ESBD_File_343776_582-24-50564-HD THIVE Replace Repower Conversion App FINAL.pdf

Project Application Form Replacement, Repower, and Conversion Projects

Texas Hydrogen Infrastructure, Vehicle, and Equipment Grant Program (THIVE)

Texas Commission on Environmental Quality (TCEQ) Texas Emissions Reduction Plan (TERP)

Solicitation No. 582-24-50564-HD

Esta es la aplicación de subvención para el Programa de Subsidios de Infraestructura, Vehículos y Equipos de Hidrógeno de Texas (THIVE por sus siglas en Inglés). Debe llenar y enviar esta aplicación para solicitar una subvención. Comuníquese al 800-919-TERP (8377) para obtener ayuda con esta solicitud.

TCEQ invites applications for the THIVE Grant Program. THIVE provides funding to offset the cost of adopting hydrogen infrastructure, vehicles, and equipment to reduce Nitrogen Oxide (NOx) emissions from high-emitting sources in Texas nonattainment areas and affected counties.

Replacement, Repower, and Conversion Projects: This project application should only be completed by applicants seeking to replace, repower, or convert heavy-duty on-road or non-road vehicles and equipment using hydrogen power technology.

Application Submission Limitations: Applicants may be subject to application submission limitations as defined in Section 4.1 d) of the RFGA. For the purposes of these limitations, “applicant” includes an individual or business and all of their associated legal affiliates.

Application Completeness: TCEQ will review applications for completeness. If an application is found to be incomplete, TCEQ will notify the applicant in writing and provide details about what is missing from the application. Applicants will be provided a deadline to submit the missing information to TCEQ.

Public Information Notice: Upon submission, all proposals become the property of the State of Texas and subject to the Texas Open Records Act, Texas Government Code, Chapter 552.

How to Submit an Application: If you have questions on how to fill out this form, please contact us at 1-800-

919-TERP (8377).

1. Applicants may include up to 10 activities on a single application. Applicants must submit separate applications for different project types (replacement, repower, or conversion), and must submit separate applications for on-road and non-road project categories.

2. Submit a completed and signed application form and the required attachments by emailing to THIVE- Apply@tceq.texas.gov, uploading to TCEQ’s File Transfer Protocol Secure (FTPS) site, or submitting the application and associated documents by mail. All applications must be received by TCEQ no later than 5:00 p.m. Central Time, February 27, 2024. Please note: submission via standard email may not be secure. Use TCEQ’s FTPS site to submit your application securely. Learn how to create an account and submit your application via FTPS (FTPS: A Step-by-Step Video Guide).

Key Events Date and Time

Program Opening Date November 29, 2023

Application Submission Deadline February 27, 2024

TCEQ-20976/a (Nov. 2023) Page 1 of 14 mailto:THIVE-Apply@tceq.texas.gov mailto:THIVE-Apply@tceq.texas.gov https://www.tceq.texas.gov/airquality/terp/thive https://www.tceq.texas.gov/airquality/terp/thive https://www.youtube.com/watch?v=GW4eEe_uUwc

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 November 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:

Individuals and Sole Proprietors only

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

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 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:

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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. If a third-party preparer was not used in the preparation of an application, select “No” from the dropdown list and proceed to Section 3.

Was this 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, including 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 cause the submitted application to be 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 Signature Date:

*If using an electronic signature instead of a typed 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.

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Section 3: Certification of Eligibility to Receive a State-Funded Grant All applicants must complete this section to certify eligibility to receive a grant under this program, even if child support obligations do not apply to the applicant. Failure to complete this section 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) of the Texas Family Code.

Please Check One of the Following Applicant Options.

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) below.

Name Social Security Number

Name Social Security Number

Name Social Security Number

Name Social Security Number

Name Social Security Number

Applicant Certification By signing this application in Section 11: Project Summary Page, under Section 231.006, of the Texas Family Code, the applicant certifies that the individual or business entity named in this application is not ineligible to receive the specified grant and acknowledges that any contract may be terminated, and any payments may be withheld if this certification is inaccurate.

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Section 4: General Certifications This section includes specific requirements and statements for funding under the THIVE Grant Program. These terms apply to any contract awarded by TCEQ from this application. The THIVE Grant Program RFGA and the draft contract, located on the THIVE Grant 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 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. 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.

3. 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.

4. 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.

5. 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.

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

7. Risk Review. The applicant’s prior performance under other TCEQ contracts; its overall compliance history; and any federal, state, or local enforcement action for violation of environmental laws or permit conditions may be considered in determining eligibility.

8. Texas Public Information Act. Information, documentation, and other material in connection with this solicitation or any resulting contract or grant may be subject to public disclosure pursuant to Chapter 552 of the Texas Government Code. In accordance with Section 252.907 of the Texas Government Code, applicant is required to make any information created or exchanged with the State pursuant to the contract and grant, and not otherwise excepted from disclosure under the Texas Public Information Act, available in a format that is accessible by the public at no additional charge to the State.

9. 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.

10. 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.

11. Disclosure Protections for Certain Charitable Organizations. 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.

12. Contract. The applicant understands that a PDF of the draft contract may be viewed and downloaded from the THIVE 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 and is under no obligation to do so.

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 THIVE webpage and the Electronic State Business Daily.

TCEQ-20976/a (Nov. 2023) Page 5 of 14 https://www.tceq.texas.gov/airquality/terp/thive https://www.tceq.texas.gov/airquality/terp/thive

a. 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.

b. 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. These documents are available at: https://www.comptroller.texas.gov/purchasing/grant-management/.

c. 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, and purchases must be made without any real or apparent personal or organizational conflicts of interest as described in TxGMS.

d. Grant Administration. The applicant will maintain an appropriate grant administration system to ensure that all terms, conditions, and specifications of the grant, including these certifications, are met.

e. Audit. Acceptance of funds under this program acts as acceptance of the authority of the State Auditor’s Office (SAO), 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 SAO with access to any information the SAO 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.

TCEQ-20976/a (Nov. 2023) Page 6 of 14 https://www.comptroller.texas.gov/purchasing/grant-management/ https://www.comptroller.texas.gov/purchasing/grant-management/

Section 5: Program Certifications

Replacement, Repower, and Conversion Project Certifications For the vehicle or equipment category selected in Section 8, the following certifications apply. By signing this application, you are certifying that you meet the applicable eligibility requirements below.

An on-road vehicle eligible for replacement, repower, or conversion must:

a) Be a heavy-duty on-road vehicle with a gross vehicle weight rating (GVWR) of 8,501 pounds (lbs.) or greater and is certified to or has an engine certified to the United States (US) Environmental Protection Agency (EPA) heavy-duty engine emissions standards.

b) Have been owned, leased, or otherwise commercially financed and registered and operated by the applicant in Texas for at least the two years immediately preceding the application signature date;

c) Have been used in its primary function in the routine operations of the applicant in Texas for at least the two years immediately preceding the application signature date; and

d) Be in good operating condition.

Non-road equipment eligible for replacement, repower, or conversion must:

a) Be a heavy-duty non-road piece of equipment powered by an engine rated at 25 horsepower (hp) or greater and certified to the applicable US EPA non-road emissions standards;

b) Have been continuously owned, leased, or otherwise commercially financed and operated by the applicant in Texas for at least the two years immediately preceding the application signature date;

c) Have been used in its primary function in the routine operations of the applicant in Texas for at least the two years immediately preceding the application signature date; and

d) Be in good operating condition.

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

TCEQ-20976/a (Nov. 2023) Page 7 of 14

Section 6: Application Score Tie-breaking Provisions Tie-breaking provisions – In the event of a tied score, the following will be used as tiebreakers in no order of preference.

Please select all that are applicable and include documentation as an attachment to the application:

� Applicant is (or is owned by) a service-disabled veteran who is a Texas resident. (Tex. Gov. Code 2155.444).

� Applicant is a Texas bidder meaning it is incorporated in this state; has its principal place of business in this state;

or has established a physical presence in this state. (Tex. Gov. Code 2155.444).

� Applicant will use USA-produced supplies, materials, or equipment in fulfilling its grant obligations. (Tex. Gov.

Code 2155.444).

� Applicant is a Historically Underutilized Business (Tex. Gov. Code 2155.505).

� Applicant is a Women-Owned Small Business as defined by the of the United States Small Business Administration.

� Applicant is a Veteran-Owned Small Business or Service-Disabled Veteran-Owned Small Business.

� Applicant is a Disadvantaged Business Enterprise (DBE) as defined by the United States Department of Transportation.

� Applicant is a Small Business Concern as defined by the regulations of the United States Small Business Administration in 13 C.F.R. Section 121.201. (Tex. Gov. Code 2155.505).

� Applicant will use products made of recycled, remanufactured, or environmentally sensitive materials in fulfilling its grant obligations. (Tex. Gov. Code 2155.445).

� Applicant will purchase and use energy efficient products in fulfilling its grant obligations. (Tex. Gov. Code 2155.442).

� Applicant will purchase and use products made by persons with disabilities in fulfilling its grant obligations. (Tex.

Gov. Code 2155.441).

� Facility will be located on formerly contaminated property. (Tex. Gov. Code 2155.450).

� Facility will be in an economically depressed or blighted area. (Tex. Gov. Code 2155.449, 2306.004).

� None of the above.

TCEQ-20976/a (Nov. 2023) Page 8 of 14

Section 7: Calculate Your Requested Grant Amount

Activity Number _____ An activity represents the individual replacement, repower, or conversion of a vehicle or piece of equipment.

Click here for additional pages ____ Applicants may include up to 10 activities on a single application.

Activity Incremental Cost Calculations Applicants will choose their requested grant amount, up to the maximum amounts described in Section 3.2 of the RFGA.

For replacement, repower, and conversion projects, applicants may request up to 100% of the incremental cost associated with the grant-funded vehicle or equipment.

In the table below, complete Steps A through D to calculate the activity incremental cost. In Step E, enter the requested grant amount, not to exceed the incremental cost listed in Step D. Applicants must submit a detailed price quote, invoice, purchase order, or other price estimate prepared by the vehicle or equipment manufacturer or dealer with the grant application. Refer to your detailed price quote to calculate the total eligible costs of the vehicle or equipment and list the amount in the space provided for Step A. Activity costs paid prior to September 1, 2023, are not eligible.

Total Eligible Costs of the Grant-Funded Vehicle or Equipment (A):

Total eligible costs include: Invoice costs of the qualifying vehicle, engine, or conversion system, including taxes and government fees, delivery and shipping fees, factory and/or extended warranties, service contracts, mechanic and safety inspections, cooperative fees, and dealer processing fees not related to financing. List the total eligible costs from the detailed price quote.

Refer to Section 3.4 of the RFGA.

(minus) Scrap Value (B):

($1,000 for replacement projects, $250 for repower projects).

Refer to Section 3.2 of the RFGA (minus) Other Financial Incentives and Tax Credits (C):

Refer to Section 3.3 of the RFGA

(equals) Incremental Cost (D):

(A – B – C = D).

Refer to Section 3.2 of the RFGA

Requested Grant Amount (E):

Enter the requested grant amount here and in the space provided in Section 8.6 below. The requested grant amount cannot exceed the Incremental Cost listed in Step D above.

TCEQ-20976/a (Nov. 2023) Page 9 of 14

Section 8: Vehicle / Equipment Information Activity Number ___ An activity represents the individual replacement, repower, or conversion of a vehicle or piece of equipment.

Click here for additional pages ___ Applicants may include up to 10 activities on a single application.

1. Project Type – Replacement, Repower, or Conversion Applicants must submit separate applications for different project types.

Select the appropriate project type.

2. Vehicle or Equipment Category – On-Road or Non-Road

Applicants must submit separate applications for on-road and non-road project categories.

Select either on-road or non-road.

3. Old Vehicle or Equipment Information

Vehicle or Equipment Type:

(i.e., haul truck, forklift, etc.)

Vehicle or Equipment Identification Number:

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

Vehicle or Equipment Make:

Vehicle or Equipment Model:

Vehicle or Equipment Model Year:

Gross Vehicle Weight Rating (GVWR) – On-Road Vehicles Only:

Engine Make:

Engine Model:

Engine Identification Number:

Engine Model Year:

Engine Horsepower Rating (bhp/hr) – Non-Road Equipment only:

Fuel Type:

(Select the fuel type of the old equipment from the dropdown list) Engine Family Code:

(12-digit emissions code required for on-road and non-road engines, 2003 and newer) Federal NOX Emissions (g/bhp-hr):

4. Qualifying Equipment to be Purchased or Leased with Grant Funds Vehicle or Equipment Type:

(Must be the same as the old vehicle or equipment type listed above) Vehicle or Equipment Year:

(For on-road, must be no more than 3 years older than the calendar year in which purchased) GVWR – On-Road Vehicles only:

Engine Year:

(For non-road, must be no more than 3 years older than the calendar year in which purchased)

Engine Horsepower Rating (bhp/hr) – Non-Road Equipment only:

Power Source:

(Select hydrogen internal combustion engine or hydrogen fuel cell) Federal NOX Emissions (g/bhp-hr):

5. Annual Usage Refer to the appropriate technical supplement to determine standard annual usage.

Standard Usage From Technical

Supplement Proposed Usage if Standard Usage Is Not

Listed in Technical Supplement Standard Usage

Unit

6. Requested Grant Amount Please indicate the requested grant amount and cost per ton of NOX reduced.

Requested Grant Amount:

(Must match Requested Grant Amount Step E from Section 7) Cost Per Ton of NOX Reduced:

Use the Grant Estimator to determine Cost Per Ton.

TCEQ-20976/a (Nov. 2023) Page 10 of 14

Section 9: Operation of Grant-Funded Equipment Activity Number ___ An activity represents the replacement, repower, or conversion of a vehicle or piece of equipment.

Click here for additional pages ___

For replacement, repower, and conversion projects, not less than 55% of the grant-funded vehicle or equipment’s annual operation must occur in one or more of the nonattainment areas and affected counties for the duration of the activity life.

Is the Percent of Annual Operation the same for all activities in this application? ______ If the percent of annual operation is the same for all activities in this application, complete only one copy of Section 9, and proceed to Section 10: Disposition of Equipment and Engine Being Replaced. Otherwise, complete one copy of Section 9 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. Applicants may elect to increase their total annual commitment up to a maximum of 95%. Refer to Section 2.9 of the RFGA for usage requirements. A map of the eligible areas and counties can be found in Appendix A of the RFGA.

Usage location and percentage become contractual obligations if selected for an award.

Nonattainment Areas and Affected Counties Percent of Operation Austin Area:

Bastrop, Caldwell, Hays, Travis, and Williamson Counties

Beaumont-Port Arthur Area:

Hardin, Jefferson, and Orange Counties

Corpus Christi Area:

Nueces and San Patricio Counties

Dallas-Fort Worth Area:

Collin, Dallas, Denton, Ellis, Henderson, Hood, Hunt, 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

Tyler-Longview Area:

Gregg, Harrison, Rusk, Smith, and Upshur Counties

Other Eligible Counties:

Anderson, Freestone, Howard*, Hutchinson*, Navarro, Panola, and Titus

Counties Total % of Annual Operation:

The total % of annual operation must be at least 55%, but not more than 95%. Select the percentage from the dropdown list. If the project’s total usage falls between two percentages, round down to the next lowest percentage.

*These counties use a different formulation of diesel fuel that we will consider in our NOx reduction calculations. Refer to the applicable technical supplement for more information.

Counties Selected

Is the primary area of operation El Paso, Howard, or Hutchinson County?

TCEQ-20976/a (Nov. 2023) Page 11 of 14

Section 10: Disposition of Vehicle, Equipment, and Engine Being Replaced If selected for a grant, the old on-road vehicles, non-road equipment, and engines being replaced must be destroyed and rendered permanently inoperable (commonly referred to as disposition) within 90 days of the reimbursement payment being issued by TCEQ. Refer to Section 4.7 of the RFGA.

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

Standard Destruction: Complete destruction or otherwise rendering permanently inoperable.

• Replacement Projects: Completely crush the vehicle or equipment and engine or make a 3-inch or larger hole in the engine block and permanently destroy the frame of the vehicle or equipment.

• Repower Projects: Make a 3-inch or larger hole in the engine block.

Section 11.

If the proposed method of disposition is Standard Destruction, check the box to the right and continue to

Alternative Destruction: TCEQ may consider alternative methods of rendering the vehicle, equipment, or disposition is Alternative Destruction, check the box to the right and complete Items 2 and 3 below.

engine permanently inoperable in lieu of the standard method of destruction. If the proposed method of

2. Alternative Destruction. If the applicant is proposing an alternative method of destruction in lieu of the Standard Destruction, 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-20976/a (Nov. 2023) Page 12 of 14

Section 11: 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 8 forms) Total Requested Grant Amount:

(Total requested grant amount of all activities from Section 8)

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 any false statement may cause the submitted application to be 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:

*If using an electronic signature instead of a typed 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.

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 TERP program staff at TERP@tceq.texas.gov or 1-800-919-TERP (8377).

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Section 12: Application Checklist All applications for funding must be submitted within the application submission period listed on the cover page of the RFGA. A complete application must include:

• all pages of the application;

• all required attachments;

• applicant's contact information;

• all required signatures; and

• any additional supporting documentation.

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.

Section 6: Application Score Tie-breaking

Provisions Please fill out entirely.

Section 7: Calculate Your Requested Grant Amount Please fill out entirely.

Section 8: Vehicle / Equipment Information Please fill out entirely.

Section 9: Operation of Grant-Funded

Equipment (Percent Annual Usage) Please fill out entirely.

Section 10: Disposition Please fill out entirely.

Section 11: Project Summary Page Please fill out entirely. Signature Required.

Section 12: Application Checklist Please fill out entirely and include with application.

Required Attachments Checklist (All Applications)

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

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

Copy of Registration Documents for Vehicle(s) Being Replaced, Repowered, or Converted

(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.

Price Quote or Price Estimate of New Vehicles or Equipment

Please include a price quote or price estimate provided by the vehicle or equipment manufacturer or dealer.

Signature Required.

Application Score Tie-breaking Documentation Please provide documentation of all selected criteria.

Non-Standard Usage Documentation (if applicable)

Please provide supporting documentation if standard usage is not listed in the Technical Supplement.

Supplemental Forms (if applicable) Please fill out entirely (if applicable) and include with Supplemental Form 1: Waiver Request application. Signature Required.

TCEQ-20976/a (Nov. 2023) Page 14 of 14 https://www.irs.gov/pub/irs-pdf/fw9.pdf