Form FDACS-01613 "Local Government Natural Gas Vehicle Rebate Program Application" - Florida

Form FDACS-01613 or the "Local Government Natural Gas Vehicle Rebate Program Application" is a form issued by the Florida Department of Agriculture and Consumer Services.

The form was last revised in July 1, 2018 and is available for digital filing. Download an up-to-date fillable Form FDACS-01613 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

ADVERTISEMENT

Download Form FDACS-01613 "Local Government Natural Gas Vehicle Rebate Program Application" - Florida

376 times
Rate
(4.6 / 5) 26 votes
Florida Department of Agriculture and Consumer Services
Office of Energy
LOCAL GOVERNMENT
NATURAL GAS VEHICLE REBATE PROGRAM APPLICATION
ADAM H. PUTNAM
COMMISSIONER
Applications must be submitted to the Florida Department of Agriculture and Consumer Services,
Office of Energy, 600 South Calhoun Street, Suite B04, Tallahassee, Florida 32399-0001, by
certified mail or hand-delivery no later than 5:00 P.M. Eastern Standard Time on June 28, 2019.
CONTACT INFORMATION
Contact Person
Phone Number
Email Address
APPLICANT INFORMATION
The following information must match the vendor information for the applicant listed in MyFloridaMarketPlace.
Applicant Name
FEIN/Tax ID Number
Authorized Corporate Officer
Mailing Address
City, State, Zip
Remittance Address
Under penalty of perjury, I affirm:
the information contained in the application and supporting documentation is true and
correct;
a Natural Gas Fuel Fleet Vehicle Rebate Program Application was submitted for the vehicle I
am seeking a rebate for under the 2016-17 fiscal year, but a rebate was not received;
the vehicle I am seeking a rebate for is in compliance with applicable United States
Environmental Protection Agency emission standards,
the vehicle I am seeking a rebate for is part of a vehicle fleet with three or more motor
vehicles registered in this state; and
the vehicle I am seeking a rebate for is used for governmental purposes.
__________________________________
________________________________
____________
Signature of Applicant/Representative
Printed Name and Title
Date
FDACS-01613 Rev. 07/18
Page 1 of 6
Florida Department of Agriculture and Consumer Services
Office of Energy
LOCAL GOVERNMENT
NATURAL GAS VEHICLE REBATE PROGRAM APPLICATION
ADAM H. PUTNAM
COMMISSIONER
Applications must be submitted to the Florida Department of Agriculture and Consumer Services,
Office of Energy, 600 South Calhoun Street, Suite B04, Tallahassee, Florida 32399-0001, by
certified mail or hand-delivery no later than 5:00 P.M. Eastern Standard Time on June 28, 2019.
CONTACT INFORMATION
Contact Person
Phone Number
Email Address
APPLICANT INFORMATION
The following information must match the vendor information for the applicant listed in MyFloridaMarketPlace.
Applicant Name
FEIN/Tax ID Number
Authorized Corporate Officer
Mailing Address
City, State, Zip
Remittance Address
Under penalty of perjury, I affirm:
the information contained in the application and supporting documentation is true and
correct;
a Natural Gas Fuel Fleet Vehicle Rebate Program Application was submitted for the vehicle I
am seeking a rebate for under the 2016-17 fiscal year, but a rebate was not received;
the vehicle I am seeking a rebate for is in compliance with applicable United States
Environmental Protection Agency emission standards,
the vehicle I am seeking a rebate for is part of a vehicle fleet with three or more motor
vehicles registered in this state; and
the vehicle I am seeking a rebate for is used for governmental purposes.
__________________________________
________________________________
____________
Signature of Applicant/Representative
Printed Name and Title
Date
FDACS-01613 Rev. 07/18
Page 1 of 6
AFFIDAVIT
Before me, the undersigned authority, this day personally appeared the affiant, who being first duly
sworn, states from his/her personal knowledge that all information contained in the foregoing
application and attached documents is true and correct.
Name & Title: ____________________________
______
(Please print)
Sworn to and Subscribed before me this ___ __ day of ___________________
__________.
Notary Public,
State of _________________: _____________
_____
______________
(Notary signature)
Print Name: ______________
___________________
________ Personally known or;
________ Produced Identification
Type of Identification produced: _________________________________
The affidavit must include an ink stamp or embossing seal of the Notary Public notarizing the
application.
FOR OFFICAL USE ONLY – To be completed by the Office of Energy.
_________
$
Total Amount of Natural Gas Vehicle Rebate: _
_____________________________________
__________________________________
______________________________
____________
OOE Authorizing Signature
Printed Name and Title
Date
FDACS-01613 Rev. 07/18
Page 2 of 6
VEHICLE INFORMATION
Vehicle Make:
Vehicle Model:
Vehicle Year:
VIN #:
Counties Where
County Where
Vehicle is Predominately
Vehicle is
Fueled:
Licensed:
Physical Address of Where Vehicle is Located:
Total number of motor vehicles registered in this
state and used for governmental purposes:
Does this vehicle contain a mechanical or
electronic device that is used to calculate
Yes:
No:
passenger fare?
