Form FDACS-01976 "Natural Gas Fuel Fleet Vehicle Rebate Program Application" - Florida

Form FDACS-01976 or the "Natural Gas Fuel Fleet Vehicle Rebate Program Application" is a form issued by the Florida Department of Agriculture and Consumer Services.

The form was last revised in March 1, 2017 and is available for digital filing. Download an up-to-date fillable Form FDACS-01976 in PDF-format down below or look it up on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-01976 "Natural Gas Fuel Fleet Vehicle Rebate Program Application" - Florida

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Florida Department of Agriculture and Consumer Services
Office of Energy
NATURAL GAS FUEL FLEET VEHICLE
REBATE PROGRAM APPLICATION
ADAM H. PUTNAM
COMMISSIONER
Rule 5O-4.001, Florida Administrative Code
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 30 of the fiscal year for which this application is to be considered.
The Department’s ability to authorize rebates pursuant to the Natural Gas Fuel Fleet Vehicle Rebate Program (Program),
Section 377.810, Florida Statutes, is contingent upon an annual appropriation by the Legislature of the State of Florida for
the specific purpose of funding the Program. In the event of a state revenue shortfall, funding for the Program may be
reduced. The Department, in accordance with direction from the Governor and/or Legislature, shall be the final determiner
of the availability of any funds.
TYPE OF FUNDING
Please select the type of funding for each vehicle.
Initial Funding (The applicant has not received the program maximum of $250,000 within the fiscal year
nn
for which the applicant is seeking a rebate.)
Supplemental Funding (The applicant has received the program maximum of $250,000 and is applying
x
for additional rebate(s) within the same fiscal year. Note: Supplemental applications will only be accepted
from June 1 to June 30 of the fiscal year for which the applicant is applying.)
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
different)
Under penalty of perjury, I affirm that the information contained in the application and supporting documentation is true and
correct. I affirm that the vehicle I am seeking a rebate for has not previously received a Natural Gas Fuel Fleet Vehicle
Rebate, is in compliance with applicable United States Environmental Protection Agency emission standards, is part of
vehicle fleet with three or more motor vehicles registered in this state and used for commercial business or governmental
purposes, and the requirements of Section 377.810, F.S. and Rule 5O-4.001, F.A.C. have been met.
__________________________________
________________________________
____________
Signature of Applicant/Representative
Printed Name and Title
Date
FDACS-01976 Rev. 03/17
Page 1 of 6
Florida Department of Agriculture and Consumer Services
Office of Energy
NATURAL GAS FUEL FLEET VEHICLE
REBATE PROGRAM APPLICATION
ADAM H. PUTNAM
COMMISSIONER
Rule 5O-4.001, Florida Administrative Code
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 30 of the fiscal year for which this application is to be considered.
The Department’s ability to authorize rebates pursuant to the Natural Gas Fuel Fleet Vehicle Rebate Program (Program),
Section 377.810, Florida Statutes, is contingent upon an annual appropriation by the Legislature of the State of Florida for
the specific purpose of funding the Program. In the event of a state revenue shortfall, funding for the Program may be
reduced. The Department, in accordance with direction from the Governor and/or Legislature, shall be the final determiner
of the availability of any funds.
TYPE OF FUNDING
Please select the type of funding for each vehicle.
Initial Funding (The applicant has not received the program maximum of $250,000 within the fiscal year
nn
for which the applicant is seeking a rebate.)
Supplemental Funding (The applicant has received the program maximum of $250,000 and is applying
x
for additional rebate(s) within the same fiscal year. Note: Supplemental applications will only be accepted
from June 1 to June 30 of the fiscal year for which the applicant is applying.)
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
different)
Under penalty of perjury, I affirm that the information contained in the application and supporting documentation is true and
correct. I affirm that the vehicle I am seeking a rebate for has not previously received a Natural Gas Fuel Fleet Vehicle
Rebate, is in compliance with applicable United States Environmental Protection Agency emission standards, is part of
vehicle fleet with three or more motor vehicles registered in this state and used for commercial business or governmental
purposes, and the requirements of Section 377.810, F.S. and Rule 5O-4.001, F.A.C. have been met.
__________________________________
________________________________
____________
Signature of Applicant/Representative
Printed Name and Title
Date
FDACS-01976 Rev. 03/17
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 Fuel Fleet Vehicle Rebate: _
_______________________________________
__________________________________
______________________________
____________
OOE Authorizing Signature
Printed Name and Title
Date
FDACS-01976 Rev. 03/17
Page 2 of 6
TYPE OF APPLICANT
Commercial
Government
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 commercial business or
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 Natural Gas Fuel Fleet Vehicle Rebate Application approved for a rebate under this program.
FDACS-01976 Rev. 03/17
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
retrofitting a diesel- or gasoline-powered
$________________
x 50% = $__________
request, up to
motor vehicle to a natural gas fuel
$25,000
powered motor vehicle.)
FDACS-01976 Rev. 03/17
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:
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;
A credit card statement reflecting the transaction showing the cardholder’s name, address, the
e.
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-01976 Rev. 03/17
Page 5 of 6
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