Project location (if different than applicant location)
City: County: Zip:
Applicant type (check one): Public Private Amount Requested: $ Matching Funds:$ (minimum 20% of total project cost)
Total Project Cost: $ Percent Matching funds of Total Project Costs _____% Project type/specifics:
Alternative Fuel or Advanced Technology Vehicles:
Vehicle type (make, model, year):
Dedicated Bi-fuel B
Number of vehicles: B
Estimated % miles using alternative fuel (bi-fuel or PHEV applications):
Estimated per-vehicle annual mileage:
Conventional fuel type:
Average conventional fuel economy (MPG):
For MD/HD average vehicle speed:
For MD/HD average vehicle road weight:
Alternative fuel station(s) where vehicle(s) will refuel or recharge (address)
AFV Conversions and Up Fits:
Vehicle type (make, model, year) to be converted/ up-fitted:
Number of conversions or up fits to be installed:
Dedicated Bi-fuel B
Estimated % miles using alternative fuel (bi-fuel applications)
Estimated per vehicle annual mileage:
Average conventional fuel economy (MPG):
Alternative fuel station(s) where vehicle(s) will refuel or recharge (address):
Refueling / Recharging Infrastructure:
Fuel type: Estimated annual gallons to be dispensed: Open to the public: Yes No
4. Idle Reduction: Technology:
Number to be purchased: Annual per vehicle hours of use:
Annual per vehicle gallons to be saved:
5. Diesel Retrofits: Technology:
Number to be purchased: Annual average per vehicle miles:
Annual per vehicle fuel use (gal):
6. Telematics: Technology: Number to be purchased:
Annual average vehicle mileage Current average miles per gallon
Parameters to be monitored:
Estimated annual per vehicle fuel savings:
Emission Reductions: total project annual grams per mile.
Check if attaching own data Leave below blank if NCSC is calculating.
CO: NOx: VOCs: PM:
“Buy America” Compliance
Applicant hereby certifies compliance with “Buy America” requirements; OR
Applicant hereby certifies “Buy America” is inapplicable to this project.
(For AFV purchases) Applicant hereby certifies that vehicle final assembly occurs in the U.S.
NC Smart Fleet /NC Coordinating Committee Participation (select one) Applicant hereby agrees to participate in the NC Smart Fleet Initiative; OR
Applicant hereby agrees to participate in the NC Clean Transportation Coordinating Committee.
Project Description Provide project description here. Include discussion of near term expansion of emission reduction plans to be pursued along with or after the proposed project. Refer to Application Instructions in Section Five of RFP.Address evaluation criteria as related in Section Three of the RFP. Include discussion of near term expansion of emission reduction plans to be pursued along with or after the proposed project and how your organization will insure implementation during project period (evaluation criteria 3 and 5).
Statement of Work Project Summary: Provide summary of project including activities. This and task deliverable descriptions will form the basis of the contract if project is selected for award. See Application Instructions in Section 5 of RFP.
Task #1: Acquisition and Installation of Equipment or Infrastructure. Provide narrative detail of activities tied to this task. Refer to Application Instructions in Section 5 of RFP. tASK 1 DELIVERABLES
Deliverable 1.1: Copies of paid invoices for all costs associated with project will be provided. If submitting more than one invoice for reimbursement, final invoice will be marked as such. If only submitting one invoice, this will be marked as final. Cost share letter will be submitted with final invoice [ refer to deliverable 4.1].
Deliverable 1.2:Brief description of what was accomplished will be provided.
Task #2: Usage tracking of project technology/fuel. Provide detail of activities tied to this task. See application instructions section 5 of RFP. tASK 2 DELIVERABLES
Deliverable 2.1: A minimum of twelve 12 months, of recorded technology/fuel usage will be provided in acceptable form.
Deliverable 2.2: An estimate of technology/fuel usage for an additional twenty-four (24) months will be provided to give a total of thirty-six (36) months of actual and estimated combined usage. Task #3: Public Awareness and Education. Provide detail of activities tied to this task. See RFP Application Instructions Section 5.
tASK 3 DELIVERABLES
Deliverable 3.1: Documentation of all Public Awareness and Education activities will be provided via quarterly report template provided by the NC Clean Energy Technology Center.
Deliverable 3.2: Copies of all press releases and promotional material used to showcase project to the public will accompany quarterly reports. All press releases will acknowledge support through the NC Clean Energy Technology Center at NC State University with federal Congestion Mitigation Air Quality funding provided from the NC Department of Transportation.
Deliverable 3.3: Photo of project signage and /or photo of vehicle decals will be provided.
Deliverable3.4: Documentation of participation in NC Smart Fleet initiative or NC Clean Transportation Committee (as applicable) Task #4: Reporting. Provide detail of activities tied to this task. See application instructions section 5 of RFP. tASK 4 DELIVERABLES
Deliverable 4.1: Cost share documentation on letterhead will accompany final invoice. If more than one invoice, each invoice will include cost share.
Deliverable 4.3 Copies of paid invoices for grant funded project [see Deliverable 1.1] will accompany all requests for reimbursement.
Deliverable 4.4: One (1) final report summarizing project deliverables.
Timeline Project Dates: April 15, 2016 – March 15, 2018 1st Quarter: *April 15, 2016 – June 30, 2016 Quarterly report due: July 15, 2016 2nd Quarter: July 1, 2016 – September 30, 2016
Quarterly report due: October 15, 2016
3rd Quarter: October 01, 2016 – December 31, 2016
Quarterly report due: January 15, 2017
4rd Quarter: January 01, 2017 – March 31, 2017
Quarters 5 - 9: April 1, 2017 – *March 15, 2018 Quarterly reports dues July 15 2017, October 15, 2017, January, 15 2018 and March 15, 2018
Quarterly and final report due: March 30, 2018 *Indicates elongated or shortened quarters due to overall project period.