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10 / 14

DERA Heavy-Duty Truck Voucher Program

Truck Replacement

Step-by-Step Claim for Payment Form Guidance

This section outlines the information required for each field of the Claim for Payment Form. Once the fields listed below have been completely filled out, the Form must signed and dated in blue ink. This will complete the Claim for Payment Form. Only originally signed Forms will be accepted. If additional assistance is needed to complete the Form, please contact the Strategies and Incentives Department and a Program staff member will assist you.

  • Project Number

The number that the District assigned to the voucher; this number can be found on the original voucher sent to the dealership.

  • Payee

The Dealership’s legal name as it appears on the Agreement with the District.

  • Address

The mailing address used by the dealership, including the city, state, and zip code. Checks from the District will be mailed to the address provided here.

  • Check Box

Check the classification of the dealership that is listed under payee.

  • Federal Tax I.D. #

Taxpayer Identification Number (TIN) of the dealership. Only the applicant’s name and TIN or SSN will be used to report incentive funding to the IRS, not the dealership’s. The District cannot give tax advice, as such, applicants should contact a tax professional or the IRS to determine the tax consequences associated with receiving incentive funding.

  • Telephone #

The main phone number, including area code, for the dealership.

  • Fax #

The fax number, including area code, for the dealership.

  • Date

Enter the date as is appears on the invoice from the replacement truck purchase.

  • Replacement Truck Make & Model

The make and model name of the replacement truck purchased.

  • Amount Paid

The amount paid for the replacement truck as it appears on the invoice prior to the reduction of the voucher amount.

Eligibility Criteria and Application Guidelines Page 10 of 14 Approved July 3, 2008

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