Efficiency Maine EV Rebate Dealer Reimbursement Form

This form is to be completed by a Participating Dealer only.

Use this form to request reimbursement for a rebate already issued to a customer. Rebates must be submitted within 60 days of the vehicle purchase date.

To expedite processing, please upload individual documents to each required field. Efficiency Maine will review, and reserves the right to audit, all information and records submitted with this form.

“*” indicates required fields

Participating Dealership*

If you do not see your dealership listed here, please contact ev@efficiencymaine.com. If you purchased a vehicle directly from a manufacturer, please complete this form.
Dealer Representative*
Dealer Representative Email Address*

This is the email that we will contact for additional information or corrections to documentation, if needed.
Customer Full Name*
Customer Address*

Street Address

Address Line 2

City

State

ZIP Code
Efficiency Maine Rebate Amount*
Vehicle Make and Model*
Vehicle Make and Model*
Required Documents:

Please attach to this form copies of the following documents. Reimbursement payment cannot be made until all required documents are completed and filed with Efficiency Maine.
Signed Efficiency Maine EV Rebate Claim Form*
Max. file size: 32 MB.

EV Rebate Claim Form. Please make sure to check ALL boxes that apply in the "Purchaser Requirements" and "Participating Dealer Checklist" sections.
Maine Bureau of Motor Vehicles Form “Application for Certificate of Title”*
Max. file size: 32 MB.
Signed Retail Purchase Agreement*
Max. file size: 32 MB.

The Efficiency Maine rebate must appear as an independent line item labeled as "Efficiency Maine" (abbreviations are acceptable). Handwritten labels are acceptable.
Vehicle Window Sticker (if vehicle is NEW)
Max. file size: 32 MB.
Customer's Maine Driver's License*
Max. file size: 32 MB.

Driver's license must be valid at the time of purchase. Temporary driver's license is acceptable.
Screenshot of Proof of Good Standing (if business/nonprofit)
Max. file size: 32 MB.

Proof of Good Standing can be found via the Maine Secretary of State’s Corporate Name Search.
Income Verification Letter from Efficiency Maine (if individual)
Max. file size: 32 MB.

Letter must be dated on or before purchase date and unexpired on the purchase date. Name OR address on letter must match name OR address on bill of sale and title application.
Additional Requirements:

Please review the following checklist to ensure that each critical rule in the Program Manual has been followed with the purchase for which your dealership is seeking reimbursement.
*
- I attest that the customer understands they must connect the off-peak charger to Wi-Fi and use the off-peak charger to avoid charging the vehicle during peak hours (5:00pm - 9:00pm on weekdays)
*
- I attest that the dealership has provided a price adjustment to the customer identified in this Reimbursement Form for a completed sale that meets the requirements of the Program Manual
*
- I attest that the required documents are complete and appear to be valid
Participating Dealership Authorized Signature*
Please Check

Efficiency Maine EV Rebate Dealer Reimbursement Form

Required Documents:

Additional Requirements: