| Diesel Replacement Rebate Application

Please note that project information may be shared with all funding parties.

Applicant Information

Organization Name*

Organization Type*

Applicant Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant Mailing Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact Name*

First Last

Primary Contact Phone*

Primary Contact Email*

Secondary Contact Name

First Last

Secondary Contact Email

This organization is submitting multiple applications*

Yes
No

If yes, please number applications here:

Existing Vehicle

Please complete one application per vehicle being replaced.

Vehicle Type*

*If Medium/Heavy Duty Truck, please indicate the truck's function

Manufacturer*

Vehicle Model*

Model Year*

Type of fuel (must be diesel)*

Diesel

MPG*

Gross Vehicle Weight Rating (GVWR)*

Class 5 (16,001 -19,500 lbs GVWR); Class 6 (19,501 -26,000 lbs GVWR); Class 7 (26,001 -33,000 lbs GVWR); Class 8 (33,001 lbs GVWR and over)

Vehicle Weight Class*

Estimate Years of Remaining Life*

Estimate miles traveled per year*

Is the existing vehicle fully operational? Operational vehicles must be able to start, move, and have all parts necessary to be operational.*

Yes
No

Does the applicant currently own and operate the existing vehicle in the State of Hawaii?*

Yes
No

Did the applicant own and operate the existing vehicle during the two-year period prior to application?*

Yes
No

Vehicle Area of Operation: Island*

Vehicle Area of Operation: Primary County (if applicable)

Vehicle Area of Operation: Primary City (if applicable)

Replacement Vehicle

Please read the Program Guide for to ensure replacement unit qualifies for funding.

Vehicle Type*

*If Medium/Heavy Duty Truck, please indicate type of truck

Manufacturer*

Vehicle Model*

Model Year*

Is this the most recent model year available?*

Yes
No

Gross Vehicle Weight Rating (GVWR)*

Vehicle Weight Class*

Type of fuel (must be electric)*

Electric

MPG equivalent*

Is this vehicle a retrofit? (vehicle must not be a retrofit)*

No

Quoted Cost of new vehicle*

Upload dated dealer quote*

The quote(s) should be dated and include a complete breakdown of all material costs as applicable: vehicle, hardware, warranty costs, freight or shipping costs, installation costs, setup fees, and the sales tax with the percentage rate indicated.

Drop files here or

Upload additional features list, if applicable.

Replacement vehicles should resemble the original in form and function. Additional features may be added at owner’s expense. Please list all additional and optional equipment or attachments separately in a line item format.

Drop files here or

If you plan to purchase a charger to accompany the vehicle, please fill out the following. This will be part of overall project value.

Charger Brand

Charger Model

Charger level

Charger address once installed

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vendor Quoted Price

Upload Vendor Quote

Drop files here or

Total project cost (vehicle and charger)*

Are you planning to apply (or have you already applied) for the Hawaii Energy charger rebate?*

Yes
No

If yes, what is your expected rebate?

The maximum rebate available is 45% of total eligible costs. Applicants must provide a minimum of 55% cost match. The cost match cannot include funding from federal sources. Please describe the proposed source of match funds:*

This program combines multiple funding sources. Some projects will be required to receive the replacement vehicle/equipment by September 30, 2022, and some will have a deadline of September 30, 2023. Successful applicants will be made aware of the deadline at time of award notification. Extensions are possible but not guaranteed. Please describe the steps your organization is taking to procure this vehicle, proposed timeline including expected delivery date.*

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