AIRCHECKTEXAS DRIVE A CLEAN MACHINE PROGRAM
Contents
1. E 1 26 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Buyer s Order YEAR MAKE BODY STYLE 1990 Ford Taurus VEHICLE IDENTIFICATION NO APPRAISED BY 1FAFP34P5RM789010 CURRENT ODOMETER READING BALANCE OWED TO 213 789 THIS VEHICLE HAS BEEN USED AS 1 POLICE DL TAXI 1 DRIVER ED VEH 0 sovr ven IF THIS IS FOR A USED CAR OR LIGHT TRUCK THE INFORMATION YOU SEE ON THE FEDERAL TRADE COMMISSION WINDOW FORM IS PART OF THIS AGREE MENT INFORMATION ON THE WINDOW FORM OVERRIDES ANY CONTRARY PROVISIONS IN THE CONTRACT SALE THIS AGREEMENT IS NOT BINDING UPON EITHER THE PURCHASER OR THE DEALER UNTIL SIGNED BY BOTH PARTIES OR SHALL NOT BE BINDING UPON THE DEALER OR THE PURCHASER UNTIL ALL CREDIT TERMS IF APPLICABLE ARE APPROVED AND ACCEPTED BY ALL THE PARTIES DEALER PURCHASER AND LENDING INSTITUTION IF CREDIT TERMS ARE NOT ACCEPTED FULL DEPOSIT WILL BE REFUNDED TO PURCHASER AGREEMENT BASED UPON AVAILABILITY OF VEHICLE PURCHASER IS OF LEGAL AGE IN THIS STATE A t DEALER OR AUTHORIZED REPRESENTATIVE 1 SALVAGE 27 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Buyer s Order Summary Participant Vehicle Owner information on this form must match same information on voucher letter f address changes provide proof of new address Iflast name changes provide proof of new name Replacement vehicle being purchased year make model VIN must match same in2. WARNING ODOMETER DISCREPANCY X Mileage Exceeds Mechanical Limits IF NO SELLER AGENT TITLE APPLICANT SHOULD CHECK ONE OF THE 3 BOXES ABOVE UNLESS NUMBER 6 INDICATES EXEMPT MOTOR VEHICLE TAX STATEMENT 19 CHECK ONLY IF APPLICABLE hold Motor Vehicle Retailer s Rental Permit No and will satisfy the minimum tax liability V A T S Tax Code 5152 046 Lam a Dealer or Lessor and qualify to take the Fair Market Value Deduction V A T S Tax Cade 8152 002 20 DESCRIPTION OF VEHICLE TRADED IN if any 21 SALES AND USE TAX COMPUTATION 04 a Sales Price 2000 rebate has been deducted 20101 85 Vehicle Identification Number 20a ADDITIONAL TRADE INS Y N 1FAFP34P5RM789010 N 90 New Resident Tax Previous State b Less Trade In Amount Describe in Item 20 Above 3000 00 5 Even Trade Tax c For Dealers Lessors Rental ONLY Fair Market Value Deduction Describe in Item 20 Above 0 00 d Taxable Amount Item a minus Item b item c 17101 85 e 6 25 Tax on Taxable Amount Multiply Item d by 0625 1068 87 f Late Tax Payment Penalty 5 or 10 0 00 g Tax Paid to STATE 0 00 10 Gift Tax 65 Rebuilt Salvage Fee 2 5 Emissions Fee Diesel Vehicles 1996 and Older gt 14 000 Ibs O 1 Emissions Fee Diesel Vehicles 1997 and Newer gt 14 000 Ibs Exempti
3. Dealer mails voucher paperwork to AirCheckTexas Dealer logs into database and processes credit card and enters transaction date AIRCHECKTEXAS DRIVE A CLEAN MACHINE Vehicle Replacement Voucher Letter Drive a AirCheckTexas Clean Machine 9 03 21 2012 John Smith NORTH CENTRAL TEXAS REGION 1212 First Street Voucher Number TAR 08259 1 41915 Fort Worth TX 76109 Expires after 06 30 2011 Dear John Smith You have been approved to receive replacement assistance through the AirCheckTexas Drive a Clean Machine Program This approval letter qualifies you to receive 3 000 toward the purchase of a qualifying car or truck or 3 500 toward the purchase of a qualifying hybrid vehicle electric vehicle natural gas vehicle or a Tier 2 Bin 3 or cleaner vehicle Please note the expiration date of 06 30 2011 below the voucher number on this letter This approval letter must be presented and vehicle purchased at a participating dealership on or before the expiration date as we are unable to provide extensions due to funding availability Retired Vehicle Information Participant Name s Eligible Co signer s 1990 Ford Taurus John Smith Peggy Smith VIN 1FAFP34P5RM789010 License No ASD123 Along with this letter you will find enclosed the Retired Vehicle Transfer Manifest form the replacement vehicle requirements insert and a list of approved participating dealerships You must present this approval letter at a dealership on th
4. AIRCHECKTEXAS DRIVE ACLEAN MACHINE PROGRAM Dealership Workshop February 3 2015 North Central Texas Council of Governments AIRCHECKTEXAS DRIVE A CLEAN MACHINE Vehicle Repair and Replacement Program Help low middle income residents repair or replace vehicles that do not pass emissions inspection or are 10 years old or older Target the highest polluting vehicles and allows citizens to contribute to the regional air quality solution 6 from emissions inspection fee from 1996 and newer vehicles Texas Commission on Environmental Quality TCEQ funds approximately 2 6 million annually to North Central Texas counties for continuous repair assistance and limited replacement assistance Provide up to 600 for repair or up to 3 500 for replacement assistance qm Drive a AirCheckTexas cian Machine gt AIRCHECKTEXAS DRIVE A CLEAN MACHINE Vehicle Repair and Replacement Program NCTCOG issues vouchers for the North Central Texas region and includes Collin Dallas Denton Ellis Johnson Kaufman Parker Rockwall and Tarrant counties The program is administered in the Houston area and Austin area by other regional administrators Dealerships need to be signed up with those administrators in order to take Houston or Austin area vouchers is the state administrator of the program TCEQ implements the rules for the program and maintains the www driveacleanmachine org website jm Drive a AirCheckTexas
