Project Information Reference # Customer Organization Name Service Agreement ID (SAID) Rebate Recipient Organization Name (if different from above) Do you want to receive your rebate payment via mail or electronic payment? Your Relationship to the Project

If you are the "Owner/Legal Representative" such an employee with legal signing authority, please select "Owner/Legal Representative"

If you are a designated applicant, such as an EV Charging Installer please fill out the Designated Applicant fields located above the submit button at the bottom of this application

Total Number of Installed Ports # Networked Level 1 Ports # Networked Level 2 Ports

Customer Contact Information First Name Last Name Title Phone Email

Customer Installation Information Installation Address

Installation City

Installation Zip Code

Permit #

Permit Application Submission Date

Building Permit Issued Date

Final Inspection Date

Optional Enrollments EVs are only as clean as the electricity that powers them. Earn a Deep Green Bonus of $500/Level 2 port and $125/Level 1 port. OPT UP to Deep Green!

Power your charging stations MCE Deep Green 100% renewable energy service. By selecting "OPT UP to Deep Green!", I, as the authorized account holder/representative of the Primary PG&E Account Number listed above, authorize MCE to enroll my accounts associated with the aforementioned Project in Deep Green service upon charger activation and agree to the Terms & Conditions of Deep Green service.

Rebate Amount Requested

MCE cannot guarantee rebate funds beyond what was reserved nor can rebate funds exceed 100% of the total project costs. Final projects with less ports than projected will only receive rebates for installed ports, up to the amount previously reserved.

Other Funding Source Name Other Funding Source Amount Total Invoiced Costs $:

MCE Rebate Requested: $0.00

Provide the following documents with this verification form: EACH CLICK will add 5 File Selections up to 20 per checkbox selection. Each Section Requires at Least 1 Attachment.

All PG&E Account Numbers, Pricing, EVITP Certification, and Plugshare Links for Installed EVSE (use provided template )

Completed W-9

Paid Invoice(s) showing proof of purchase of EVSE Hardware

Paid Invoice(s) showing proof of purchase of EVSE Installation

Documentation of Additional External Funding Commitments (e.g. TAM, CALeVIP, BAAQMD)

If you selected "Designated Applicant" please complete this section.
If you selected "Owner/Legal Representative" please leave this section blank

Designated Applicant Information EVSE Designated Applicant Organization EVSE Designated Applicant Mailing Address

EVSE Designated Applicant City

EVSE Designated Applicant State

Zip Code

Designated Applicant Contact Information EVSE Designated Applicant First Name EVSE Designated Applicant Last Name EVSE Designated Applicant Title EVSE Designated Applicant Phone EVSE Designated Applicant Email

The Applicant must accept the Terms and Conditions established and provided by MCE

By checking the box, the Applicant certifies that all of the attached project documentation has been completed to program standards outlined in the associated Terms & Conditions. The property owner agrees that the EVSE rebate payment should be sent to the recipient and location listed above.

Yes, I will submit annual EV charging utilization reports by March 31 for the subsequent 5 years this project is under MCE's Terms & Conditions using this Reporting Template.

(Optional) Yes, I want MCE to provide their employee & tenant EV engagement program at our workplace or multi-family property.

For government entities and public districts in Marin County or eligible workplaces and multi-family properties in Contra Costa County: you're eligible for additional rebate funding provided by the Transportation Authority of Marin (TAM) and Contra Costa Transportation Authority (CCTA). If eligible for the additional TAM or CCTA rebates, you consent to MCE sharing this Project Verification form with TAM or CCTA. MCE bears no responsibility or liability for the TAM or CCTA Rebate Programs

After clicking "Submit" below, there are additional steps you need to complete to claim your rebate, which you will also receive by email. Unless you indicate otherwise, we'll go ahead and send stickers to the installation address listed in your application. Please apply the stickers based the MCE EV Charging Sticker Instructions and take photos of your newly stickered EV charging stations (including visible make & model nameplate). If you applied for TAM funding, your stickered EV charging station photos will need to include the TAM sticker as well. Please compress the photos to a zip file and send to mce-evcharging@clearesult.com using the subject "[Street Address] + Stickered EVSE Photos". This is the last step needed to claim your rebate. Once your email is received we will process your application and email you regarding its status within 10 business days. Please allow an additional 5-7 days for an update on TAM rebate processing

MCE EV Charging Project Verification Form