Fillable Maine governmental entities, including rules about eligibility, rebate (Efficiency Maine)

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Maine governmental entities, including rules about eligibility, rebate (Efficiency Maine)

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ELECTRIC VEHICLE REBATE PROGRAM
FORM #5 – GOVERNMENTAL ENTITY PRE-APPROVAL APPLICATION
168 Capitol Street, Suite 1, Augusta, ME 04330 | (866) 376-2463 | efficiencymaine.com
1
6/30/2021
INSTRUCTIONS
1. Complete form (typed if possible) and submit a signed copy by email to ev@efficiencymaine.com.
2. If approved, you will receive a letter from Efficiency Maine stating that you are eligible for enhanced rebates as a governmental
entity.
3. Present the pre-approval letter from Efficiency Maine at the dealership to receive an enhanced rebate.
4. Please notify Efficiency Maine promptly of any changes to the number and type of vehicles that the entity plans to purchase or
lease.
PRIMARY CONTACT/GOVERNMENTAL ENTITY INFORMATION
Name of Governmental Entity
Employer Identification Number (EIN):
Primary Contact Name
Number of vehicles the entity intends to purchase or lease:
Primary Contact Phone
Make
Primary Contact Email
Will the vehicle(s) be replacements for existing
vehicles or adding new vehicles to the fleet?
Replacements __
New vehicles __
Mailing Address:
Physical Address (if different):
City
State
ZIP
City
State
ZIP
SIGNATURE OF AUTHORIZED REPRESENTATIVE (Required)
This form certifies that the entity identified herein is a Maine Governmental Entity or a Tribal Government located in the State of Maine
1
,
duly formed and validly existing under applicable law. We acknowledge that execution and delivery of this certification is a condition for
pre-approval by Efficiency Maine for eligibility to receive enhanced rebate amounts in the EV Accelerator Program.
Executed as of the date noted below by its duly authorized officer.
Full Name:
Title:
Signature of duly authorized officer:
___________________________________________________
Date: _________________________
1
For purposes of the Efficiency Maine EV Rebate Program, a Maine Governmental Entity means the State of Maine (including state departments, agencies, and
authorities) and its political subdivisions (including a city, town, plantation, county, quasi-municipal corporation, school district, utility district, transit district or
regional transportation corporation), all as further defined in 14 M.R.S. §8102. A “Tribal Government” means a federally-recognized tribal government located
in the State of Maine, which are: the Aroostook Band of Micmacs, the Houlton Band of Maliseet Indians, the Passamaquoddy Tribe - Indian Township, the
Passamaquoddy Tribe - Pleasant Point, and the Penobscot Indian Nation.
For general information about electric vehicles (EV) and charging visit efficiencymaine.com/ev. For more information about rebates for
Maine governmental entities, including rules about eligibility, rebate limits, and limited-time promotions, visit
efficiencymaine.com/electric-vehicle-rebates/.
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Maine governmental entities, including rules about eligibility, rebate (Efficiency Maine)

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Completed 23 July 2021

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