ESBD_File_328572_582-23~2.PDF

TCEQ-20970/e (06-29-23) Page 1 of 15

Application Form

Forklifts and Port Cargo Handling Equipment

Replacement, Repower, and Refueling Infrastructure Projects

Texas Volkswagen Environmental Mitigation Program (TxVEMP) Texas Commission on Environmental Quality (TCEQ)

Solicitation No. 582-23-44687-VW

If you have questions on how to fill out this project application, please contact us at (833) 215-TXVW or VWSettle@tceq.texas.gov.

Esta es la Aplicación de Subvención para el Programa de Mitigación Ambiental de Texas (TxVEMP por sus siglas en Inglés). Debe llenar y enviar esta aplicación para solicitar una subvención.

Comuníquese al 833-215-TXVW (8989) para obtener ayuda con esta solicitud.

TCEQ invites applications for the TxVEMP Grants for Replace and Repower to encourage an entity to upgrade or replace older forklifts and port cargo handling equipment with new, all-electric models.

Replacement and Repower Projects: This project application form should only be completed by applicants seeking to replace or repower forklifts and port cargo handling equipment.

Infrastructure Projects: Applicants purchasing a qualifying vehicle or piece of equipment under this grant program may request additional funding for onsite refueling infrastructure to fuel one or more of the qualifying vehicles or pieces of equipment.

Application Submission Limitations: Please be aware that applicants will be subject to application submission limitations as described in the Request for Grant Applications (RFGA). Applicants are limited to submitting no more than 10 activities in a single application, and TCEQ reserves the right to limit the award of more than 50% of a funding allocation to a single applicant. For the purposes of these limitations, applicant includes an individual or business and all of their associated legal affiliates.

Application Completeness: All applications for funding must be substantially complete and must be submitted by the application deadline. Submission of a grant application that is not substantially complete may be disqualified from consideration under this RFGA.

Application Deadline: As long as funding is available, applications will be accepted for consideration on a first-come, first-served basis during this grant period only if received by TCEQ no later than 5:00 p.m., Central Time, August 31, 2025. Please see Section 12 of this application for application submission instructions.

Key Events Date

Program Opening Date June 29, 2023

Application Submission Deadline August 31, 2025 mailto:VWSettle@tceq.texas.gov

TCEQ-20970/e (06-29-23) Page 2 of 15

Section 1: Applicant Information

1. Legal Name of Entity Applying for the Grant If selected for a grant, the legal name of the applicant will be used for contracting purposes.

Applicant Legal Name:

(must match W-9 Form)

2. Business Information All business entities such as corporations or partnerships must have an active registration with the Texas Secretary of State by June 29, 2023, 5:00 p.m. CT. Businesses must maintain an active registration for the contract period.

Ownership / Business Type:

Federal Employer Identification Number (FEI):

Social Security Number (SSN):

Individuals and Sole Proprietors

3. Authorized Official (AO) The applicant or an employee who has legal authority to sign for and speak on behalf of the entity.

AO Prefix:

AO First Name:

AO Middle Initial:

AO Last Name:

AO Suffix (If applicable):

AO Title:

AO Primary Phone Number:

AO Cell Phone Number:

AO Email Address:

AO Mailing Address (Street or PO Box):

AO City, State, and Zip Code:

4. Designated Project Representative (DPR) The applicant or an employee who will serve as the point of contact for this application.

Is the DPR the same person as the AO?

(If the DPR is the same as the AO, select Yes and continue to Section 2.

Otherwise, enter DPR information)

DPR Prefix:

DPR First Name:

DPR Middle Initial:

DPR Last Name:

DPR Suffix (If applicable):

DPR Title:

DPR Primary Phone Number:

DPR Cell Phone Number:

DPR Email Address:

DPR Mailing Address (Street or PO Box):

DPR City, State, and Zip Code:

TCEQ-20970/e (06-29-23) Page 3 of 15

Section 2: Third-Party Preparer Signature Page

1. Third-Party Preparer

A third-party preparer is someone other than the applicant or an employee of the applicant.

Was the application prepared by a third party?

