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 reimbursement for a rebate already issued or to apply for a hold for a future rebate. Rebates must be submitted within 60 days of purchase/lease. All rebates except those issued to qualifying low-income Mainers must have been submitted by December 16, 2024.

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 or leased a vehicle directly from a manufacturer, please complete this form.
I am submitting a:*
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 Email
Customer Address*

Street Address

Address Line 2

City

State

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

A rebate hold cannot be approved until Efficiency Maine receives documentation that the vehicle has been ordered and a deposit has been paid.
Vehicle Order Confirmation*
Max. file size: 32 MB.

Include documentation that a deposit has been paid.
Customer Low-Income Verification Letter*
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.
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 "Participating EV Dealer Requirements Checklist" section.
Maine Bureau of Motor Vehicles Form “Application for Certificate of Title”*
Max. file size: 32 MB.
Signed Retail Purchase or Lease 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. Documentation of a 36+ month lease term is required for leased vehicles.
Vehicle Window/Monroney Sticker*
Max. file size: 32 MB.

Not required for used vehicle rebates. For used vehicles, please re-upload the purchase/lease agreement.
Applicant'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.
Low-Income Eligibility Verification letter from Efficiency Maine*
Max. file size: 32 MB.

Letter must be dated on or before date of sale and unexpired. Name on letter must match name on bill of sale and title application.
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 this Reimbursement Form for a completed sale/lease 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

EV Rebate Program Changes

For EVs purchased from a Maine Participating Dealer

Required Documents:

Required Documents:

Additional Requirements: