Lassen Electric Vehicle Rebate

Electric Vehicle Type*

All-Electric

Plug-In Hybrid EV

Standard hybrid gas-electric models without plug-in charging do not qualify.

Make*

Model*

Model Year*

Vehicle Identification Number (VIN)*

Cost (pre-tax)*

Date of EV Purchase*

Where will you charge your EV? Select all that apply*

Home

Work/School

Other

What type of EV charger will you use at home?*

Level 1 (120V plug that can be used in a standard outlet)

Level 2 (240V plug)

APPLICANT INFORMATION

Applicant Name*

First Last

Are you the utility account holder at the service address?*

Yes

No

What is the account holder's name?

Utility account number

Service Address*

Street Address City State ZIP Code

Do you have a different mailing address?*

Yes

No

Mailing Address*

Street Address City State ZIP Code

Email*

Enter Email Confirm Email

Phone*

UPLOAD DOCUMENTS

Electric Vehicle Invoice*

Provide your invoice, order confirmation, contract/agreement, or receipt from the seller.

Max. file size: 20 MB.

DMV Bill of Sale*

The Bill of Sale is submitted to DMV with your vehicle registration application. Provide your complete DMV Bill of Sale form or use any acceptable version of the bill of sale.

Max. file size: 20 MB.

Final Vehicle Registration*

Provide your final vehicle registration after you receive it from DMV.

Max. file size: 20 MB.

Notes

Include notes you would like on the application, or leave this box blank.

Applicant Release*

I have read and understand this application, including the Terms and Conditions linked at the end of this form.

I certify that the information I have provided in this application is true and correct.