2. Third-Party Preparer Certification

I hereby certify to the best of my knowledge and belief that all information provided in this application and any attachments is true and correct, as represented to me by the applicant. I understand that failure to sign the application will make this application ineligible. I understand that making a false statement may make the submitted application ineligible, may make any resulting contracts voidable, and may subject me to criminal and civil penalties.

3. Third-Party Preparer Information

Third-Party Preparer Printed Name:

(First, Last)

Title:

Company Name:

Mailing Address:

(Street or PO Box)

City:

State:

Zip Code:

Primary Phone Number:

Cell Phone Number:

Email Address:

Third-Party Preparer Signature*:

Third-Party Preparer Signature Date:

*If using an electronic signature, please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

TCEQ-20970/e (06-29-23) Page 4 of 15

Section 3: Certification of Eligibility to Receive a State-Funded Grant

All applicants must complete this section of the form to certify eligibility to receive a grant under this program, even if child support obligations do not apply to the applicant. Failure to submit this form may result in rejection of the application.

Certification Regarding Child Support Obligations.

Under Section 231.006, Texas Family Code, a child support obligor who is more than 30 days delinquent in paying child support and a business entity in which the obligor is a sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25%, is not eligible to receive a state-funded grant or loan. All applicants must include in the application the name and social security number of the individual or sole proprietor and each partner, shareholder, or owner with an ownership interest of 25% or more of the business entity submitting the application.

FEDERAL PRIVACY ACT NOTICE: This notice is given pursuant to the Federal Privacy Act. Disclosure of your Social Security Number (SSN) is required under Section 231.006(c) and Section 231.302(c)(3) of the Texas Family Code. The SSN will be used to identify persons that may owe child support. The SSN will be kept confidential to the fullest extent allowed under Section 231.302(e), Texas Family Code.

Please Check One of the Following Applicant Options (Check only one).

1. Individual or Sole Proprietor

2. One or more individuals own 25% or more of the business entity

3. No individual owns 25% or more of the business entity

4. Governmental Entity

If Option 1 or 2 is checked above, list the name(s) and social security number(s) (SSN) below.

Name Social Security Number (SSN)

Name Social Security Number (SSN)

Name Social Security Number (SSN)

Name Social Security Number (SSN)

Name Social Security Number (SSN)

By signing this application in Section 10: Project Summary Page, the applicant certifies that the individual or business entity named in this application is not ineligible to receive a grant under Section 231.006 of the Texas Family Code, and acknowledges that any contract may be terminated, and any payments withheld if this certification is inaccurate.

TCEQ-20970/e (06-29-23) Page 5 of 15

Section 4: General Certifications

This section includes specific requirements and statements for funding under the TxVEMP Grants Program. These terms apply to any contract awarded by TCEQ from this application. The TxVEMP Grants Program RFGA and the draft contract, located on the TxVEMP Grants Program webpage, contain additional terms and conditions that the applicant should review before submitting an application.

By signing this application, you understand and certify compliance with all the statements below, as well as with any state statutes, regulations, policies, guidelines, and requirements as they relate to the application, acceptance, and use of funds for this project. If any of these certifications materially change after submittal of the application, you will provide prompt written notification to TCEQ within three (3) business days of becoming aware of the change. Failure to notify TCEQ and/or any changes to your certifications may make the application ineligible and may make any resulting contracts voidable.

1. Legal Authority. The applicant has the legal authority in the State of Texas to apply for the grant. The applicant's governing body has authorized the filing of the application, understands these requirements and certifications, and has authorized the person identified as the Authorized Official to act in connection with the application and to provide such additional information as may be required.

2. If awarded a grant, the applicant certifies that it will provide written notification to TCEQ within 30 calendar days of any termination of use, change in use, sale, transfer, or accidental or intentional destruction of grant-funded vehicles during the activity life. The applicant further agrees that TCEQ may be entitled to the return of all or a prorated share of the grant funds for any loss of emissions reductions compared with the emissions reductions projected in awarding the grant.

3. Texas Grant Management Standards. In accordance with Chapter 783, Texas Government Code, if the applicant is a local government, state entity, or political subdivision, it will comply fully with the Texas Grant Management Standards (TxGMS). This includes compliance with the relevant sections of TxGMS when procuring goods and services under a resulting contract. For all other applicants, the selected items of cost of TxGMS apply to any resulting contract. The document is available at: Comptroller - Grant Management

4. Procurement of Goods and Services. If this application results in a contract, all procurement transactions made with (or to be reimbursed by) grant funds must be conducted in a manner providing full and open competition. All purchase decisions must be based on sound business decisions and arm’s length bargaining. Purchases must be made without any real or apparent personal or organizational conflicts of interest as described in TxGMS.

5. Conflict of Interest. The applicant has not given, offered to give, nor intends to give any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted application. All purchase decisions must be based on sound business decisions and arm’s length bargaining.

6. Nondiscrimination. The applicant will comply with all State and Federal statutes relating to nondiscrimination.

7. Grant Administration. The applicant will maintain an appropriate grant administration system to ensure that they meet all terms, conditions, and specifications of the grant, including these certifications and assurances.

8. Audit. Acceptance of funds under this program acts as acceptance of the authority of the State Auditor’s Office, or any successor agency, to conduct an audit or investigation in connection with those funds. The applicant or other entity that may receive funds directly or indirectly from TCEQ must provide the state auditor with access to any information the state auditor considers relevant to the investigation or audit. Applicant will include this clause concerning the authority to audit funds received indirectly and the requirement to cooperate in any subcontract it awards.

9. Debt to the State. The applicant is not indebted to the state nor has an outstanding tax delinquency. The applicant must comply with all State and Federal tax laws and fee requirements and is solely responsible for filing all State and Federal tax and fee forms.

10. Contract. The applicant understands that a PDF of the draft contract may be viewed and downloaded from the

TxVEMP Grants webpage. The draft contract is for reference only and contains terms and conditions which are standard provisions for grants awarded under this program. Any requested changes to the draft contract must be received by TCEQ no later than the date of the submission of this application. However, the applicant further understands that TCEQ will not normally change the contract language in response to individual requests from grant recipients, is under no obligation to do so, and requests for changes will delay any resulting contract. TCEQ reserves the right to modify the draft contract terms as necessary due to statutory, rule, or policy changes. Modifications will be posted to the TxVEMP Grants webpage and the Electronic State Business Daily.

11. Contracting with an Executive of a State Agency. Under Texas Government Code Section 669.003, relating to contracting with an executive head of a state agency, applicant represents that no person who, in the past four years, served as an executive of TCEQ or any other state agency, was involved with or has any interest in this application. If applicant employs or has used the services of a former executive head of TCEQ or other state agency, the applicant shall provide the following information: name of former executive, name of state agency, date of separation from state agency, position with applicant, and date of employment with applicant.

https://www.tceq.texas.gov/agency/trust/all-electric https://www.comptroller.texas.gov/purchasing/grant-management/ https://www.tceq.texas.gov/agency/trust/all-electric https://www.tceq.texas.gov/agency/trust/all-electric

TCEQ-20970/e (06-29-23) Page 6 of 15

12. Debarment. The applicant certifies that the applying entity and its principals are eligible to participate in this transaction and have not been subjected to suspension, debarment, or similar ineligibility determined by any federal, state, or local governmental entity. The applicant also certifies that it and its principals are not listed on the State of Texas Debarred Vendor List maintained by the Texas Comptroller of Public Accounts, or the System for Award Management (SAM) maintained by the General Services Administration as authorized by Executive Order No. 13224, “Blocking Property and Prohibiting Transactions with Persons Who Commit, Threaten to Commit, or Support Terrorism,” published by the U.S. Department of Treasury, Office of Foreign Assets Control.

13. Abortion Funding Limitation. The applicant represents and warrants it is not an abortion provider or an affiliate of an abortion provider under Texas Government Code, Chapter 2273, Prohibited Transactions.

14. COVID-19 Vaccine Passport Prohibition. Under Section 161.0085 of the Texas Health and Safety Code, the applicant certifies that it is not ineligible to receive funds.

15. If the applicant is a governmental entity, it represents and warrants that it will comply with Section 2252.906 of the Texas Government Code relating to disclosure protections for certain charitable organizations, charitable trusts, and private foundations.

TCEQ-20970/e (06-29-23) Page 7 of 15

Section 5: Program Certifications

Replacement and Repower Project Certifications

For each vehicle category selected in Section 6, the following certifications apply. By signing this application, you are certifying the applicable eligibility requirements listed herein.

