WSDOT e-bike rebate applicant registration form

Thank you for your interest in the WE-bike instant rebate program! The information you provide below will be used to ensure your eligibility and provide you with the best possible experience. If you would like to apply for an income qualified rebate, you will need to share your income information below. Rest assured, your data is handled with utmost care and confidentiality. We prioritize your privacy and guarantee that your information will not be shared with any third parties. 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, most application materials are considered public records and must be released if requested.

PERSONAL INFORMATION

First Name

Last Name

Date of Birth

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.

Full Address

You must select an address from the pre-populated list to proceed. Begin typing in the address where you receive mail in the state of Washington in the “Full Address” field and select from the list of addresses. If you do not see your address, please contact customer service for support.

Street

County

City

Postal Code

State/Province

Home Phone

Mobile Phone

ELIGIBILITY INFORMATION

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

NoYes

What type of E-Bike are you interested in?

I would like to be considered for any future e-bike rebate programs should the opportunity be available

Annual Household Income

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.

Total Household members