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OMB Number: 2060-0686Expiration Date: 10/31/2015United States
Environmental Protection Agency
National Clean Diesel Rebate ProgramRebate Application
Funding Year Target Fleet
Applicant Information
Organization Name
Address
City County/Parish State ZIP
Employer/Taxpayer No. (EIN/TIN) Organizational DUNS Code
Eligible Entity Information (Private Equipment Owner Applicants
Only)Private equipment owners are able to apply for funding from
the National Clean Diesel Rebate Program if the equipment, for
which funding is beingrequested, is currently contracted or leased
to an eligible entity. An eligible entity is a federal, regional,
State, local, or tribal agency or port authority withjurisdiction
over transportation or air quality. For additional information
regarding private equipment owner applicants and eligible entities,
please refer tothe Program Guide.
Eligible Entity Type Eligible Entity Name Eligible Entity
Location (City, State)
I certify the equipment, for which rebate funds are being
requested, meet the requirements for private equipment owners as
describedabove and in the terms and conditions within the Program
Guide.
Original Equipment
EquipmentType
Technology **
Engine SerialNumber
Engine
Family Name
EngineModelYear
GalsUsedLast
12 Mos
Hrs ofUseLast
12 Mos
HPLocation ofOperation:
County State
RebateAmount
* Excavator T1 to T3 6NC13641 YCPXL10.SMRF 2000 3759 500 225
Lake IN $15,000
* Crane T3 add DPF MHX02642 6CPXL12.5ESK 2008 4632 600 388 Cook
IL $30,000
1
2
3
4
5
*Example ** UR = unregulated, also referred to as Tier 0 Total
$
I certify that the engines listed for retrofit or replacement
are operational and meetthe eligibility requirements defined in the
Program Guide.
Replacements only: I certify that the engines listed for
replacement will be properlydisposed of according to the
requirements defined in the Program Guide.
Applicant Signature
By signing, I certify the statements and information provided in
this application are true and accurate to the best of my knowledge.
Ifselected for funding, I agree to provide the required
documentation and assurances necessary for funding.
Funding for the National Clean Diesel Rebate Program is subject
to continuing federal appropriations. Please see the Program Guide
foradditional funding information.
Authorized Representative Name
Title E-mail Phone
Authorized Representative Signature Date
EPA Form 5600-260 (9-12)
Rebate Type2013 Construction Retrofit/Replacement
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Item: Entry:
Organization Name Enter the legal name of Applicant applying for
the rebate.
Address Enter the Street Address where the Applicant is
located.
City Enter the City where the Applicant is located.
County / Parish Enter the County / Parish where the Applicant is
located.
State Enter the State where the Applicant is located.
Zip Enter the Zip where the Applicant is located.
Employer / Taxpayer Number
(EIN/TIN)
Enter the Employer or Taxpayer Identification Number (EIN or
TIN) as
assigned by the Internal Revenue Service.
Organizational DUNS CodeEnter the Applicant's DUNS or DUNS+4
number received from Dun andBradstreet. Information on obtaining a
DUNS number can be found atwww.dnb.com.
Eligible Entity Type
Eligible Entity NameFor Private Equipment Owner Applicants Only
- Enter the name of theentity with which the Applicant has a
current contract or lease foroperation of the construction
equipment (e.g., Tennessee Department ofEnvironment).
Eligible Entity Certification
For Private Equipment Owner Applicants Only - In order to be
eligible toapply for rebate funding, the Applicant must own and
operate theequipment under a contract, or lease with one of the
following entitieswith jurisdiction over transportation or air
quality:
a. federal department or agency
b. regional, state, local, or tribal government agency or port
authorities
List the type of the entity with which the Applicant has a
current contractor lease for operation of the equipment (e.g.,
state agency).
Applicant Information
Eligible Entity Location (City,State)
For Private Equipment Owner Applicants Only - Enter the location
(cityand state) where the Eligible Entity with which the Applicant
has a currentcontract or lease is located.
For Private Equipment Owner Applicants Only - Check the box to
certifythat the Applicant's equipment, for which rebate funds for
retrofits orreplacements are being requested, meet the requirements
for privateequipment as described above and in the Program
Guide.
Rebate Application Instructions
EPA Form 5600-260
http://www.dnb.com/http://www.dnb.com/
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The public reporting and recordkeeping burden for this
collection of information is estimated to average 4hours per
response. Send comments on the Agency's need for this information,
the accuracy of the providedburden estimates, and any suggested
methods for minimizing respondent burden, including through the
useof automated collection techniques to the Director, Collection
Strategies Division, U.S. EnvironmentalProtection Agency (2822T),
1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
controlnumber in any correspondence. Do notsend the completed form
to this address.
Original Equipment
Item: Entry:
Select from drop down menu.
Select from drop down box
Sum the requested rebate amounts for each piece of equipment and
enter thetotal.
Check the box to certify that the equipment are operational and
meet the eligibilityrequirements defined in the Program Guide.
Check the box to certify that the equipment will be properly
disposed of accordingto the requirements defined in the Program
Guide.
Statement Certification
Check the Applicant Signature box to certify that the statements
andinformation provided in this application are true and accurate
to the best of the
Applicant's knowledge. By checking the box, Applicant agrees to
provide therequired documentation and assurances necessary for
funding.
Equipment type
Technology
Rebate Amount
Total Rebate Funds Requested
Scrappage Certification
Eligibility Certification
To be signed and dated by the authorized representative of the
Applicantorganization. Enter the name (first and last name
required), title (required), E-mail address (required), and
telephone number (required), of the personauthorized to sign for
the Applicant.
Name, Title, E-mail, Phone,Signature, Date
Application packages must include copies of the original bill of
sale, original invoice, or otherdocumentation that demonstrates
ownership for each piece of equipment to be replaced. Please
reviewthe Program Guide(see Appendix C - Rebate Application
Checklist) to ensure all program requirements
have been met before submitting application packages to
[email protected].
Select from drop down menu.
Enter engine serial # for current engine. See Appendix D in
Program GuideExisting Engine Serial NumberExisting Engine Family
Name Enter family name for the current engine. See Appendix D in
Program Guide
Enter model year of current engine. See Appendix D in Program
GuideExisting Engine Model Year
Gals Used Last 12 mos Enter gallons of diesel fuel used in last
twelve months for this piece of equipment
Enter hours of operation for the equipment in the last twelve
monthsHrs of Use Last 12 mos
Location of OperationEnter county and two letter state
abbreviation for county where equipment isoperated at time of
application and the three months prior to application.
Applicant Signature
Rebate Application Instructions - Page 2
http://epa.gov/cleandiesel/documents/420b13042.pdfmailto:[email protected]:[email protected]://epa.gov/cleandiesel/documents/420b13042.pdf