Non-Road equipment eligible for grant-funding must:

a) Be certified to emit at least 25% less nitrogen oxides (NOX) than the old equipment;

b) Have an electric engine (including hydrogen fuel cells and battery-electric vehicles);

c) Have an engine model year no more than one year older than the calendar year in which the equipment was purchased; and

d) Be of the same type and intended for the same use in the same application or vocation.

Unless the vocational type of the new vehicle is exempt from registration requirements, the vehicle must be registered for operation in Texas.

A waiver may be submitted for any ownership, registration, and use requirements pursuant to Appendix B in the RFGA.

Refueling Infrastructure Project Certifications

This Section must be completed by applicants requesting grant funds for refueling infrastructure.

1. Site Ownership

Applicants are required to be the owner of the site where the equipment is installed unless the applicant establishes permission to install and operate the grant-funded equipment at the site during the activity life. The information below must be completed if the applicant does not own the site where the equipment will be installed, and the applicant and site owner must provide their signatures.

Is the Applicant the Property Owner?

If not, the property owner must provide their name, title, and signature below.

Property Owner Name:

Title:

I, the undersigned owner of the real property located at the address identified in Section 7. Project Location below, consent to the installation of the refueling infrastructure on this property. I understand and agree that the applicant listed above is obligated, unless otherwise approved by TCEQ, to keep the refueling infrastructure in operation and in service for the duration of the activity life.

Signature*: Date:

*Please complete the entire application before signing electronically. The ability to edit, add, or remove information will not be available after the application is electronically signed.

2. Refueling Infrastructure Equipment Ownership

By signing this application, the applicant certifies that it will purchase and own the grant-funded equipment during the contract period and throughout the activity life subject to the following: Any sale of the grant-funded equipment during the activity life will be subject to approval and consent to assignment by TCEQ in accordance with the contract terms.

TCEQ-20970/e (06-29-23) Page 8 of 15

Section 6: Vehicle / Equipment Information Activity Number ___ An activity represents the individual replacement or repower of a vehicle.

Click here for additional pages ____

Applicants may include up to 10 activities on a single application.

This project application form should be completed by applicants seeking to replace or repower forklifts and port cargo handling equipment. When determining the requested grant amount, applicants should refer to Section 3 of the RFGA to determine the maximum grant amount and eligible costs. Applicants may receive up to the lesser of the following options: 1) The grant amounts shown in the TxVEMP Grant Tables; or 2) 100% of the incremental cost for government entities or 75% of the incremental cost for non-governmental entities.

1. Old Vehicle / Equipment Information

Vehicle / Equipment Type:

Vehicle / Equipment Identification Number:

(For non-road, list the entire ID number; for on-road, enter only the last four digits of the VIN)

Vehicle / Equipment Make:

Vehicle / Equipment Model:

Vehicle / Equipment Model Year:

Gross Vehicle Weight Rating (GVWR):

(On-Road Only)

Engine Make:

Engine Model:

Engine Identification Number:

Engine Model Year:

Engine Horsepower Rating (bhp/hr):

(Non-Road Equipment only)

Fuel Type:

Engine Family Code:

(12-digit emissions code required for engines 2003 and newer)

Federal NOX Emissions (g/mi or g/bhp-hr):

2. Qualifying Vehicle / Equipment to be Purchased with Grant Funds

Vehicle / Equipment Type:

(The new vehicle/equipment type must be the same as the old vehicle/equipment type above)

Vehicle / Equipment Year:

(For on-road, the vehicle model year must be no more than 1 year older than the calendar year in which it was purchased)

Engine Year:

(For non-road, the equipment’s engine model year must be no more than 1 year older than the calendar year in which the equipment was purchased)

Fuel Type:

(Choose new vehicle / equipment fuel type from the dropdown list)

Federal NOX Emissions (g/mi or g/bhp-hr): 0.00

Requested Grant Amount:

TCEQ-20970/e (06-29-23) Page 9 of 15

Section 7: Refueling Infrastructure (optional)

This Section must be completed by applicants who are requesting grant funds to purchase and install refueling infrastructure for qualifying alternatively fueled vehicles or equipment detailed in Section 6 of this application. At least one qualifying vehicle or piece of equipment must operate on the fuel type selected in Part 1 of this Section. All grant-funded refueling infrastructure must be owned and operated by the applicant; leased equipment is not eligible.

