WSDOT e-bike rebate applicant registration form

The information you provide below will be used to ensure your eligibility for this program. If you want to apply for an income qualified rebate worth $1200, you will need to share your income information below. Information shared with us is securely stored and handled confidentiality. We prioritize your privacy and guarantee that your information will not be shared, including with any third parties. All information provided in this form will be verified before a rebate is issued. Thank you and we look forward to helping you enjoy the benefits of our program. .

By submitting this e-bike rebate application, you acknowledge that the information provided creates a public record subject to the Washington State Public Records Act (RCW 42.56). All submitted information will be maintained in accordance with state records retention requirements (RCW 40.14) and may be subject to public disclosure upon request. While certain personal information may be exempt from disclosure under state law.

ELIGIBILITY INFORMATION

Unhoused or No Permanent Residence

Please provide an address where you can be contacted, this can be the address of an agency you are working with. If you cannot provide this, please contact customer service for assistance by email at EBikesWSDOT@aptim.com or call 1-833-909-4222.

Date of Birth

Full Address

Street

County

City

State/Province

Postal Code

REBATE VALUE

Do you want to be considered for the $1200 income eligible voucher?

NoYes

Total Household members

Annual Household Income (add numbers only no $ or commas)

Income and household information required to determine which rebate you can apply for. Enter the gross annual income for your entire tax household. Please ensure this is accurate as you will be required to provide proof of income if selected during the random selection process. Income eligibility is determined by income and household size, based on the Area Median Income (AMI). Tax households earning at or below 80% of the county AMI are eligible.

PERSONAL INFORMATION

First Name

Last Name

Preferred Language

Mobile Phone