5. See below or Federal Tax ID Number 14a Registrant s Name Renewal Notice Recipient Address City State Zip Code Tarrant County Name Statement of Fact for Non Disclosure County Name VTR 171 Attached 14b Vehicle Physical Location City State Zip Code Fort Worth TX 76109 15 Previous Owner s Name Car World Address 175 South Street City State ZipCode Fort Worth Texas 76109 THIS MOTOR VEHICLE IS SUBJECT TO THE FOLLOWING FIRST LIEN 15 GDN Dealer Use Only P11111 16 1st Lien Date 1st Lienholder Name Bank of Texas 16a Electronic Title Request YES 16c cannot be checked 07 01 09 Address 123 Maple Street 16b Certified Lienholder ID No City State Zip Code Fort Worth TX 76115 16c Additional Lien s YES Attach Form VTR 267 17 FOR CORRECTED TITLE Change in Vehicle Description VIN No Changein Add Remove Odometer Odometer CHECK REASON S D Year Body Style Other Ownership Lien Lien Lien Brand Reading 18 ODOMETER DISCLOSURE FEDERAL AND STATE LAW REQUIRES THAT YOU STATE THE MILEAGE UPON TRANSFER OF OWNERSHIP FAILURE TO COMPLETE OR PROVIDING A FALSE STATEMENT MAY RESULT IN FINES AND OR IMPRISONMENT Car World Name of Seller Agent THE MILEAGE SHOWN IS X A Actual Mileage N Not Actual Mileage State that the odometer now reads 158 no tenths
6. Address 1212 First Street Tarrant City State Zip Code Fort Worth TX 76109 14a Registrant s Name County Name Renewal Notice Recipient Address City State Zip Code County Name 14b Vehicle Physical Location City State Zip Code Fort Worth TE 76109 15 Previous Owner s Name Car World Address 175 South Street City State Zip Code Fort Worth Texas 76109 THIS MOTOR VEHICLE IS SUBJECT TO THE FOLLOWING FIRST LIE 16 1st Lien Date 1st Lienholder Name Bank of Texas 16a Electronic 07 01 09 Address 123 Maple Street City State Zip Code Fort Worth TX 76115 16c Additional 17 FOR CORRECTED TITLE LI Change in Vehicle Description LJ VIN No Change in L Add O Re CHECK REASON S L Year Make Body Style Other Ownership Lien Lien i 18 ODOMETER DISCLOSURE FEDERAL AND STATE LAW REQUIRES THAT YOU STATE THE MILEAGE UPON TRANSFER OF OWN PROVIDING A FALSE STATEMENT MAY RESULT IN FINES AND OR IMPRISONMENT h Car Word state that the odometer now reads 158 Name of MILEAGE SHOWNIS X A Actual Mileage CI N Not Actual Mileage _ WARNING ODOMETER D DISCREPANCY IF NO SELLER AGENT TITLE APPLICANT SHOULD CHECK ONE OF THE 3 BOXES ABOVE UNLESS NUMBER 6 INDICATES EXEMH MOTOR VEHICLE TAX STATEMENT 19 CHECK ONLY IF APPLICABLE hold Motor Vehicle Retailer s Rental Permit No and will satisfy the minimum t4 am a Dealer or Lessor and qualify to
7. West Avenue ciy Foer U beHa State TM zip Zoll Texas Dept of Transportation TxDOT Salvage Vehicle Dealers License Number 11213 14 b Isle 4l 2191 1 Storm Water Permit Number Joe Tones 7 3 09 Salvage Dismantiing Facility Representative Verifying VIN amp Receipt of Vehicle pig jature ile Destruction CERTIFICATION 1 certify that the emissions control equipment AND THE ENGINE of this vehicle have been destroyed Emissions control equipment may include but is not limited to the following exhaust gas recirculation system power control module catalytic converter oxygen sensors evaporative purge canister positive crankcase ventilation valve gas cap SEE PENALTY NOTICE ON REVERSE SIDE All mercury switches have been removed and also certify that the vehicle has been destroyed and the remaining residual scrap metal will be conveyed to a participating recycling facility Dismantier Representative Verilying Destruction of Equipment and Vehicle Signature Recycuine Facitity Receivina ResipuaL Scrap METAL SEE INSTRUCTIONS ON REVERSE SIDE Recycling Facility Phone _ H County Physical Address Zip Scale Ticket Number Print Name Recycling Representative Receiving Residual Scrap Metal Date White Automobile Dealership Green Automobile Dealership Yellow Salvage Dismantling Facility Pink Recycling Facility Goldenrod Auto Dealership to NCTCOG
8. regarding the vehicle retirement replacement procedure Thank you AirCheckTexas Program Regional Administrator FOR DEALERSHIP USE ONLY X Drive a NORTH CENTRAL TEXAS REGION AlrCheckTexas Clean Machine 5 DEALER CHECKLIST All boxes below must be clearly checked and vehicle information completed by a participating dealership representative Incomplete information may result in delayed processing Checklist is not inclusive of all program requirements Participant presents valid voucher letter do not begin negotiations until customer has voucher letter in possession and make sure voucher letter has not expired Buyer is the same person s as the Participant Name s printed on the voucher letter If needed ensure co signer s name appears in the Eligible Co signer s printed on the voucher letter Trade in vehicle is drivable and matches Retired Vehicle Information printed on voucher letter Record all details of replacement vehicle below before it is sold Obtain information directly from the vehicle VIN Engine Displ liters Year Drive 2WD 4WD Make Fuel Type Underhood ID Model Test Group No of Cylinders Odometer Inspection Transmission Sticker Number Vehicle qualifies for program compare details above against eligible vehicles list at www nctcog org airchecktexas Odometer reading of replacement vehicle being sold is 70 000 miles or less Sales price o
9. 9 i 2 24 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Buyer s Order VEHICLE PURCHASE AGREEMENT PURCHASER CAR WORLD John Smith Peggy Smith 7 1 2009 175 South Street nn Fort Worth TX 76109 1212 First Street 817 557 5555 CITY STATE ZIP ge e BODY SLE COLOR Fort Worth 16109 RES PHONE BUS PHONE COUNTY OF RESIDENCE VEHICLE IDENTIFICATION NUMBER ODOMETER DRIVERS LICENSE NO STATE BIRTHDATE 1FTFP78P5TB875640 158 12345678 TRIM STOCK NO WEIGHT FEE CAT TO BE DELIVERED NO LATER THAN INSURANCE COMPANY AGENT PHONE NO P2750 wu 7 1 2009 First Insurance 355 555 5555 THIS VEHICLE WILL BE USED AS O Pouce ven O taxi O salvace oriver eo ven O covt ven POLICY NO BINDER NO O Pouce ven O O sa vace 157918 THIS VEHICLE HAS BEEN USED AS 25 AIRCHECKTEXAS DRIVE A CLEAN MACHINE SUBTOTALEROUCHTFORWARD 101 85 REBATE O O 200d Buyer s Order SUB TOTAL 1 INCLUDING FREIGHT amp PRICE OF VEHICLE ACCESSORIES OTHER TAXABLE CHARGES TOTAL TAXABLE PRICE a SALES TAX b LICENSE FEE c TITLE FEE Documentary Fee TOTAL DELIVERED PRICE CASH DUE ON DELIVERY TRADE IN ALLOWANCE Less LIEN TOTAL DOWN PAYMENT BALANCE SEE SEPARATE FINANCING FINANCE CHARGE CONTRACT INSURANCE CHARGE TOTAL AMOUNT OF AGREEMENT 2010 2010 oo E oo C Un Un Un 17101 1068 N O uo o q ol po
10. OF ALL PROGRAM REQUIREMENTS Participant presents valid voucher letter to the dealer representative do not begin negotiations until customer has handed the voucher letter to you and make sure voucher letter has security features and has not expired Dealer representative must verify that their dealership is a North Texas approved participating dealer Call 817 608 2350 or visit www nctcog org airchecktexas and locate the NCTCOG participating dealership list Im ar Agreement form must be completed and returned the Regional Administrator BEFORE being approved to accept replacement vouchers from program participants Before accepting a voucher from a participant please make sure your dealership is on the participating dealer list The program cannot reimburse non participating dealerships This participation list will change next year AIRCHECKTEXAS DRIVE A CLEAN MACHINE Back Dealer Checklist FOR DEALERSHIP USE ONLY NORTH CENTRAL TEXAS REGION EC Drive a AirCheckTexas cea icine DEALER CHECKLIST All boxes below must be clearly checked and vehicle information completed by a participating dealership representative Incomplete information may result in delayed processing Checklist is not inclusive of all program requirements Participant presents valid voucher letter do not begin negotiations until customer has voucher letter in possession and make sure voucher letter has not e
11. VEHICLE MES HT LI OTHER TAXABLE CHARGES TOTAL TAXABLE PRICE 0 SALES TAX BODY STYLE 1990 Ford Taurus b LICENSE FEE VEHICLE IDENTIFICATION NO APPRAISED BY 1FAFP34P5RM789010 CURRENT ODOMETER READING BALANCE OWED TO Y Y Documentary Fee 215 789 THIS VEHICLE HAS BEEN USED AS Pouce ven wu O satvace I Driver ED ven ovr ven TITLE FEE TOTAL DELIVERED PRICE IF THIS IS FOR A USED CAR OR LIGHT TRUCK THE INFORMATION YOU SEE ON THE FEDERAL TRADE COMMISSION WINDOW FORM IS PART OF THIS AGREE MENT INFORMATION ON THE WINDOW FORM OVERRIDES ANY CONTRARY PROVISIONS IN THE CONTRACT SALE THIS AGREEMENT IS NOT BINDING UPON EITHER THE PURCHASER OR THE DEALER UNTIL SIGNED BY BOTH PARTIES OR SHALL NOT BE BINDING UPON CASH DUE ON DELIVERY THE DEALER OR THE PURCHASER UNTIL ALL CREDIT TERMS IF APPLICABLE ARE APPROVED AND ACCEPTED BY ALL THE PARTIES DEALER PURCHASER AND LENDING INSTITUTION IF CREDIT TERMS ARE NOT ACCEPTED FULL DEPOSIT TRADE IN ALLOWANCE WILL BE REFUNDED TO PURCHASER AGREEMENT BASED UPON AVAILABILITY OF VEHICLE PURCHASER IS OF LEGAL AGE IN THIS STATE a Un oo oo oo N p un Una Less LIEN HAVE READ TERMS ON THE T AND HAVE RECEIVED A COMPLETED COPY OF THIS AGREEMENT TOTAL DOWN PAYMENT BALANCE 32 FINANCE CHARGE ERR o FINANCING 4 Pr il i INSURANCE CHARGE DEALER OR AUTHORIZED REPRESENTATIVE TOTAL AMOUNT OF AGREEMENT t 8 3 1
12. cian Machine gt AIRCHECKTEXAS DRIVE A CLEAN MACHINE Participation Requirements Texas Department of Motor Vehicles TxDMV Licensed Motor Vehicle Dealer Read and Follow the Dealership Requirements Procedures Terms and Conditions Send at Least One Dealer Representative to a Dealer Workshop for Program Training or Complete Other Designated Training Sign and Submit a Dealer Participation Agreement Outlining the Program Rules and Regulations to Which Dealer will be Subjected AIRCHECKTEXAS DRIVE A CLEAN MACHINE Participation Requirements Continued Maintain at Least Two Valid Email Addresses Attend All Mandatory Workshops as Required by Regional Administrator Sell Vehicles that Meet the Requirements Listed in Section 5 2 of the Terms and Conditions Have Internet Access to the AirCheckTexas Dealer Database and for the Public to Access the Drive a Clean Machine Website Have Credit Card Transaction Processing Capabilities with the Ability to Enter Credit Card Number and Expiration Date into a Terminal AIRCHECKTEXAS DRIVE A CLEAN MACHINE Major Steps in the Process Participant applies for replacement voucher Approved participant receives voucher letter amp manifest in the mail Dealer starts checklist after participant hands it over Dealer determines eligible car or truck and completes sale Dismantler picks up retired vehicle and completes manifest Dealer completes checklist and enters data online
13. reimbursement User s manual steps dealer through database and is on website Dealer will receive a login user name and password Dealer logs in to database before mailing all voucher paperwork to regional administrator Voucher found on voucher needs to be entered into Search for Vouchers Have the completed dealer checklist with you in order to enter the information Click the Update button and get Successfully entered message and the voucher goes to Vouchers Pending Payment Dealer mails all voucher paperwork to regional administrator Each dealership is responsible for regularly logging in and checking status of their submitted vouchers AIRCHECKTEXAS DRIVE A CLEAN MACHINE Surveying Participants All Participants Surveyed After Using Their Voucher to Determine Were they treated fairly Were they charged fees to use their voucher Have they had problems with their replacement vehicle Should the dealership be allowed to continue participating in the AirCheckTexas Program 40 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Site Visits and Monitoring Regional Administrator May Conduct Periodic Onsite Monitoring Visits to Ensure Compliance With Program Rules at Participating Dealerships Documentation of Vehicle Purchases Retirement Vehicle Transfers Account Activity May Be Reviewed for Consistent Information and Inspection of Any Retirement Vehicle Awaiting Transfer to an Approved Dismantler Deale
14. to file tto Me to file ito NCTCOG TCEQ 20412 NCTCOG Rev 3 29 10 21 AIRCHECKTEXAS DRIVE A CLEAN MACHINE AirCheckTexas Retired Vehicle Transfer Manifest INSTRUCTIONS pi ive ch AiRCHECKTEXAS RETIRED VEHICLE TRANSFER MANIFEST 4 0 0 1 7 5 0 PROGRAM ADMINISTRATOR NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS NCTCOG PHONE Toll Free P O BOX 5888 ARLINGTON TEXAS 76005 5888 817 608 2350 AUTOMOBILE DEALERSHIP SECTION To be filled out by Dealership VEHICLE OWNER Name Jo hn Se mith Phone 817 5 55 5555 Date 7 09 Mailing Address _ 1212 eet city Foe Worth state TX Zip 76104 VEHICLE INFORMATION ilFlAlFiPiaM iPis Ri Md24 o1lo Ailbii23 111517141 Vehicle Identification Number VIN License Plate Number dometer Reading Year 7 10 Make Ford __ Model Tau rus Title Document Number OS 7 y 5 6 7 8 12 3 760 193 Signature of Vehicle Owner AUTOMOBILE DEALERSHIP Dealership CAR World Phone 317 557 5555 County TARRANY Physical Address 15 South Street City Foe Lon State x Zip 76 0 7 Mailing Address E o South Street City Fort vorn State 1 Zi E ob Representative ores VIN amp Receipt of Vehicle Mu Date NOTE Payment to Automobile Dealership Contingent Upon Signature Below of Dismantler Verifying Receipt of Vehicle La 22 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Retired Vehicle Manifest Summary Complete all information in the Automobile
15. will result in delayed reimbursement AIRCHECKTEXAS DRIVE A CLEAN MACHINE AirCh eckTexas Retired Vehicle Transfer Manifest AinCuEckTExas ReriRED VEHICLE TRANSFER MANIFEST 1001750 on REVERSE PROGRAM ADMINISTRATOR NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS NCTCOG Phone Toll Free 0 BOX 5888 ARLINGTON TEXAS 76005 5888 817 608 2350 AUTOMOBILE DEALERSHIP SECTION To be filled out by Dealership VEHICLE OWNER Name _ John Smith Phone 11 555 5555 Date 7 LO Mailing Address _ 217 First Street city Foe Worth state TX Zip 76109 VEHICLE INFORMATION NN un ERE DIDI TIU year ID Make FORD vode Taurus Title Document Number _ 05745678 123 740 99 Signature of Vehicle Owner AUTOMOBILE DEALERSHIP Dealership CAR World Phone 0417 557 5555 County TARRAN Physical Address 17 5 South Street ciy Foret Loe State TX zip 76 09 Mailing Address _ 79 South Street ciy Fort State T Zip 70104 _Bpb Thomas Baba Ti log Dealership Representative Verifying VIN amp Receipt of Vehicle ignatre Date NOTE Payment to Automobile Dealership Contingent Upon Signature Below of Dismantler Verifying Receipt of Vehicle Sauvage DismantLing FaciLiTY SECTION To be filled out by Dismantler Salvage Dismantling Facility Salvage Phone _ 17 554 5555 County Tarrant Physical Address Ut West Avenue Fort State _ Te Zip 76 1 Maling Address _
16. CKTEXAS DRIVE A CLEAN MACHINE Potential Locations of Underhood ID Label AIRCHECKTEXAS DRIVE A CLEAN MACHINE AIRCHECKTEXAS DRIVE A CLEAN MACHINE AIRCHECKTEXAS DRIVE A CLEAN MACHINE 18 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Verifying From Checklist to the Eligible Vehicle Lists Replacement Vehicle Details From the Checklist Y Record all details of replacement vehicle below before it is sold Obtain information directly from the vehicle eremum 2190 mes Imane Eligible Vehicle Lists From the Website MODEL YEAR MODEL DISP CYL TRANS DRIVE FUEL STND UNDERHOOD ID 2009 FORD Explorer 4 6 Auto L5 2WD Gasoline 4 9FMXT04 03DC AIRCHECKTEXAS DRIVE A CLEAN MACHINE Dealer Checklist Summary Complete all details of vehicle being purchased Include full name of the make and model no abbreviations Test Group is found on a Vehicle Emission Control Information label under the hood Vehicle must have 70 000 miles or less Inspection Sticker Number is the certification number found on the sticker and on the vehicle inspection report This number is required whether the vehicle has a safety only inspection or safety and emissions inspection Dealer representative must print sign and date the checklist e Write in all information correctly in order for staff to verify the vehicle is eligible and can proceed with reimbursement Inconsistencies or missing information
17. Dealership Section Participant Vehicle Owner information on this form must match same information on voucher letter f address changes provide proof of new address Iflast name changes provide proof of new name Retired vehicle year make model VIN and license plate must match same information on voucher letter Spell out make and model names no abbreviations Participant must sign Dealer contact information must be completed Dealer representative must sign and date Write in all information correctly in order for staff to verify the manifest meets requirements and can proceed with reimbursement Inconsistencies or missing information will result in delayed reimbursement AIRCHECKTEXAS DRIVE A CLEAN MACHINE VEHICLE PURCHASE AGREEMENT PURCHASER DATE CAR WORLD John Smith Peggy Smith 7 1 2009 175 South Street cM Fort Worth TX 76109 1212 First Street 817 557 5555 city STATE zie Be Tor Booy STE Fort Worth TX 76109 nn sa ODOMETER VEHICLE IDENTIFICATION NUMBER TUE WE 1FTFP78P5TB875640 158 12345678 TX STERNE To BE DELIVERED NO LATER THAN SOR aan as P2750 7 1 2009 First Insurance 555 555 5555 THis VEHICLE WLL BE USED AS D rouce ven Dux D savace D oriver ED ven covr ven POLICY NO BINDER NO THIS VEHICLE HAS BEEN USED 0 Pouce ven O sawvace 157918 D DRIVER ED VEH D covt ven 7 Buyer s Order SUB TOTAL PRICE OF
18. SONS WE THE PERSONS WHOSE SIGNATURES APPEAR HEREIN HEREBY AGREE THAT THE OWNERSHIP OF THE VEHICLE DESCRIBED ON THIS APPLICATION FOR TITLE SHALL FROM THIS SIGNATURE DAY FORWARD BE HELD JOINTLY AND IN THE EVENT OF DEATH OF EITHER OF THE PERSONS NAMED IN THE AGREEMENT THE OWNERSHIP OF THE VEHICLE SHALL VEST IN THE SURVIVOR NON MARRIED PERSONS ARE REQUIRED TO EXECUTE A RIGHTS OF SURVIVORSHIP SIGNATURE OWNERSHIP AGREEMENT FOR A MOTOR VEHICLE FORM VTR 122 WARNING Transportation Code 501 155 provides that falsifying information on transfer documents is a third degree felony offense punishable by not more than ten 10 years in prison or not more than one 1 year in a community correctional facility In addition to imprisonment a fine of up to 10 000 may also be imposed NOTE Transportation Code 501 0235 REQUIRES that the applicant s social security number be provided when applying for a certificate of tile If the applicant does have a social security number Form VTR 171 Statement of Fact for Non disclosure of a Social Security Number must accompany this application This information is requested for owner identification purposes Form 130 U Rev 05 09 31 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Title Application Summary Participant Vehicle Owner information on this form must match same information on voucher letter f address changes provide proof of new address Iflast name changes provide proof of new
19. e participating dealerships list The participant s will be responsible for any costs incurred prior to receiving this letter as no reimbursements are allowed Along with your approval letter the Retired Vehicle Transfer Manifest form and clear vehicle title you drive the approved retired vehicle listed on this letter to a participating dealership Your approved vehicle will be left with the dealership and the appropriate voucher amount will be applied as the trade in value at the time of purchase You may wish to negotiate a final sales price to ensure you take advantage of all rebates discounts and other incentives being offered by the dealer The participant s named on the approval letter must be the name s on the replacement vehicle title as the voucher is not transferrable Also the approval letter may include the names of all adults in your household verified by the Regional Administrator as possible eligible co signers You may be contacted by participating dealers who may be offering their services however you can choose from any participating dealers on the list The replacement vehicle being purchased must meet certain criteria and refer to the enclosed insert for important details For a list of eligible Tier 2 Bin 5 or cleaner vehicles meeting the requirements visit www nctcog org airchecktexas or contact our office to obtain a copy of the list Please visit www nctcog org airchecktexas or call 1 800 898 9103 if you have any questions
20. efore the voucher letter is issued Vehicle Replacement Voucher Verification AIRCHECKTEXAS DRIVE A CLEAN MACHINE PROGRAM NORTH CENTRAL TEXAS REGION Fiscal Year 2015 Voucher Letter Verification Checklist All AirCheckTexas replacement voucher letters have the following features 1 Tamper Resistant Paper a Onthe Voucher Letter Side with the participant s information i Light blue color ii The hidden message COPY appears on a photocopied page iii The words Secure Rub appear and will disappear when rubbed b On the Dealer Checklist Side i Tan color with basket weave pattern ii The watermark is a star symbol Y with words Check Protect This watermark will not appear if the original document is photocopied Hold to light to view watermark to identify original 2 Participant Information all participant information name s address eligible co signer s retired vehicle information voucher number and expiration date is automatically printed on the voucher letter 3 Letter Heading a North Central Texas Region issued by the North Central Texas Council of Governments for Collin Dallas Denton Ellis Johnson Kaufman Parker Rockwall and Tarrant counties Voucher No used to uniquely identify the voucher and participant used by dealer to claim in the AirCheckTexas database Expires After replacement vehicle purchase date must be on or before the date listed Note purchase mus