1. Fuel Type and Information

Select the fuel type from the dropdown menu:

What is the charge rate (kW) or throughput rate (kg/day) of the refueling infrastructure?

Charge Rate of Refueling Infrastructure:

Charge Rate Unit of Measure:

2. Project Location

Please list the location of the proposed refueling infrastructure project

Physical Address:

City:

State:

Zip Code:

County:

3. Project Details

Please briefly describe the proposed refueling infrastructure project below. Be sure to describe how this refueling infrastructure will support, at the very least, the qualifying vehicles or equipment detailed in this application. If this project will expand existing refueling infrastructure, please indicate this as well.

4. Required Documentation

Applicants with projects that include refueling infrastructure must provide documentation that includes:

a) a site plan with the application (including a scaled map which could be a photograph, satellite map, drawing, or similar graphic of the proposed site) that shows the planning and design of the proposed facility. The site plan must:

i. demonstrate how the vehicle or equipment may access the proposed facility; and

ii. provide the location of the facility within the property and include any easements, set-back requirements, and property boundaries.

b) a demonstration of the applicant’s ability to install, operate and maintain the refueling infrastructure at the proposed site by providing documentation, such as property ownership records, lease agreements or other legal agreements, that can show the following:

i. the ability to complete any required construction on the proposed site; and

ii. the ability to operate on the proposed property for at least 5 years from the date the application is signed.

TCEQ-20970/e (06-29-23) Page 10 of 15

5. Infrastructure Grant Amount

Please indicate the projected costs and requested grant amount in the space provided below. Refer to Section 3 of the RFGA to determine the maximum grant amount and eligible costs.

Applicants may receive up to the maximum reimbursement rate by entity type as listed below:

a) Governmental entities may request up to 100% of the incremental cost of the project.

Governmental entities include a state or local government agency (including school district, municipality, city, county, special district, joint powers authority, or port authority owning fleets purchased with government funds), and a tribal government or native village. A federal government agency or entity is not included in this definition and will be considered a private entity for this grant program.

b) Non-governmental entities may request up to 75% of the incremental cost of a project.

Equipment Total:

Supplies and Materials Total:

Construction Total:

Contract Services Total:

Total Incremental Project Costs:

Refueling Infrastructure Grant Amount (based on a or b):

TCEQ-20970/e (06-29-23) Page 11 of 15

Section 8: Operation of Grant-Funded Equipment Activity Number An activity represents the purchase of a single vehicle or piece of equipment.

Click here for additional pages ____

For replacement and repower projects, not less than 51% of the grant-funded vehicle or equipment annual operation must occur in one of the Priority Area and affected counties for the duration of the five-year activity life. A single unit of measurement (miles, hours, or fuel) must be used for determining the total annual operation. If awarded a grant, the grantee will use this unit of measurement to report annual usage for the duration of the five-year activity life.

Activity Unit of Measurement:

Is the Unit of Measurement and the Percent of Annual Operation the same for all activities?

If the unit of measurement and the percent of annual operation are the same for all activities in this application, complete only one copy of Section 8, and proceed to Section 9: Disposition of Vehicle, Equipment and Engine Being Replaced.

Otherwise, complete one copy of Section 8 for each activity.

In the table below, identify the areas where the grant-funded vehicle or equipment will operate and provide the percent of annual operation in the space provided. Not less than 51% of the annual operation of each grant-funded vehicle or equipment must occur in one Priority Area. Refer to Section 2.8 of the RFGA for usage requirements. Refer to Appendix A of the RFGA to see a map of the Priority Areas.

