Form Dr 0168 - Alternative Fuels Rebate - 2009 printable pdf download

Departmental Use Only

DR 0168 (09/30/09)

COLORADO DEPARTMENT OF REVENUE

DENVER CO 80261-0009

ALTERNATIVE FUELS REBATE

(FOR COSTS INCURRED ON OR AFTER JULY 1, 2009)

Part 1: Applicant Information for Businesses

Qualified Entity

Contact

Street Address

City

State

Zip

phone

Fax

(

)

(

)

Mailing Address

City

State

Zip

Department of Revenue Account Number

If vehicle is leased to applicant, please provide owner information. Remember to attach a letter from the owner (lessor) stating the applicant (lessee) will

be the sole recipient of the rebate.

Owner (lessor)

Contact

Street Address

City

State

Zip

phone

Fax

(

)

(

)

Department of Revenue Account Number

•

Type of Qualifying Entity 56

Please see page 1 of DR 0166 Alternative Fuels Rebate Instructions for entity code.

This motor vehicle must be titled and registered in the state of Colorado. Attach a copy of the Colorado title and

Vehicle Information

a copy of the Colorado registration.

Manufacturer

Year

Model

ViN

•

incremental purchase price (OEM)

Conversion Cost $

Date Cost is incurred

(Attach copy of purchase order or copy)

•

Is this motor vehicle used solely and exclusively for the business or official activities of the qualified entity?

Yes

If no, what percent of the time during the calendar year is the motor vehicle used for the business or official activities of the entity? ________________ %

•

Does this motor vehicle or power source permanently displace a motor vehicle or power source that is ten years old or older?

Yes

If yes, attach documentation.

Category (see instructions): ______________________________________________________________________________________________

Applicant Certification

I certify under penalty of perjury in the second degree that the above statements are true.

Signature

Date

print Name

Title

Part 2: Dealer or Installer Technical Information