Request for Reimbursement Form Name of School District: Date new school bus was delivered: Fill in the information to summarize the Reimbursement Request. Instructions: Reimbursement Summary Final Purchase Price of Bus $ Reimbursable Amount (not to exceed awarded amount) = $ Purchase Price X percentage from award *Program Income from Salvage/Scrappage $ Total Reimbursement Amount $ *If scrapped or salvaged engines/vehicles are to be sold, program income requirements apply. 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 to DENR at: Clean Diesel Rebate Program SD DENR AQ Program – 523 E Capitol Pierre, SD 57501
Request for Reimbursement Form Name of School District: Date new school bus was delivered: Instructions: Fill in the information to summarize the Reimbursement Request. Reimbursement Summary Final Purchase Price of Bus $ Reimbursable Amount (not to exceed awarded amount) = Purchase Price X percentage from award $ *Program Income from Salvage/Scrappage $ Total Reimbursement Amount $ *If scrapped or salvaged engines/vehicles are to be sold, program income requirements apply.  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 to DENR at: Clean Diesel Rebate Program SD DENR – AQ Program 523 E Capitol Pierre, SD 57501
R10RequestForReimburse.docx