Priority Areas Percent of Operation

Austin Area:

Bastrop, Caldwell, Hays, Travis, and Williamson Counties

Beaumont-Port Arthur Area:

Hardin, Jefferson, and Orange Counties

Dallas-Fort Worth Area:

Collin, Dallas, Denton, Ellis, Hood, Johnson, Kaufman, Parker, Rockwall, Tarrant, and Wise Counties

El Paso Area:

El Paso County

Houston-Galveston-Brazoria Area:

Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and

Waller Counties

San Antonio Area:

Bexar, Comal, Guadalupe, and Wilson Counties

Other Eligible Counties:

Bell County

Total % of Annual Operation:

The total amount must be at least 51%, but cannot be more than 100%

TCEQ-20970/e (06-29-23) Page 12 of 15

Section 9: Disposition of Vehicle, Equipment, and Engine Being Replaced

If selected for a grant, the old non-road vehicles and engines being replaced must be destroyed and rendered permanently inoperable (commonly referred to as disposition) before reimbursement payment will be issued by TCEQ. Refer to Section

4.6 of the RFGA.

1. Method of Disposition. Mark the proposed method of disposition below.

Standard Destruction: Complete destruction or otherwise rendering permanently inoperable by crushing the vehicle or equipment and engine or cutting a 3-inch or larger hole on both sides of the engine block and cutting both frame rails in half. If the proposed method of disposition is Standard Destruction, mark the box to the right and continue to Section 10.

Alternative Destruction: TCEQ may consider alternative methods of rendering the vehicle, equipment, or engine permanently inoperable in lieu of the standard method of destruction. If the proposed method of disposition is Alternative Destruction, check the box to the right and complete Sections 2 and 3 below.

2. Alternative Destruction. If the applicant is proposing an alternative method of destruction in lieu of the standard method of destruction outlined in Section 4.6 of the RFGA, please explain the alternative method of destruction in the space provided below.

3. Activities Selected for Alternative Destruction.

Alternative Destruction: Does the alternative destruction apply to all vehicles, equipment, and engines listed in this application?

If No, list the activity numbers for which the proposal applies:

TCEQ-20970/e (06-29-23) Page 13 of 15

Section 10: Project Summary Page

1. Applicant Information

Applicant Legal Name:

Applicant Type:

Applicant Mailing Address:

(Street or PO Box)

Applicant City:

Applicant State:

Applicant Zip Code:

2. Project Information

Primary Project Area:

Emission Source:

Project Type:

Total Number of Activities in this Application:

(This number should match the number of Section 6 forms)

Total Eligible Costs of Project:

(Enter Requested Grant Amount from Section 6)

Total Requested Grant Amount:

(Total requested grant amount of all activities from Section 6, plus Total Infrastructure Grant Amount from Section 7 if applicable)

3. Authorized Official

The applicant or an employee of the applicant who has the legal authority to sign on behalf of the entity.

I hereby certify to the best of my knowledge and belief that all information provided in this application and any attachments is true and correct, including any representations made by a third-party preparer. My signature also constitutes acceptance of the certifications in Sections 4 and 5 of this application, the terms of the RFGA, and any other changes posted through addenda on the Electronic State Business Daily. I understand that failure to sign the application will make this application ineligible. I understand that making a false statement may make the submitted application ineligible, may make any resulting contracts voidable, and may subject me to criminal or civil penalties.

Printed Name of Authorized Official:

Authorized Official Title:

Signature of Authorized Official*:

Date of Signature:

The application, signed by the Authorized Official, must be received by the application deadline or the application will not be accepted.

Upon submission, all proposals become the property of the State of Texas and as such become subject to the Texas Public Information Act, Texas Government Code Chapter 552.

Personal Information Policy: Individuals are entitled to request and review their personal information that the agency gathers on its forms. Individuals may request to have their provided personal information updated. To review such information, contact TxVEMP program staff at (833) 215-TXVW or VWSettle@tceq.texas.gov.

*If using an electronic signature, please complete the entire application before signing electronically. The ability to add, edit, or remove information will not be available after the application is electronically signed.

mailto:VWSettle@tceq.texas.gov

TCEQ-20970/e (06-29-23) Page 14 of 15

Section 11: Application Checklist

All applications for funding must be substantially complete and must be submitted within the application submission period listed on the cover page of the RFGA. Submission of a grant application that is not substantially complete will disqualify the applicant from receiving a grant under this RFGA. A substantially complete application must include:

• all pages of the application;

• all required attachments;

• applicant’s contact information;

• all required signatures; and

• all information necessary for TCEQ to review the application for selection according to the program requirements listed in the RFGA.

