Form Il 532 2598 - Vehicle Rebate Application Form - Illinois Environmental Protection Agency

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ILLINOIS ENVIRONMENTAL PROTECTION AGENCY
Illinois Alternate Fuels Rebate Program
VEHICLE REBATE Application Form
This form is to be used for the "(2) VEHICLE REBATE" Section in Program Summary and Instructions
Applicant Information
Name ______________________________________
Daytime Phone #
______________________________________
(Last)
(First)
(Area Code)
Address ___________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Your Email address _________________________________________________________________________________
For Individual Applicants Only
Social Security Number ________ - ________ - ________
For Businesses/Governments/Organizations
Company Name ____________________________________________
# Vehicles in fleet ______________________
Federal Employer Ident. Number (FEIN) _________________________
# Employees __________________________
Type of Alternate Fuel Vehicle
_____Hydrogen
_____E85 Flexible Fuel Vehicle
_____Natural Gas
_____Propane
______Electricity (see website)
Vehicle is primarily fueled at a: _____ public/retail fueling station
_____ private/fleet fueling station
Vehicle Information
Make __________________________________
Model ____________________Model Year __________________
Purchase Date __________________________
VIN # _________________________________________________
License Plate #__________________________
State _________________________________________________
Authorization
NOTE: THIS CERTIFICATION MUST BE SIGNED BY A RESPONSIBLE OFFICIAL/APPLICANT. APPLICATIONS WITHOUT A
SIGNED CERTIFICATION WILL BE DEEMED AS INCOMPLETE. I CERTIFY UNDER PENALTY OF LAW THAT, BASED ON
INFORMATION AND BELIEF FORMED AFTER REASONABLE INQUIRY, THE STATEMENTS AND INFORMATION CONTAINED IN
THIS APPLICATION ARE TRUE, ACCURATE AND COMPLETE. ANY PERSON WHO KNOWINGLY MAKES A FALSE, FICTITIOUS,
OR FRAUDULENT MATERIAL STATEMENT, ORALLY OR IN WRITING, TO THE ILLINOIS EPA COMMITS A CLASS 4 FELONY. A
SECOND OR SUBSEQUENT OFFENSE AFTER CONVICTION IS A CLASS 3 FELONY (415 ILCS 5/44(H))
Applicant Signature _________________________________________
Date _____________________________
Mail this rebate application form and documentation as described in the Program Summary within one year of the vehicle
purchase date to the address below. The Program Summary and Rebate Forms can be found at
If you have any questions that are not addressed on the website or need clarification, call the
Illinois EPA at (217) 557-1441.
Illinois Environmental Protection Agency
Alternate Fuels Rebate Program #6
P.O. Box 19276
Springfield, Illinois 62794-9276
IL 532 2598
APC 573 Rev. Oct-12

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