Charge Up Michigan

Grant Application

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* 1. Applicant Information

Organization

Address

City

State

ZIP

Federal ID # (TIN/EIN)

Unique Entity ID # (Required for Federal Awards) To register, go to SAM.gov

Organization Type

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* 2. Applicant Contact Information

Contact Name

Contact Title

Email Address

Phone Number

Authorized Signer Name

Authorized Signer Title

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* 3. Contractor Contact Information

Organization

Contact Name

Contact Title

Email Address

Phone Number

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* 4. What is the Closest Node? Funding is available for the nodes below. (To see a list of node locations on the Michigan Electric Vehicle Infrastructure Programs Map )

Node 4 - Bruce Crossing

Node 24 - Covington

Node 36 - Seney

Node 39 - Champion

Node 50 - Greenbush

Node 52 - Atlanta

Node 61 - Cooper Harbor

Node 62 - Ironwood

Node 70 - Ontonagon

Node 71 - Grand Marais

Node 72 - Paradise

Node 74 - Garden

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* 5. Project Information

Address

City

State

ZIP

Latitude

Longitude

Number of Chargers

Number of Ports per Charger

Simultaneous Charging Ability (Y or N)

Power Output per Port (kW)

Charger Connector Type

Charging Network

Site Host

Utility

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* 6. Project Timeline

Anticipated Start Date

Anticipated End Date

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* 7. Project Cost

Estimated State Cost ($)

Estimated Utility Cost ($)

Estimated Applicant Cost ($)

Estimated Total
Project Cost ($)

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* 8. Funding Request

Funding Requested ($)

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* 9. Will other funding be used to support this project?

Yes

No

If yes, please indicate the funding source and amount.

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* 10. Project Quote

Please attach a quote of the total project cost that lists out the following expenses per line item: design and permitting, construction and installation, utility infrastructure, charger hardware, charger software, operation and maintenance, and other. If these expenses are not listed per line item, this application will automatically be rejected.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 11. Proof of Utility Support

Please upload proof of utility support such as a rebate acceptance letter or a letter stating the utility's intent to provide interconnection services. If such a letter is not included, this application will automatically be rejected.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 12. Equipment Specification Sheet

Please attach an equipment specification sheet that provides details of the following: power capacity per port, connector type, payment capabilities, interface, communication protocol. If these items are not listed, this application will automatically be rejected.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 13. Site Host Agreement [If Applicable]

If the applicant is not the property owner of the charging station site, please attach the agreement between the applicant and the property owner (i.e., site host) that describes the arrangement between the parties to deploy and sustain the project. If a site host agreement is determined applicable and it is not included, this application will automatically be rejected.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 14. Other Supporting Documentation

Please attach any additional supporting documentation related to this project if needed.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 15. Other Supporting Documentation

Please attach any additional supporting documentation related to this project if needed.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 16. Other Supporting Documentation

Please attach any additional supporting documentation related to this project if needed.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 17. Assurances

Applicant certifies they are authorized to negotiate and bind the applicant to the provisions listed in this application.

Applicant agrees that all work will be performed following all applicable Federal and State rules and regulations, as well as local ordinances.

Applicant understands that this application is not a guarantee of funding. Funding is subject to availability on a first come, first served basis until funding is depleted.

Applicant understands should the company be awarded funding, the company must be registered as a vendor with the State of Michigan SIGMA Vendor Self Service (VSS) to receive the rebate reimbursement.

Applicant understands that they will be notified of the funding decision by email. Funds will be dispersed only on a reimbursement basis. Should Applicant company be funded, they agree to submit a payment request within 30 days of completing the charger installation that includes proper backup documentation (i.e. invoices and proof of payments) and a brief summary of the completed activity addressing energy and cost saving impacts.

Applicant understands that if awarded, applicant will be required to enter into a grant agreement with the Michigan Department of Environment, Great Lakes, and Energy.

Applicant understands that the Michigan Department of Environment, Great Lakes, and Energy reserves the right to award a different amount than the requested amount.

Applicant understands that fund can only be used for charging equipment.

By signing this application, I certify (1) to the statements contained in the list of certifications and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I will also provide the required assurances and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.