Application Section Checklist (All Applications)

Section 1: Applicant Information Please fill out entirely.

Section 2: Third-Party Preparer Signature Page Please fill out entirely if application was prepared by a third party. Signature Required.

Section 3: Certification of Eligibility Please fill out entirely.

Section 4: General Certifications Please read and include with application.

Section 5: Program Certifications Please read and include with application. Signature Required (if requesting infrastructure).

Section 6: Vehicle / Equipment Information Please fill out entirely.

Section 7: Refueling Infrastructure (Optional) Please fill out entirely (if applicable).

Section 8: Operation of Grant-Funded Equipment (Percent of Annual Usage)

Please fill out entirely.

Section 9: Disposition Please fill out entirely.

Section 10: Project Summary Page Please fill out entirely. Signature Required.

Section 11: Application Checklist Please fill out entirely and include with application.

Section 12: Application Submission Instructions Please read important submission instructions.

Required Attachments Checklist (All Applications)

W-9 Form Please download, fill out entirely, and include with application. Signature Required.

Copy of State or Federal Identification Card Include only if applying as an Individual or Sole Proprietor.

Copy of Registration Documents for Vehicle(s) Being Replaced or Repowered (on-road only)

Please include registration documents for the 12 months immediately preceding the application signature date.

Copy of Title of Vehicle(s) Being Replaced or Repowered (on-road only)

Please include proof of ownership for the 2 years immediately preceding the application signature date.

Color Photographs of Vehicle, Equipment, or Engine Being Replaced

Please attach color photographs of the front, right side, left side, rear, engine, and engine data plate of the vehicle, equipment, and engine being replaced. Photographs of the vehicle and equipment should include tires or tracks.

Required Refueling Infrastructure Attachments Checklist (Applications with Refueling Infrastructure)

Site Plan Include with the application

Site Property Rights or Ownership Documentation

Include with the application

Supplemental Forms (if applicable)

Supplemental Form 1: Waivers of Program Requirements

Please fill out entirely (if applicable) and include with application. Signature Required.

https://www.irs.gov/pub/irs-pdf/fw9.pdf

TCEQ-20970/e (06-29-23) Page 15 of 15

Section 12: Application Submission Instructions

Electronic Application Submissions

Applications will be accepted for consideration during this grant period only if received by TCEQ via electronic mail (email) at VWsettle@tceq.texas.gov or via mail, no later than 5:00 p.m., Central Time, on the application submission deadline listed on the cover page of this application. Applications may be submitted electronically using one of the methods listed below. It is preferable that the application and its attachments be submitted as a single PDF. If the attachments for an application will be submitted as separate files, each attachment must be grouped by activity and clearly labeled with the activity number at the top of each page.

1) Submitting Applications via Email. For applications that are submitted via email to VWSettle@tceq.texas.gov, please use the following naming convention for your application file in the subject line: “FY23 TxVEMP and [your legal name].” Only one application may be submitted per email at a maximum total file size of 25MB.

2) Submitting Applications via TCEQ’s FTPS Server. If the application is larger than 25MB, please submit by uploading the file to TCEQ’s file transfer protocol secure (FTPS) server and selecting the share file(s) button. Enter VWSettle@tceq.texas.gov as the email address. Detailed directions for using TCEQ’s FTPS Server can be found at TCEQ’s FTPS Help. Please note:

Applications uploaded to TCEQ’s FTPS server without completing the share file(s) step will not be considered as submitted. See detailed instructions on how to share files via TCEQ’s FTPS server.

Physical Application Submissions

Applications may also be submitted by mailing a physical copy to one of these addresses:

Standard Mail:

Texas Commission on Environmental Quality Air Grants Division (TxVEMP), MC-204 P.O. Box 13087 Austin, TX 78711-3087

Express Mail:

Texas Commission on Environmental Quality Air Grants Division (TxVEMP), MC-204 12100 Park 35 Circle, Building F, 1st Floor, Suite 1301 Austin, TX 78753 mailto:VWSettle@tceq.texas.gov https://ftps.tceq.texas.gov/ mailto:VWSettle@tceq.texas.gov https://ftps.tceq.texas.gov/help/ https://ftps.tceq.texas.gov/help/#share