Efficiency Maine EV Rebate Reimbursement Form

Dealer Pathway (for EVs purchased from a dealer)

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

All fields must be completed and all documentation must be valid. Efficiency Maine will review, and reserves the right to audit, all information and records submitted with this form.

Participating Dealership*

If you do not see your dealership listed here, please contact ev@efficiencymaine.com. If you purchased or leased a vehicle directly from a manufacturer, please complete this form.
Sales Representative*
Sales Representative Email*
Customer Full Name (as it appears in the EV Purchaser Agreement)*

First

Last
Customer Email
Efficiency Maine Rebate Amount*
Type of Electric Vehicle Purchased or Leased*

Please select battery electric vehicle (BEV) or plug-in hybrid electric vehicle (PHEV)
Battery Size of the Vehicle Model Purchased or Leased (kWh)*
Required Documents:

Please attach to this form copies of the following required documents. The Dealership's reimbursement cannot be made until all documents on this list are completed and filed at Efficiency Maine. Documents are ordered for reference and are available here.
Copy of Signed EV Accelerator Purchaser Agreement (EV Form #3)*
Copy of Maine Bureau of Motor Vehicles Form “Application for Certificate of Title” (EV Form #10)*
Copy of Signed Retail Purchase or Lease Agreement (EV Form #11)*
Copy of Applicant's Maine Driver's License (EV Form #12)*
Copy of Governmental Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #5)
Copy of Qualified Low-Income Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #6)
Proof of Good Standing for Maine business or nonprofit entities (if applicable; EV Form #13)

Please provide a screenshot of the entity’s “Status” from the Maine Secretary of State’s website (https://icrs.informe.org/nei-sos-icrs/ICRS).
Additional Requirements:

Please review the following checklist to ensure that each critical rule in the EV Program Manual has been followed with the purchase or lease for which your dealership is seeking reimbursement.
*
- I attest that the dealership has provided a price adjustment to the Customer identified in their Reimbursement Form for a completed sale/lease that meets the requirements of the Program Manual
- I attest that the vehicle purchased/leased cost no more than $50,000 where the cost is defined as MSRP minus destination/delivery charges, with no other discounts, deductions, credits or rebates counted in the calculation
- I attest that the vehicle is on the Efficiency Maine list of eligible vehicles at the time of purchase or lease
- I attest that the Required Documents are complete and appear to be valid
Participating Dealership Authorized Signature*

(As indicated in the Participating Dealership Agreement)
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Dealer Pathway (for EVs purchased from a dealer)

Required Documents:

Additional Requirements: