purpose by
checking the box for “Bus” and/or “Electric
Bus Charging Infrastructure.” Then select
the “Purchaser Name” using the drop-down
menu. If your purchaser’s name is not listed,
select “Other” from the drop-down menu and
fll in the appropriate information. Then enter
the required data felds with the information
for the purchaser and vendor. Lastly, attach
a PDF or image of the purchase order. The
image fle size must be between 1KB and
5MB. Accepted fle types include .pdf, .png,
.jpeg, and .jpg. When all felds have been
entered, click the “Complete” button for
the purchase order. Note that this button
does not save your form, and you must
click the “Save” or “Next” button to save
your information.

elc,pmentenvlronment The conten! c,n th,s page ,snot product,c,n data and lhiss,te ,st,e;ng u~ for d911etc,pment and/or IM!l"I pur;,o1,esc,nly

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F.nvironmenlal Topl cs

ReportaV1olat,on

About EPA

Clean School Bus Rebate Forms
• CIMO ¥boo! HII< Rrtwe Prov.ii.ID
• OolioeRetweAoolifMioolofmmatio0

Elfri'§t IE

csb-test@erg.com -

Edit Your Payment Request
.

Rt bate ll>: 010716

C, of 6

Purchase Orde rs

Add Per O "

PurchaseOrdl"rOateO "
IMM/00/l'YYY

Purchas.eOrderPurpos.e(Choos.eallthalapply) " O
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EiecukBusCharginglnfrastructure

Purchaser Information

Add another purchase order by selecting
“+ Add a Purchase Order” at the bottom of
the screen. You may add as many purchase
orders as you need and delete or edit them
at any time. Deleting a purchase order is
permanent, so please do not do so unless
you are sure it is necessary. We encourage
you to delete purchase orders that are not
used to document new buses or electric bus
charging infrastructure to eliminate unneeded
information. You must click the “Complete”
button at the bottom of the purchase order
before moving on.
The “Cancel” button should be used to revert
back to the previously saved purchase order
if changes were made (and the “Complete”
button was not selected), or to review what
you entered for a saved purchase order.

Laws&Reguldtions

Clean School Bus

f'urchaserOfganizationO "

Purchasero,ganization (Oth<'f) "

Purchaser!kJ.,nessPhoneNumt>erO ·

LJ_·_
PurchaserZip O '

Vendor Info rmation
VendorAddressO ·

VPndorNameO ·

VPne< O •

LJ _ ·_

Purchase Order Attachment
AttachPurchaseOrde,-0 "

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Environmental Top1<.'S

Laws& Regulati<>ns

Report a Vi<>latmn

li.1

About EPA

Clean School Bus

Clean School Bus Rebate Forms
• Clean School BmBrhillr Pmg,aw

1.

The bus VIN is prepopulated from
the information in the Application
and is not editable. See the
Create/Edit a New Payment
Request Form if you need to
change information for an old bus
to be replaced.

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csb·te43534

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0ldBusNCES[);slfkll0O •

4. Bus Model Year is prepopulated
from the information in the
Application and is not editable. See
the Create/Edit a New Payment
Request Form section if you need
to change information for an old
bus to be replaced.

E>.cludeBusO

EstimatedRema iningUle(yeari)O •

lL8_"00_'_'------~I

L'--------~

The [);strkt 10 a bow is incom.iste,,t with
applkMioo0istrictlD. lfthisis intentional.
pleasevetifywiththe N(f5diWir:l'iN'[bl991

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C=~thl'abo"".NCE50isttict 1Dchange

New Bus Infor ma tion

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Purchase0rderUstingNewBusO ·

Ma .. RebateAmoun1O

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NewBusMakeO "

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NewBusModelYearO '

1 3 NewBusModelO ·

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lL20_n_ _ _ _ _ _ _
NewBusEstimatedDeliVl'fyDateO ·

NewBus PurchasePriceO ·

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1 6 NewBusGVWRO '

s2ss,ooo.oo

11

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3. See information on Excluding
a Bus in Section 2.11. If a bus
is to be excluded, entering the
remaining bus information felds
for this bus is not needed.

Q

S350.ooo.oo

Bus Reb.ateAml>untO

s2ss.ooo.oo

1 7 ApplicamBusCostResponsibilityO

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The Ne wBu, Est.DelivHyDue isbeyond
l0/3l/ 24andwillrequi,e anextension

The GVWRentered has changed the Muimum
Re bate Amount dueachangeinweightcla,sfor
thist>usfromwhatwaseote,edinlhe
applkati<>n

$65,ooo.oo

OLdBusVIN : 34>45345345343453

0LdBusFue lType :CNG
N• wBu,Fu•lTyp•:Electrk

NumberofBusnRequestedFromApplicationO

Tota l PurchasePriceforAllReplaceme,,tBusesO

$350,000.00

Tota l Bu,RebateAmountO

$285,000.00

Tota lAppl icantBu sCostResponsibilityO

$65,000.00

-

NOTE: Use of the browser back, forward, or refresh buttons will result in Joss of work. Please navi ga te using the bu ttons a t the bottom of the form.

~

toaskaquestion , p,ovidefeedback.orreportaproblem

5. The Old Bus NCES District ID*
feld will prepopulate with the School District ID from the application, but you may change the value
if the old bus served a different school district than the district listed on your application. The new
replacement bus must serve the school district that was listed on your application. Changing the Old
Bus NCES ID from the default value will require you to confrm that the new value is accurate. If you
need to look up an NCES ID, please click here to refer to the instructions in Section 2.10 of the rebate
application User Guide.

•
14

6. The Estimated Remaining Life* feld is for your best estimate of the years of remaining operational
life of the old bus starting from the time of application submittal. This fgure should be inclusive of
the years of operation the bus may have had if not for the scrappage requirements and the years of
operation the bus may have had even if it were sold to another feet.
7.

Purchase Order Listing New Bus* In this feld, select the purchase order that is associated with this
new bus from the purchase orders entered on Screen 3 with a Purchase Order Purpose of “Bus.”
If you don’t see the purchase order associated with this new bus, go back to Screen 3 and enter the
purchase order, or make sure you selected a Purchase Order Purpose of “Bus” if it is a purchase order
that contains new buses.

8. The Max. Rebate Amount feld is read-only and displays the applicable rebate amount for this bus. If a
GVWR is provided that would reduce the awarded rebate amount, the updated value will display here.
The maximum rebate cannot increase based on information in the Payment Request Form, but it may
decrease due to a lower GVWR as noted.
9. New Bus Fuel Type is prepopulated from the information in the Application and is not editable.
10. New Bus Make* provides a list of bus manufacturers to choose from. If the manufacturer of your new
bus is not shown, choose the “Other” option and an additional feld will appear allowing you to enter
the make of your new bus.
11. New Bus Purchase Price* should include the total price of the new bus and must be between
$30,000 and $700,000. The total purchase price of the ordered replacement school bus should include
tax and any eligible training/consulting/warranty line-item expenses associated with the individual bus
in the purchase order. Do not include charging infrastructure costs here.
12. New Bus Model Year* is the manufacturing year of the new bus, which must be 2021 or later.
13. New Bus Model* is the model name (not the bus type) of the new bus.
14. The Bus Rebate Amount feld is read-only and displays the amount of the designated rebate for this
bus, based on the Max. Rebate Amount and the New Bus Purchase Price.
15. The New Bus Estimated Delivery Date* feld is for the best estimate of the bus delivery date
provided by the vendor. If the delivery date is past 10/31/2024, the form will let you know that an
extension is required, although this will not prevent you from submitting your payment request form.
EPA’s payment request form reviewer will reach out to you to request documentation for a delivery
date extension if needed.
16. The New Bus GVWR* feld is for the bus gross vehicle weight rating in pounds. The form will provide
a notice if a value entered warrants a lower rebate value. This could happen if the Rebate Application
had a GVWR of >26,000 lbs. for this bus, but the bus is actually <=26,000 lbs.
17. The Applicant Bus Cost Responsibility feld is read-only and displays the amount that the applicant
will be responsible for paying, based on the Max. Rebate Amount and the New Bus Purchase Price.

--------------•
15

When editing a purchase order or providing bus information, you must click the “Complete” button (shown
below) prior to “Save” or the data will be lost. The “Cancel” button, next to the “Complete” button, should
be used to revert back to the previously saved bus information if changes were made (and the “Complete”
button was not selected), or to review what you entered for a saved purchase order.
Old Bus Information

1

2

VINO

34534534534543534

4

s

Model Year 0

1982

Old Bus Fuel Type 0

30
6

Diesel
Old Bus NCES District ID O

·

ExcludeBusO

Estimated Remaining Li fe {years) 0 •

~I

~I ~'- ----------~

s_1E_oo_1_, _ _ _ _ _ _ _ _ _

The District 10 above is inconsistent with
a pplication District ID. If this is intentional,

please verify with the NCES district search tool.

a

Con firm the above NCES Dist rict ID change

above is accurate ·

New Bus Information

7

Purchase Order Listing New Bus O

8

·

Max. Rebate Amount 0

PO#: 1111111 I PO Date: 2022-11-16 I Vendor Name: Electric Bus Em porium

g

1

New Bus Fuel Type 0

Q

1 3 NewBusModel f) '

NewBusModelYearf) ·

~1 I

New Bus Esti m ated Del ivery Date O

·

1 11/ 19/ 2025
~

- - - - - - - - -~

The New Bu s Est . Del ive ry Date is beyond

10/ 31/ 24 and will require an extension .

14
I

Yellow

16
I~

New Bus GVWR O

·

17

I2s,ooo
~

New Bus Purchase Price O ·

I $350,000.00

Lion Electric Company

1~2_02_2_ _ _ _ _ _ _ _ _ _

15

1

New BusMakeO ·

Electric

12

$285,000.00

- - - - - - - - - - -~

I

Bus Rebate Amount f)

$285,000.00
Applicant Bus Cost Responsi bilit y 0

$65,000.00

The GVWR entered has changed the Maximum
Rebate Am o u nt due a change in weight cl ass fo r
th is bus from what was entered in t he

-

•
16

application .

Bu s Number

Old Bus VIN : 34545345345343453
Old Bus Fu el Ty pe: CNG
New Bu s Fu el Type: Electric

Bus Excluded from Rebat e

2.11 Exclude a Bus
If a bus that was previously entered in the Rebate Application will not be included in your Payment Request
Form, you can select the Exclude Bus checkbox at the upper right of the Old Bus Information screen. No
further information will be required for this bus, and the costs and awards for this bus and any associated
electric charging infrastructure will not be included in totals presented elsewhere on the form.
An officia! website of the Uni ted Sta tes go~rnm ent ~~ ,.,

EPA development environment: The content on this page 1s not production data and this site 1s being used for development and/or testing purposes only

ft

~.,
,

EA~

Unit ed States
Environmenta l Protection
Agency

I Search EPA.gov

Environmental Topics

Laws & Regulations

Report a Violation

About EPA

Clean School Bus

CONTACT US

Clean School Bus Rebate Forms
Clean School Bus Rebate Prog@m
Online Rebate ARp[ication Information

EMHH:::15

EMME

csb-test@erg.com

W):IHIM

Edit Your Payment Request
•

Rebate ID: 010716

O

of 6 Buses

..

This screen shows t he buses that were submitted in your rebate application. Update Old Bus information and add New Replacement Bus info rmation here.
' denotes req uired field

Bus Nu mbe r

Old Bu s VIN : 34534534534543534

New Bu s Rebate Amount: S285,000

Old Bu s Fuel Type: Diesel

New Bu s Purc hase Price: S350,000

New Bus Fuel Type: Electric

Old Bus Information
VINO

Old Bus Fuel Type 0

34545345345343453

CNG

Mode l Yea r O

Old Bus NCES District ID O .

1985

I BIE0013

-- a

Exclude BusO

1115
Nu mber of Buses Requested From App licat io n 0

Tota l Purchase Price fo r All Replacement Bu ses 0

S350,000.00

Nu mber of Buses Ordered

Tota l Bu s Rebate Amount 0

S285,000.00

Tota l Applicant Bus Cost Responsibility 0

$65,000.00

-

NOTE: Use of the browser back, forward , or refresh buttons will result in loss of work Please navigate using t he buttons at the bottom of the form.

Previous

~

1m

to ask a q uest io n, provide feedback, or report a problem .

•
17

2.12 Complete Bus Information
Once information has been entered completely for the buses, the felds at the bottom of the page will
calculate totals based on this information. This information includes the total number buses from the
application and the number ordered, in case a bus(es) is excluded. The total price of all buses, the total rebate
amount for all buses, and the total applicant cost responsibility (if the total price is higher than the rebate
amount) are also presented.
Once your new bus information has been entered, select “Next” to continue.
!ll'J Anoffici11l websiteof theUrn tedSta tesgovernment Here's howyou k!'IOW v

EPA development environment: The content on this page 1s not production data and this site 1s being used for development and/or testing purposes only

ft

...,..~
.
,,-

EA~

United States
Environmenta l Protection
Agency

I Search EPA.gov

Environmental Topics

Laws & Regulations

Report a Violation

El

About EPA

Clean School Bus

CONTACTUS

Clean School Bus Rebate Forms
Clean School Bus Rebate Program
On line Rebate Application Information

E%¥1

EifrMWl:::fi

csb-test@e rg.com

Wtth•M

Edit Your Payment Request
~ Re bat e ID: 010716

O

of6 Buses

This sc reen shows t he buses that were subm itted in your rebate appli cation. Update Old Bus information and add New Replacement Bu s information here.

--

· denotes required field

Old Bu s VIN : 34534534534543534

New Bus Reb ate Amount : $285,000

Old Bu s Fu el Type: Diesel

New Bus Purcha se Price: $350,000

New Bu s Fuet Type: Electric

Bu s Number

Old Bu s VIN : 34545345345343453
New Bu s Fuel Type: Electric

Tot al Purchase Price for All Replacemen t Buses 0

$350,000.00

Number of Buses Ordered

Tota l Bus Rebate Amount f)

S28S,000.00

Tot al Applicant Bus Cost Responsibilit y f)

S6S,000.00

NOTE: Use of the browser back, fo rward , or refresh buttons will result in loss of wo rk Please navigate using the buttons at t he bottom of the form.

1 Previous

Im

.c..o.n..tac1.. to ask a question, p rovide feedback, or report a p roblem .

•
18

Bu s Excluded from Rebat e

Old Bu s Fu el Type: CNG

Number of Buses Requested From Applicat ion 0

I
•

Bu s Number

Ill

2.13 Infrastructure Information
If any of the replacement buses have a New Bus Fuel Type of “Electric,” the Infrastructure step will be
included in the Payment Request form. Enter the applicable data felds for Level 2 or DC Fast Charging
systems, as well as other eligible costs related to charging infrastructure. Level 2 charging infrastructure must
be Energy Star® certifed, and EPA encourages DC fast chargers to be listed by a Nationally Recognized Testing
Laboratory. The form will then display the following felds to provide totals based on the information entered:
■

Maximum Infrastructure Rebate Funds Based on Application – Preflled based on information from
the Application, and not editable. If you excluded an old bus associated with new electric replacement
bus infrastructure rebate funds, that amount will be deducted from the Maximum Infrastructure
Rebate Funds Based on Application feld.

■

Total of All Eligible Charging Infrastructure Costs – Calculated feld summarizing the three “Cost”
felds above.

■

Total Infrastructure Rebate Amount – The amount of the rebate that will be utilized, based on the
entered costs.

■

Applicant Infrastructure Cost Responsibility – The amount that the applicant will be responsible
for paying, based on the Total of All Eligible Charging Infrastructure Costs and the Maximum
Infrastructure Rebate Funds Based on Application.

Select “Next” to continue.
If infrastructure costs are entered,
you must confrm that purchase
orders have been entered in the
Payment Request Form to account
for those costs. If there are
infrastructure costs, at least one
Electric Bus Charging Infrastructure
purchase order is required.
Any purchase order indicated
with a “Purchase Order Purpose”
of “Electric Bus Charging
Infrastructure” will be listed on this
screen for your reference. If there is
a problem, such as a purchase order
that was not entered, or a purchase
order that needs the “Purchase
Order Purpose” corrected, select
“Back to PO Entry.”

Edit Your Payment Request
.

Re ba te lD: 010716

e

of 6 Infrastructure

Enter el igibleelectric bus charginginlrast ructureinformationbelow

" denoiesrequiredfield

Totalof Level2ChargerPedesta1CostsO

Numbero1Level2Chargers0

Level2charger.;mustbeEnergySl:ilrCertified.

TotalofDC Fast ChargerPedestalCostsO

Numberof0CFastChargersO

TotalofOtherEligibleCharginglnfrastructureCostsO

Infrastructu re Purchase Orders

MaximumlnfrastnictureRebateFundsBasedon
ApplicationO

S40,000.00

Purchase Order.; (PO) listed below were identified on t he PO entry (Screen J) as including
"Electric Bus Ch arging Infrastructure"

Totalof AllEligibleCharging lnfrast n,ctureCostsO

S-0.00

Total lnlrastructureRebateAmountO

S-0.00

Applicantlnfrastructu reCostResponsibilityO

$0.00

Charger Emporium

Q

1confirmthatexpensesenteredabove,ifany,areaccurate '

select the "Back to PO Entry" button below, if ot her PO's need to be entered for tile
infrastructurelistedaboveon thisscreen

I

Backto POEntry

I
~

I

NOTE, Use of the bcowsec bock, focwacd, oc cefresh buttons will cesnlt in loss of woe~ Please navigate using the buttons at the bottom of the fonn

to ask a question,provide feedback,or reporta problem.

•
19

2.14 Signature
To complete your payment request form, you must read and agree to the “Total Bus and Infrastructure Rebate
Amount” and the “Total Applicant Bus and Infrastructure Cost Responsibility” shown at the top of the screen
as well as certify to the items listed on this page by signing, confrming your signature, and clicking “Submit
Form.” The “Name” and “Title” felds on this page are auto-flled for the individual that initiated the form based
on their SAM.gov Point of Contact information.
If you sign and confrm your signature, but then return to a previous screen to make edits, you will need to
repeat the signature and confrmation steps.
If a different user wishes to sign and
submit the form, they must also be
a SAM.gov point of contact for your
organization and will need to use
Login.gov to enter the Clean School
Bus Rebate Forms site to complete
the payment request form (saved
as a draft). In this case, they must
edit the “Name” and “Title” felds
to show their full name and title
before signing and submitting.

11n--.o111,eu,utedSl.ltd lnlrastructureRebateAmountO

S325,000.00

Tota(ApplicantBusandlnlrastructureCost
Responsibility@

$80,000.00

Signature and Certification
The ind ividual listed below must sign and submit this pa ymed/or
other criminal, civil or administrative penalties, sanctions, and remedies available to the Federal government.
2. Old buses listed to be replaced and new replacement buses must meet the eligibility requirements in the 2022 C5B Rebates Program Guide ar>d, if selected forlurnling. old buses will be
disposedofaccord ingtotheProgramGuid.tssociatedcha rging/fuelinginfr.tstructurefunded in thisprogr3mwasnotordereduntilafter offici.alnotific.ationofselection.
4.Theyhavetheauthoritytorepresent theapplicantorganizationlistedonthis lorm.
5. Thepub lic schoolsystemthatwillbe servedby thereplacementbusesforatleast fiveyearshasbeennotifiedandapprovesof theproposedbusreplacements
f>. Thestatements.and inform.ationpmvidedinthisapplic.ationare trueandaccuratetothebestoftheirknowledge
7. TheywillrespondtoEPAor itsrepresentativesifcontactedtoclarify informationsubmitted inthispaymentrequest.
Signtheformbyusingyourmousecursorasapen.
Once this payment request form is submitted, you, the other SAM.gov points of contact listed in the first pa r.agraph on this screen, and the P,ima,y and Al tern.ate app lic.ant contacts will
receive an email confi rmation. The applicant dashboard will show submittM as the status.
Title@ ·

NameO '

~ ctronicSignatureofAuthorizedRepresenrative '

•

•

a

I

1confirmlhaveprovidedmysignatureabove '

NFile Typeapplication/pdfFile Title2022 EPA Clean School Bus Rebate Forms: Payment Request User Guide (EPA-420-B-22-049, November 2022)Subjectclean, school, bus, program, payment, rebate, request, form, application, key, required, field, definition, instructions, infrasAuthorU.S. EPAFile Modified2023-01-13File Created2022-11-23