Efficiency Maine EV Rebate Dealer Reimbursement Form

For EVs purchased from a Maine Participating Dealer

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

Use this form to request a reimbursement (must be submitted within 60 days of purchase) or a rebate hold (for a vehicle on order that won’t be delivered until a later date).

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.

“*” indicates required fields

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.
I am submitting a:*
Sales Representative*
Sales Representative Email*
Customer Full Name (as it appears in the EV Purchaser Agreement)*

First

Last
Customer Email
Customer Address*

Street Address

Address Line 2

City

State

ZIP Code
Efficiency Maine Rebate Amount*
Type of Electric Vehicle Purchased or Leased*
Please select battery electric vehicle (BEV) or plug-in hybrid electric vehicle (PHEV). Only vehicles with a charging plug are eligible for a rebate.
Vehicle Make*
Vehicle Model*
Battery Size of the Vehicle Model Purchased or Leased (kWh)*
Required Documents:
Please attach to this form a copy of the Vehicle Order Confirmation. A rebate hold cannot be approved until Efficiency Maine receives an order confirmation showing that the vehicle has been ordered and a deposit has been paid.
Copy of Vehicle Order Confirmation (EV Form #18)*
Max. file size: 32 MB.
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)*
Max. file size: 32 MB.
Copy of Maine Bureau of Motor Vehicles Form “Application for Certificate of Title” (EV Form #10)*
Max. file size: 32 MB.
Copy of Signed Retail Purchase or Lease Agreement (EV Form #11)*
Max. file size: 32 MB.
Copy of Applicant's Maine Driver's License (EV Form #12) - Must be valid at time of purchase
Max. file size: 32 MB.
Copy of Vehicle Window/Monroney Sticker (EV Form #17)*
Max. file size: 32 MB.
Copy of Vehicle Order Confirmation (EV Form #18) - Only required if vehicle was ordered before 10/11/22 in order to receive the previous rebate amount
Max. file size: 32 MB.
Copy of Governmental Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #5)
Max. file size: 32 MB.
Copy of Qualified Low or Moderate Income Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #6)
Max. file size: 32 MB.
Proof of Good Standing for Maine business or nonprofit entities (if applicable; EV Form #13)
Max. file size: 32 MB.
Please provide a screenshot of the entity’s “Status” from the Maine Secretary of State’s website.
Copy of Eligible Nonprofit Service Provider Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #14)
Max. file size: 32 MB.
Copy of Special Business Promotion Pre-Approval Letter from Efficiency Maine (if applicable; customer must request through EV Form #16)
Max. file size: 32 MB.
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:
  1. $73,000, in the case of an eligible pickup truck or commercial van with an EPA-rated range of 300 miles or more;
  2. $65,000, in the case of an eligible pickup truck or commercial van with an EPA-rated range of less than 300 miles; or
  3. $50,000, for all other eligible vehicles.
  where the cost is defined as total Manufacturer’s Suggested Retail Price (MSRP), or “sticker price,” 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*
Please Check

For EVs purchased from a Maine Participating Dealer

Required Documents:

Required Documents:

Additional Requirements: