Grant Recipient Fleet Name:Recipient Address

StateofWisconsin

DepartmentofNaturalResources

POBox7921,MadisonWI53707-7921

dnr.wi.gov

WisconsinCleanDieselGrantProgramReimbursementRequest-SchoolBusOnly

Form 4500-181A (R 10/16)

Notice:Complete this form for Diesel Emission Reduction Act (DERA) grant funds administered by the Department of Natural Resources (DNR), received from US EPA. Incomplete forms may not be considered. Personal information collected will be used for grant administration and may be provided to requestersto the extent required by Wisconsin’s Open Record law

(ss. 19.31-19.39, Wis Stats.).

Grant Recipient Fleet Name:Recipient Address:

Ifnotcompletedelectronically,copiesofthisformshouldbemadeforadditionalbuses.Purchasesmadebeforeawarddateareineligibleforreimbursement.Reimbursementrequestsmustalsoinclude:

1.) An invoice/receipt and copy of cancelled check showing full payment of bus(es);

2.) Proof of proper disposal of engine and chassis (including photographs of VIN, engine label, side profile of bus and the disabled engine and chassis); and 3.) Documentation of any income generated for disposal of bus(es).

1Enter the chassis VIN and engine serial number for the original and new bus(es).

2Include the make and model of the new chassis and engine, as well as make and model of any idle reduction device installed.

3Cost of the bus, taxes and fees (if applicable)

4Report any income generated from the sale or salvage of parts from old bus(es) (after permanently disabling engine and chassis)

5Subtract any Income Generated from the Unit Cost and enter the amount here. Reimbursement will be made on this amount, which is generally at 25% of the Adjusted Total Cost unless additional match was indicated in the contract agreement.

You will not be reimbursed for any amount over the approved award amount shown in the contract agreement.

Certification

I hereby certify that the expenses reported on this form are in accordance with the grant agreement and that complete and accurate records are being kept to substantiate such expenses.

Print Name of Authorized Representative / Title of Authorized Representative
Signature of Authorized Representative / Date Signed

Retain a copy of this complete form for your

records and send the original to: OR

Wisconsin Department of Natural Resources Clean Diesel Grant Program– Peter McMullen

2300 N. Dr. Martin Luther King Jr Drive

Milwaukee, WI 53212