Has this vehicle previously received a rebate under
Yes:
No:
the Natural Gas Fuel Fleet Vehicle Rebate Program?
Upon request of the Department, the applicant shall make the vehicles for which the applicant has
applied for a rebate available for on-site inspection by the Department to verify the VIN number, the
conversion kit ID number, and other information contained in the Local Government Natural Gas
Vehicle Rebate Program Application approved for a rebate under this program.
FDACS-01613 Rev. 07/18
Page 3 of 6
TYPE OF NATURAL GAS FUEL SYSTEM
“Natural Gas Fuel” is defined by s. 377.810(2)(f), F.S. as any liquefied petroleum gas product, compressed natural gas
product, or combination thereof used in a motor vehicle as defined in s. 206.01(23), F.S.. This term includes, but is not
limited to, all forms of fuel commonly or commercially known or sold as natural gasoline, butane gas, propane gas, or any
other form of liquefied petroleum gas, compressed natural gas, or liquefied natural gas.
Compressed Natural Gas (CNG)
Propane
Indicate Type of Natural Gas Fuel System:
Other: _____________________________________
(Indicate type of natural gas fuel)
Bi-Fuel System: ______________________________
(Indicate type of natural gas fuel)
NATURAL GAS VEHICLE INVESTMENT INFORMATION
Indicate Natural Gas Investment Type:
Natural Gas Vehicle Conversion (A diesel or gasoline powered motor vehicle that was retrofitted to a natural gas fuel
powered motor vehicle after the vehicle was purchased.)
Natural Gas Vehicle Purchase (The acquisition of a natural gas fuel powered motor vehicle, new or used, through the
owner’s existing funds or credit. This includes a diesel or gasoline powered motor vehicle that was retrofitted to a natural
gas fuel powered motor vehicle as part of the purchase price.
Natural Gas Vehicle Lease (A contractual agreement requiring payment for the use of a natural gas fuel powered motor
vehicle not owned by the applicant for a minimum of five years.)
Seller or Conversion Company
Address
Date of Conversion, Purchase, or
Lease
Conversion Kit Serial Number
(If purchase or lease put “N/A”)
Total Eligible Conversion Costs
= Amount of rebate
(The excess cost associated with
$________________
x 50% = $__________
request, up to
retrofitting a diesel- or gasoline-powered
motor vehicle to a natural gas fuel
$25,000
powered motor vehicle.)
FDACS-01613 Rev. 07/18
Page 4 of 6
SUPPORTING DOCUMENTATION
Attach the listed supporting documentation, required by s. 377.810, F.S., to this application. Please check each box to
indicate that the corresponding supporting documentation has been attached to this application.
A legible photocopy of the purchased/leased or converted vehicle’s valid and current registration
A clear and legible photograph of the Vehicle Identification Number (VIN) from the vehicle (VEHICLE
CONVERSIONS ONLY)
A clear photograph of purchased/leased or converted vehicle (VEHICLE CONVERSIONS ONLY)
A clear photograph of the natural gas fuel tank system installed on the vehicle (VEHICLE CONVERSIONS ONLY)
Environmental Protection Agency Certificate of Conformity
Documentation of the equivalent diesel or gasoline vehicle cost (VEHICLE PURCHASES AND LEASES ONLY)
Valid and current Weights and Measures Permit pursuant to 531.60, F.S. (TAXI CONVERSIONS ONLY)
INVOICE AND PROOF OF PAYMENT
Attach an approved form of invoice and corresponding proof of payment as required by s. 377.810(4)(a), F.S. Please
check each box to indicate that the corresponding documentation has been attached to this application.
Invoice
The invoice must contain at least:
a.
The name and address of the seller from whom the vehicle was purchased or leased, or the company
that completed the vehicle conversion;
b.
The price of the vehicle purchase, lease, or conversion;
c.
The Vehicle Identification Number of the purchased, leased or converted vehicle represented on the
application; and
d.
A clear indication on the invoice that the vehicle represented on the invoice is a natural gas fuel
powered motor vehicle.
Proof of Payment
Acceptable forms of proof of payment include; but not limited to:
a.
A canceled check with proof of deposit;
b.
A copy of an electronic funds transfer from a financial institution including the purchase amount and to
whom the payment is being made;
c.
A bank statement or a screenshot of an online bank statement reflecting the transaction (with unrelated
information redacted) showing the purchase amount and to whom the payment is being made;
d.
A signed and executed lease contract;
e.
A credit card statement reflecting the transaction showing the cardholder’s name, address, the
purchase amount, and to whom the payment is being made; or
f.
A signed and executed promissory note or signed and executed auto loan.
g.
An explanation if the amount provided on the invoice and corresponding proof of payment do not
match.
Legible copies of the documents, in place of originals, will be accepted. If the Florida Department of
Agriculture and Consumer Services, Office of Energy, determines the supporting documentation is
illegible, the application will be determined incomplete. Incomplete applications submitted to the
department will not secure a place in the first-come, first-served application process.
FDACS-01613 Rev. 07/18
Page 5 of 6
ADVERTISEMENT