MHD Reimbursement

1
Grant Number* This field is required.You can find this information in the Grant Agreement. It should be of the form YYYY-XX-528S1 (for AOI 1: On-Road Grants) OR YYYY-XX-529S1 (for AOI 2: Off-Road Grants)
2
Grantee Name* This field is required.You can find this information in the Grant Agreement
3
Email* This field is required.Any questions we have about this reimbursement request will be sent to this email
example@example.com
4
Reimbursement Request Invoice* This field is required.This must be on the Grantee letterhead, and must include the Grant Number, and Grantee's Federal Identification Number. A template can be found here.
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Max. file size: 10.6MB
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5
Signed final invoice/vehicle purchase order(s) * This field is required.This must confirm both the final incremental cost and total vehicle cost paid
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Max. file size: 10.6MB
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6
Proof of payment* This field is required.
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7
ZEV Summary Table* This field is required.Documentation that lists the vehicle identification number (VIN), tag number, and vehicle in-service date for each ZEV denoted by model year, make and model. A template can be found here.
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Max. file size: 10.6MB
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8
Factory build sheet * This field is required.This document must clearly confirm the Vehicle Identification Number (VIN) and Gross Vehicle Weight Rating (GVWR)
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Max. file size: 10.6MB
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9
Copy of vehicle registration* This field is required.This can be a photograph or a scanned document
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Max. file size: 10.6MB
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10
Photographs of the vehicle* This field is required.These photographs must show the left side, front side - showing the license plate, VIN tag, odometer reading
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Max. file size: 10.6MB
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11
Cost breakdown of cost-shared items in an Excel spreadsheet * This field is required. Grantee must verify that the total cost share amount and items invoiced are equal to the total project cost. A template can be found here.
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Max. file size: 10.6MB
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12
NotesAny other materials that support your report (e.g., notes, questions, press coverages, ribbon cutting events, etc.).
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MHD Reimbursement