ALL INFORMATION MUST BE PRINTED

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                                                  DEPARTMENT OF ENERGY
                                                REQUEST FOR REIMBURSEMENT
                                                   VEHICLE- NEW (CFDA #81.086)
ALL INFORMATION MUST BE PRINTED OR TYPED.                                                     RRC Invoice # ________
                                                                                              Tax ID # ____________
 SUBGRANTEE INFORMATION

 Business Name:                                             Street:


 City:                          State: Texas                Zip:


 RTI #: (state agencies only)                               Propane Supplier: Various


 Printed Name of Contact Person:                            Title:                            Telephone No:


 Email:                                                     FAX No :




 NEW VEHICLE INFORMATION

 PHYSICAL ADDRESS OF VEHICLE:


 City:                 State:            ZIP:                           County :


 Manufacturer:                           Model #:                       Model Year:


 Engine Make: Ford                       Engine Model:                  VIN # see list


 Invoice Total: $                        Invoice #                      Date Paid:                Reimbursement Amount:




 VENDOR INFORMATION

 VENDOR NAME:                                            Street:


 City:                                                   State: TEXAS                     ZIP:



 Printed/Typed Name of Contact Person:                                        Telephone No.




revised 3/16/11                                               1
                                              DEPARTMENT OF ENERGY
                                            REQUEST FOR REIMBURSEMENT
                                               VEHICLE- NEW (CFDA #81.086)
I have read and understand the following:
a. The applicant agrees to maintain sufficient property insurance for the equipment and use any proceeds due to
damage or destruction of equipment to acquire an equivalent or better vehicle.
b. The applicant agrees to keep the equipment in good operating condition and to maintain it per manufacturer’s
recommendations.
c. The applicant will notify the Railroad Commission of Texas of any termination of use, change in use, sale, transfer,
or destruction of grant funded equipment, or change in use of fuel, during the activity life. The applicant further agrees
that, during the activity life, the Commission retains the right to require funds be returned if the equipment is not used
in accordance with the grant provisions.
d. The applicant agrees to maintain and preserve all financial, contractual, and applicable program records at a
location in Texas for a period of four years after the end of the life of all activities funded under the grant. It will give the
Railroad Commission of Texas, the Department of Energy and/or the State Auditor, through any authorized
representative, access to examine all records, books, papers, or documents related to the grant.
e. I affirm that adequate maintenance procedures have been developed to keep the property in good condition and
that a control system is in place to ensure adequate safeguards to prevent loss, damage or theft of the property.




Signature of Authorized Person: _______________________________________________________


Title of Authorized Person: _________________________________________Date: _____________




Checklist:
Please confirm these items are included with your application.

     Original completed DOE Grant Vehicle- New Request for Reimbursement (this form). (MUST include ORIGINAL
      signatures.) Including Terms and Conditions of operation as outlined in Grant Subcontract. Note must be
      reviewed by RRC legal.

     Invoice from your organization (indictating paid by your entity, check #, date of payment)

     Copy of payment check

     Receiving/Acceptance Document

Other Federal Grants Received for this Equipment?         Yes       No 

If Yes, please explain___________________                       How much? __________________


RRC Only:
Reviewed by:                                                                   RETURN TO:
(please initial and date)                                              Railroad Commission of Texas
                                                              Alternative Fuels Research & Education Division
______________                                                    P.O. Box 12967 • Austin, TX 78711-2967


______________

revised 3/16/11                                                  2

				
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