Request for Reimbursement Form Name of Applicant: Date new bus was delivered: Engine Model Year of New Bus: _______________ Instructions: Fill in the information below to summarize the Reimbursement Request. Reimbursement Summary Final Purchase Price of Bus $ Rebate Amount (not to exceed awarded amount) = $ Purchase Price X percentage from award *Program Income from Salvage/Scrappage $ *If scrapped or salvaged engines/vehicles are to be sold, program income requirements apply. Program income may be used to meet the cost-sharing or matching requirement of the award, including any mandatory or voluntary cost-share. The amount of the award remains the same. Please attach evidence of final bus purchase price such as a copy of the dealer invoice, receipt, or canceled check Please attach Certificate of Disposal and photos verifying disposal if requesting the 35% rebate, please attach a copy of the engine certificate showing it meets CARB’s Low-NOx Standards. Requests are to be submitted by email to or by mail to: Bus Rebate Programs SD DENR AQ Program – 523 E Capitol Pierre, SD 57501
Request for Reimbursement Form Name of Applicant: Date new bus was delivered: Engine Model Year of New Bus: _______________ Instructions: Fill in the information below to summarize the Reimbursement Request. Reimbursement Summary Final Purchase Price of Bus $ Rebate Amount (not to exceed awarded amount) = Purchase Price X percentage from award $ *Program Income from Salvage/Scrappage $ *If scrapped or salvaged engines/vehicles are to be sold, program income requirements apply. Program income may be used to meet the cost-sharing or matching requirement of the award, including any mandatory or voluntary cost-share. The amount of the award remains the same. Please attach evidence of final bus purchase price such as a copy of the dealer invoice, receipt, or canceled check Please attach Certificate of Disposal and photos verifying disposal if requesting the 35% rebate, please attach a copy of the engine certificate showing it meets CARB’s Low-NOx Standards. Requests are to be submitted by email to or by mail to: Bus Rebate Programs SD DENR – AQ Program 523 E Capitol Pierre, SD 57501