Replace Your Ride Efmp Consumer Application Form – Fill Out and Use This PDF

REPLACE YOUR RIDE (EFMP) CONSUMER APPLICATION

This application may be completed and submitted online to aabarca@topshelfec.com or faxed to (562)360-1530

	Participant and Retirement Vehicle Information			Application ID.
1.	Registered Owner	Last Name:		First Name:
2.	Co-Owner (if applicable)	Last Name:		First Name:
3.	Have you been the registered owner of the vehicle for the last two years?
4.	Mailing Address:
5.	City:	6.	State:	7.	Zip Code:
8.	Home Phone:	9.	Cell Phone:	10.	Email address:
11.	Vehicle Identification Number (VIN)	12.	Vehicle License Plate	13.	Odometer Reading (Mileage)
14.	Vehicle Model Year:	15.	Vehicle Make:	16.	Vehicle Model:
17.	Vehicle Powered by:	18. Preferred Method of Notification:
19.	Number of People (Include Yourself) you claim on your income taxes:
20.	Gross Household Income is:			Per Month			Per Year
	Based Upon Your Responses, You appear to be eligible for up to $____________ in Incentives
21.	I am seeking to retire the vehicle described above and wish to obtain:
	A New or Newer Vehicle	A Transit Pass		A Rideshare Subscription
22.	I would like information on financial assistance to purchase a new or newer car					YES		No
23.	Application Status:

Consumer Representations:

The vehicle described above is the vehicle to be retired and:

∙Is currently registered in the South Coast Air Quality Management District (SCAQMD) as an operational vehicle. This includes zip codes in all of Orange County and the urban portions of Los Angeles, Riverside and San Bernardino counties.

∙Has been continuously registered in a SCAQMD Zip code as an operational vehicle for the past 2 years with exceptions (See allowable exceptions section)

∙Is a gasoline or diesel powered light or medium vehicle (up to 10,000 pounds Gross Vehicle Weight Rating [GVWR])

∙	Is a le to dri e for ard a dista e of at least	ards u der its o	po er u affe ted	da age to ehi le’s od , steeri g or suspension and
	is able to start readily through ordinary means without the use of starting fluids or booster batteries and has operational interior pedals, doors,
	hood lid, dash oard, i dshield, e haust s ste	, a d dri er’s seat, has at least o e side		i do glass, u per, headlights, taillight, brake light,
	and has all side and/or quarter panels.

I understand that the vehicle to be retired may be required to undergo a smog check inspection

I understand that I must retire my vehicle by transferring title to an authorized automobile dealership or dismantler and provide proof of ownership and photo identification.

I understand that the replacement vehicle must be eight (8) model years old or newer and meet minimum fuel economy ratings.

My signature below gives express written consent to Top Shelf Environmental Consulting, LLC and/or its agents or designees to capture, use, study, report, and disclose information provided in this application and any related vehicle emissions data to other third parties as allowable under applicable federal, state, and/or local laws or regulations.

By submission of this document, I declare, under penalty of perjury, under the laws of the state of California, the information provided within this Consumer Application is true and correct.

Under penalty of perjury, I certify that:

I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding

Date:	Date:
Registered Vehicle Owner Signature	Co-Owners Signature (Must sign if indicated at top)

Offer is valid for only 30 days following the application date. If expired, please request an extension by contacting Top Shelf at 1(844)214-0933.

Please provide the information from the Consumer and Retirement Vehicle Information portion of this application.

Allowable Exemptions

REPLACE YOUR RIDE (EFMP) CONSUMER APPLICATION

This application may be completed and submitted online to aabarca@topshelfec.com or faxed to (562)360-1530

a.A vehicle may also be eligible if placed in planned non-operation (PNO) status for a total of 60 or fewer days during the continuous 24 months registration period and occurring at least 90 days prior to the postmarked date of application or

b.If the registration has lapsed for fewer than 121 days during the previous 24 months, and all appropriate registration fees and late penalties have been paid to the DMV, provided that the vehicle is registered for at least 90 days immediately prior to the postmarked date of application.

∙Eligible vehicles may be operating under a Smog Check repair cost waiver or economic hardship.

∙Tampered vehicles are eligible for acceptance into the program.

∙Unregistered vehicles may be eligible if proven to have been driven primarily in the SCAB for the last two years and not to have been registered in any other state or country in the last two years.

O Documentation of operation in SCAB includes the following:

Proof of insurance for the last two years; or

Invoice(s) showing the vehicle identification number for vehicle repairs and/or maintenance

	duri	g the pre ious t o ears a d proof of o	er’s reside e i the state duri g the sa e
	period.
∙	Deter i atio of a i di	idual ehi le’s registratio histor shall e	ased o :

ORegistration data for that vehicle obtained from DMV records; and

OIf this source provides inconclusive results for an individual vehicle, then copies of the applicable vehicle registration certificates may be used.

∙Dismantled or salvaged vehicles that have been registered pursuant to section 11519 of the Vehicle Code are ineligible.

∙Vehicles registered to a non-profit or business are ineligible.

∙Vehicles operated by a public agency or fleet licensed and registered pursuant to Health and Safety Code sections 44019 and 44020 are ineligible

∙Vehicles undergoing a transfer of ownership are ineligible

Fuel Economy Standards for Replacement Vehicles

	Minimum USEPA	Minivan Minimum
Model Year	Combined	Combined Fuel
	Fuel Economy Rating	Economy Rating
2006 to 2009	20	19
2010	22	19
2011	25	21
2012	28	21
2013	29	21
2014	30	21
2015	31	21

Vehicle Replacement Incentives

		8 year old		Plug-In Hybrid	Alternative
Income		or newer	35+ MPG	and Zero-
					Transportation
Eligibility		20+ MPG	(Combined)	Emission
					Mobility Options
		(Combined)		Vehicle
Level I	BASE INCENTIVE	$4,000	$4,500	$4,500	$4,500
Level II	BASE INCENTIVE	N/A	$3,500	$3,500	$3,500
Level III	BASE INCENTIVE	N/A	N/A	$2,500	$2,500

For additional information on the Replace Your Ride Program and/or assistance in filling out this

application, please contact us Toll Free at 1(844)214-0933