Form Dr 0167 Proto - Alternative Fuels Rebate - 2004
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1Departmental Use Only
60
DR 0167 PROTO (11/15/04)
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0010
ALTERNATIVE
FUELS REBATE
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
(
)
(
)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
Department of Revenue Account Number
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
•
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6
Type of Qualifying Entity 56
Please see page 1 of DR 0166 Alternate Fuel Rebate Instructions for entity code.
This motor vehicle must be titled and registered in the state of Colorado. Attach a copy of the
Vehicle Information
Colorado title and 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 of warrant)
•
•
•
•
Is this motor vehicle used solely and exclusively for the business or official activities of the qualified entity?
Yes
No
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
No
If yes, attach documentation.
•
LEV (Lower-emitting vehicle)
ULEV or ILEV (ultra) low-emitting vehicle or inherently-low-emitting vehicle
ZEV (zero-emitting vehicle)
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
AFS Emissions Certification: (Vehicle must be certified by EPA.)
EPA Federal Certification:
LEV (Low-emitting vehicle)
ULEV or ILEV (ultra low-emitting vehicle or inherently-low-emitting vehicle)
ZEV (zero-emitting vehicle)
Attach documentation of EPA emissions certification
Cost of AFS$
Date of AFS purchase or installation
Attach invoice that details the actual
price paid, including parts and labor.
Certification:
I certify the information of Part 2 is accurate and that a true and accurate invoice reflecting the cost to the applicant is attached.
Dealer or Installer
Date
Address
City
State
ZIP
Phone
Fax
(
)
(
)
Signature
Title
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