21. f vehicle is 35 000 or less for Tier 2 Bin 4 or Bin 5 vehicles or 45 000 or less for Tier 2 Bin 3 or cleaner hybrid electric or natural gas vehicle see the STND column in the eligible vehicle list for Bin level 3 000 00 voucher value Tier 2 Bin 4 or 5 or 3 500 voucher value Tier 2 Bin 3 or cleaner hybrid electric or natural gas vehicle is listed as trade in on Buyer s Order and Title Application Line 21a voucher value reduces taxes owed Manifest signed and dated by participant s and dealer representative Buyer s Order Bill of Sale and Title Application signed and dated by participant s and dealer representative Trade in vehicle is marked AirCheckTexas and locked and secured on store lot Retired vehicle transferred to participating dismantler see list at www driveacleanmachine org Keep goldenrod page of manifest and make two copies of white front page after dismantler signs but before they leave with vehicle Login to AirCheckTexas database and complete data entry before mailing all required documents Mail completed dealer checklist goldenrod page of manifest photocopy of front page of manifest Buyer s Order Title Application and VIR if applicable Make keep copies of all documents for dealership records prior to mailing ALL VOUCHER DOCUMENTS MUST BE RETURNED TO AIRCHECKTEXAS OFFICE WITHIN 30 DAYS OF REPLACEMENT VEHICLE SALES DATE Mail to AirCheckTexas Program P O Box 5888 Arlingto
22. for Payment Vouchers Denied for Payment Historical Vouchers Denied for Payment Historical Vouchers Paid Change Password Dealer Agreement Instructions 1 Dealership representative will need to log into the AirCheckTexas Dealer Database and enter the username and password that was provided Each physical location has its own username and password For example if you have two locations then you will need to log in one location at a time and complete all these steps Texas Automotive Dealership Logged In As Example Dealer LOGOUT Dealer Agreement New 2014 Replacement Vehicle Requirements URGENT Correspondence Eligibile 2014 Vehicles Eligible 2013 Vehicles Eligible 2012 Vehicles Eligible 2011 Vehicles trucks not eligible 2010 vehicles are no longer eligible Database User s Manual Participating Auto Salvage Dismantlers Dealer Terms and Conditions You have 1 voucher s approved for payment 35 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Dealer Database Main Page Main Page View If You DO See the Search for Vouchers Then Your Location Has Been Activated to Accept Replacement Vouchers Al CheckTexas Clean Machine EE Search for Vouchers Vouchers Pending Payment Vouchers Authorized for Payment Vouchers Denied for Payment Historical Vouchers Denied for Payment Historical Vouchers Paid Change Password Dealer Agreement Instructions 1 Dealership representative will need to log into the AirCheckTe
23. formation on dealer checklist Voucher amount 3 000 or 3 500 listed as trade in sales tax calculations will be checked Vehicle sales price must meet program guidelines Purchase date must be within voucher issued date and expiration date dates shown before voucher issued or after expiration date will NOT be reimbursed Participant and dealer must sign and date Complete all information correctly in order for staff to verify the vehicle meets requirements and can proceed with reimbursement Inconsistencies missing info will result in delayed reimbursement 2 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Title Application APPLICATION FOR TEXAS CERTIFICATE OF TITLE SHADED AREAS ARE TO BE COMPLETED BY THE SELLER lt TYPE OR PRINT NEATLY IN INK TAX OFFICE USE ONLY Tax Collector Betsy Price ONLY County Use Only County Date 07 01 09 Transaction Number 1 Vehicle Identification Number 2 Year 3 Make 4 Body Style SPVS 1FTFP785TB875640 2009 Ford 5 Model 6 Odometer Reading 7 Empty Weight 8 Carrying Capacity lbs 9 Tonnage Explorer 158 Esq 4000 Appraisal Vala 10 Trailer Type 11 Plate No 12 Vehicle Unit No 13 Applicant s Additional Applicants Semi Full Social Security Numbers 14 Applicant s Owner s Name s John Smith and Peggy Smith Address 1212 First Street City State Zip Code Fort Worth TX 76109
24. n TX 76005 5888 Overnight Delivery Service AirCheckTexas Program 616 Six Flags Drive Centerpoint Two Arlington TX 76011 Dealership representative must sign and date below to ensure processing hereby certify under penalty of perjury that all information provided and contained herein is complete accurate and true understand that falsification of this information and or attachments may result in criminal penalties punishable by law 1 acknowledge that all information given is subject to verification and or monitoring authorize AirCheckTexas Program representatives to verify information needed to certify eligibility and release the Regional Administrator of all liability for personal injury death or property damage Dealer Signature FOR DEALERSHIP USE ONLY AIRCHECKTEXAS DRIVE A CLEAN MACHINE Tamper Resistant Paper Light blue color on one side Tan color basket weave on other side COPY appears if photocopied Unique watermark Participant Information Participant name and address Eligible co signer s Retired vehicle information Voucher number Expiration date Letter Heading Issued by NCTCOG for nine North Central Texas counties Voucher number used by dealer to claim in the database Expires After replacement vehicle purchase date must be on or before the date listed No negotiations or purchase of vehicle may take place b
25. name Replacement vehicle being purchased year make model VIN must match same information on dealer checklist Voucher amount 3 000 or 3 500 listed as trade in sales tax calculations will be checked Vehicle sales price must meet program guidelines Purchase date must be within voucher issued date and expiration date dates shown before voucher issued or after expiration date will NOT be reimbursed Participant and dealer must sign and date Complete all information correctly in order for staff to verify the vehicle meets requirements and can proceed with reimbursement Inconsistencies missing info will result in delayed reimbursement 32 AIRCHECKTEXAS DRIVE A CLEAN MACHINE AirCheckTexas Retired Vehicle Transfer Manifest SALVAGE DISMANTLING Facitity SECTION To be filled out by Dismantler Salvage Dismantling Facility Auto Salvage Phone 817 558 5555 County Tarrant _ Physical Address West Avenue Fort ube State Tx zip 76 Mailing Address _ West Avenue city Fort Lae State TM zip ZO Texas Dept of Transportation TxDOT Salvage Vehicle Dealers License Number lalala 4 Isle lg Storm Water Permit Number Tlxi amp lolo im 9 9 Joe Janes Salvage Dismantling Facility Representative Verifying VIN amp Receipt of Vehicle DESTRUCTION CERTIFICATION certify that the emissions control equipment AND THE ENGINE of this vehicle have been destr
26. on claimed under the Motor Vehicle Sales and Use Tax Law because h AMOUNT OF TAX AND PENALTY DUE s 1068 87 ftem pius tem f minus item Mem O 28 or 33 APPLICATION FEE FOR CERTIFICATE OF TITLE Contact your County Tax Assessor Collectar for the correct tee CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF Bob Thomas I HEREBY CERTIFY THAT ALL STATEMENTS IN THIS DOCUMENT ARE TRUE AND 07 01 09 PRINTED NAME Same as signature John Smith Peggy Smith Date 07 01 09 PRINTED NAME Same as signature RIGHTS OF SURVIVORSHIP OWNERSHIP AGREEMENT MARRIED PERSONS WE THE PERSONS WHOSE SIGNATURES APPEAR HEREIN HEREBY AGREE THAT THE Dale OWNERSHIP OF THE VEHICLE DESCRIBED ON THIS APPLICATION FOR TITLE Sti SIGNATURE THE AGRE NON MARRIED PE Form 130 U Rev 05 09 29 Title Application APPLICATION FOR TEXAS CERTIFICATE OF TITLE SHADED AREAS ARE TO BE COMPLETED BY THE SELLER TYPE OR PRINT NEATLY IN INK OFFICE USE_ONLY County Tarrant Date 07 01 09 Transaction Number Tax Collector Betsy Price 1 Vehicle Identification Number 2 Year 3 Make 4 Body Style 1FTFP785TB875640 2009 Ford 5 Model 6 Odometer Reading 7 Empty Weight 8 Carrying Capacity Ibs 9 Tonnage Explorer 158 4000 10 Trailer Type 11 Plate No 12 Vehicle Unit No Semi Fun 14 Applicant s Owner s Name s John Smith and Peggy Smith
27. oyed Emissions control equipment may include but is not limited to the following exhaust gas recirculation system power control module catalytic converter oxygen sensors evaporative purge canister positive crankcase ventilation valve gas cap SEE PENALTY NOTICE ON REVERSE SIDE All mercury switches have been removed and also certify that the vehicle has been destroyed and the remaining residual scrap metal will be conveyed to a participating recycling facility Dismantler Representative Verifying Destruction of Equipment and Vehicle RecycLinG Facitiry Receivinc REsipuAL Scrap METAL SEE INSTRUCTIONS ON REVERSE SIDE Recycling Facility Phone County Physical Address CH os ser cul AN Er REIR ee C zn Scale Ticket Number Print Name Recycling Representative Receiving Residual Scrap Metal Date White Automobile Dealership Green Automobile Dealership Yellow Salvage Dismantling Facility Pink Recycling Facility Goldenrod Auto Dealership to NCTCOG to file to file to file to NCTCOG TCEQ 20412 NCTCOG Rev 3 29 10 33 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Dealer Database Main Page Login Using Your Specific Dealership Username and Password Main Page View If You DO NOT See the Search for Vouchers then Your Location Has Not Been Activated to Accept Replacement Vouchers AfrCheckTexas Clean Machi ean Machine 9 Vouchers Pending Payment Vouchers Authorized
28. r Representative Will Need to Be Onsite to Meet and Assist Regional Administrator Staff Regional Administrator Shall Notify Dealerships Verbally and or in Writing of Any Findings Dealership May Be Given an Opportunity to Correct These Findings Additional Site Visits May Be Required to Follow Up on These Findings 41 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Sign and Submit Participation Agreement Important Steps After Completing Workshop By Signing and Submitting an Agreement Dealership Agreed to All Terms and Conditions Allow 5 Business Days for Processing You Will See the Search For Vouchers Link on the Main Page of the Dealer Database 42 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Contact Information For Dealerships Phone Fax Email Website Address 817 608 2350 817 695 9292 airchecktexas nctcog org www nctcog org airchecktexas AirCheckTexas Program PO Box 5888 Arlington TX 76005 5888 43
29. t not take place before the voucher letter is issued AIRCHECKTEXAS DRIVE A CLEAN MACHINE Front Voucher Letter ri Drive a Acheta cache 03 21 2012 John Smith ee GENTRAL TEXAS REGION 1212 First Street aardlek 08259 1 41915 Fort Worth TX 76109 Xpies after 06 30 201 Dear John Smith You have been approved to receive replacement assistance through the AirCheckTexas Drive a Clean Machine Program This approval letter qualifies you to receive 3 000 toward the purchase of a qualifying car or truck or 3 500 toward the purchase of a qualifying hybrid vehicle electric vehicle natural gas vehicle or a Tier 2 Bin 3 or cleaner vehicle Please note the expiration date of 06 30 2011 below the voucher number on this letter This approval letter must be presented and vehicle purchased at a participating dealership on or before the expiration date as we are unable to provide extensions due to funding availability Retired Vehicle Information Participant Name s Eligible Co signer s 1990 Ford Taurus John Smith Peggy Smith VIN 1FAFP34P5RM789010 License No ASD123 11 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Back Dealer Checklist n PORE Drive a NORTH CENTRAL TEXAS REGION AirCheckTexas Clean Machine DEALER CHECKLIST ALL BOXES BELOW MUST BE CLEARLY CHECKED AND VEHICLE INFORMATION COMPLETED BY A PARTICIPATING DEALERSHIP REPRESENTATIVE INCOMPLETE INFORMATION MAY RESULT IN DELAYED PROCESSING CHECKLIST IS NOT INCLUSIVE
30. take the Fair Market Value Deduction V A T S Tax Code 152 002 c 20 DESCRIPTION OF VEHICLE Vehicle Identification Number TRADED IN if any 1FAFP34P5RM789010 AIRCHECKTEXAS DRIVE A CLEAN MACHINE 30 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Title Application 21 SALESAND USE TAX COMPUTATION E 2 CI 90 New Resident Tax Previous State b Less Trade In Amount Describe in Item 20 Above 3000 00 5 Even Trade Tax c For Dealers Lessors Rental ONLY Fair Market Value C 10 Gift Tax Deduction Describe in Item 20 Above 0 00 65 Rebuilt Salvage Fee d Taxable Amount Item a minus Item b ltem c 17101 85 2 5 Emissions Fee Diesel Vehicles 1996 and Older gt 14 000 lbs e 6 25 Tax on Taxable Amount Multiply Item d by 0625 1068 87 1 1 Emissions Fee Diesel Vehicles 1997 and Newer gt 14 000 lbs f Late Tax Payment Penalty 5 or 110 0 00 C Exemption claimed under the Motor Vehicle Sales and Use Tax Law because g Tax Paid to STATE 0 00 h AMOUNT OF TAX AND PENALTY DUE 1068 87 0 28 or 33 APPLICATION FEE FOR CERTIFICATE OF TITLE tem e plus Item minus Item g Contact your County Tax Assessor Collector for the correct fee HEREBY CERTIFY THAT ALL STATEMENTS IN THIS DOCUMENT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF John Smith Peggy Smith 07 01 09 PRINTED NAME Same as signature Date RIGHTS OF SURVIVORSHIP OWNERSHIP AGREEMENT MARRIED PER
31. xas Dealer Database and enter the username and password that was provided Each physical location has its own username and password For example if you have two locations then you will need to log in one location at a time and complete allthese steps Texas Automotive Dealership Logged In As Example Dealer LOGOUT Dealer Agreement New 2014 Replacement Vehicle Requirements URGENT Correspondence Eligibile 2014 Vehicles Eligible 2013 Vehicles Eligible 2012 Vehicles Eligible 2011 Vehicles trucks not eligible 2010 vehicles are no longer eligible Database User s Manual Participating Auto Salvage Dismantlers Dealer Terms and Conditions You have 1 voucher s approved for payment 36 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Reimbursement of Voucher Amount Enter Voucher and Replacement Vehicle Information into the Dealer Database Submit by Mail Completed and Signed Voucher Paperwork Totally completed and signed voucher letter or dealer checklist Manifest photocopy Goldenrod copy of manifest Buyer s order Title application Other docs if applicable VIR Proof of address change Verification of name change Must Send All Paperwork Within 30 Days of Sale Date Make Copies of Everything You Send Us and Keep for Three 3 Years 37 AIRCHECKTEXAS DRIVE A CLEAN MACHINE Dealer Database Follow up Summary Dealer must have computer with internet access and credit card terminal to obtain
32. xpired Buyer is the same person s as the Participant Name s printed on the voucher letter If needed ensure co signer s name appears in the Eligible Co signer s printed on the voucher letter vf Trade in vehicle is drivable and matches Retired Vehicle Information printed on voucher letter Y Record all details of replacement vehicle below before it is sold Obtain information directly from the vehicle IETEPTSPSTR ISOS U liters fee Eyplorer Seters AFMATOH OSDE Automatic sticker Number 12 871362 19 Vehicle qualifies for program compare details above against eligible vehicles list at www nctcog org airchecktexas Odometer reading of replacement vehicle being sold is 70 000 miles or less 13 AIRCHECKTEXAS DRIVE A CLEAN MACHINE FY 2015 Replacement Vehicle Requirements As of September 1 2014 Eligible Models Changed to 2012 2015 Cars SUVs and Minivans 2012 2015 Hybrid Electric and Natural Gas Vehicles and Tier 2 Bin 3 or Cleaner Vehicles 2013 2015 Trucks Sales Price Maximum 35 000 for Tier 2 Bin 4 amp Bin 5 Vehicles Vehicles Eligible for 3 000 Voucher 45 000 for Hybrid Electric Natural Gas and Tier 2 Bin 3 or Cleaner Vehicles Vehicles Eligible for 3 500 Voucher Mileage Limitation Must Have 70 000 Miles or Less at Time of Purchase Meet Federal Tier 2 Bin 5 or Cleaner Emissions Standards and Intended for Everyday Use Not to Exceed 10 000 Pounds AIRCHE
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