NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS
Vehicle/Equipment and Engine Disposition Verification Form
PERFORMING PARTY:
Grant Program Name:
Project Number (from Scope):
Scope Activity Number:
Project Contact Name:
Project Contact Title:
Phone Number:
E-mail:
Address:
Part 1: Vehicle/Equipment Information
Please provide information on the vehicle/equipment being replaced/repowered. Refer to the
vehicle/equipment Operations Manual or contact the dealer for information.
Vehicle/Equipment Type:
Vehicle/Equipment Identification Number:
Vehicle/Equipment Make:
Vehicle/Equipment Model:
Vehicle/Equipment Year:
Gross Vehicle Weight Rating (GVWR) (Vehicles Only):
Part 2: Engine Information
Engine information is listed on the engine’s emissions label, usually located on the topside of
the engine. The serial number should also be stamped on the engine block.
Engine Serial Number:
Engine Make:
Engine Model:
Engine Year:
Engine Horsepower:
Fuel Type:
If any of this information is unavailable, provide an explanation below:
Project Number:___________________
Activity Number:___________________
Page 1
NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS
Vehicle/Equipment and Engine Disposition Verification Form
Part 3: Verification of Destruction
Complete either Repower Project Verification (if only the old engine was destroyed) or
Replacement Project Verification (if the old vehicle/equipment and engine were destroyed).
I certify the engine and/or the vehicle/equipment have been destroyed or rendered
permanently inoperable by one of the methods described below (initial the box next to the
statements which apply):
Repower Project Verification
A 3-inch hole has been drilled into
the old engine block.
OR
The old engine has been
completely destroyed (explain
details on the destruction method
below):
Replacement Project Verification
A 3-inch hole has been drilled into the
old engine block
A wedge 75% of the way through the
frame rails or major structural
components of the old
vehicle/equipment have been cut.
(need to ensure structural integrity of
chassis is compromised)
OR
The old engine and vehicle/equipment
have been completely destroyed
(explain details on the destruction
method below):
If the vehicle/equipment/engine was rendered inoperable or destroyed by a third party, such as
a recycler, salvage yard, or disposal facility, please list the entity. The NCTCOG may contact
the entity for additional information.
Third-Party Information
Company/Facility Name:
Contact Person:
Contact Title:
Phone Number:
E-mail:
Address:
Project Number:___________________
Activity Number:___________________
Page 2
NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS
Vehicle/Equipment and Engine Disposition Verification Form
Part 4: Required Documentation
Attach photographs, written documentation, and/or similar proof of destruction. A checklist of
required photographs is outlined below.
Photographs
Vehicle/Equipment (required for Replacement projects)
_____ Photo(s) of entire vehicle/equipment prior to destruction
_____ Photo(s) of VIN/Equipment ID or other identifying unit number
_____ Photo(s) of wedge cut in frame rails/chassis OR photo(s) of other destruction
method in process (i.e. vehicle crushed) – (need to show same section of chassis
before and after destruction)
_____ Photo(s) of the entire vehicle/equipment after destruction
Engine (required for both Repower and Replacement projects)
_____ Photo(s) of entire engine prior to destruction
_____ Photo(s) of Engine Serial number and/or data plate
_____ Photo(s) of 3-inch hole drilled in engine block (NCTCOG recommends clearly
identifying the location of the drilled hole with a pointer stick or label in the photo
OR photo(s) of other destruction method in process – (need to show same
section of engine before and after destruction)
_____ Photo(s) of the entire engine after destruction
Written Documentation
If a third party entity completed the destruction, attach a salvage certificate or other
signed statement from the facility indicating that destruction has been completed in
accordance with the methods outlined above.
Project Number:___________________
Activity Number:___________________
Page 3
NORTH CENTRAL TEXAS COUNCIL OF GOVERNMENTS
Vehicle/Equipment and Engine Disposition Verification Form
Part 5: Program Income
Any revenue received from the sale of scrap metal or other materials from destroyed
vehicles/equipment/engines is considered Program Income associated with this project. This
revenue must either be reported at the time reimbursement is requested, or the Performing
Party must commit to retaining the destroyed vehicle/equipment/engines within its ownership
through the end of the Agreement termination date.
Documentation of Program Income (Check One)
Amount Received for Scrap Value
(if sold):
(Attach receipt or other
documentation from scrap facility)
OR
I do hereby certify and affirm that the
vehicle/equipment/engines destroyed as a part of
grant activities under the Project and Activity
Number identified on this form, and described in
this document, is still in my possession and has not
been sold for scrap. I understand that any revenue
received by selling for scrap prior to the Agreement
termination date is considered Program Income
and must be reported at the time of requesting
reimbursement. By signing and submitting this
document, I certify that I will retain said
vehicle/equipment in my possession for a period of
60 days beyond the termination date of my
Agreement with NCTCOG for this Project Number
and will not sell for scrap for the duration of the
Agreement.
Part 6: Certification
I, the undersigned, certify that to the best of my knowledge all submitted information is true. I
understand that the NCTCOG may not reimburse grant funding or may require return of funds if
disposition requirements are not met.
__________________________________
Signature of Performing Party
__________________________________
Printed Name and Title of Performing Party
__________________________________
Date
Project Number:___________________
Activity Number:___________________
Page 4