$1500 to upfit a Sprinter/Metris with "Adaptive" equipment

How it works:

1. . The program applies to all models and model years of new Sprinter or Metris vehicles sold or leased and
   delivered through an authorized Sprinter/Metris dealer.

1. Adaptive equipment must be installed within six months of the new vehicle purchase or lease. A completed
   application form (attached) with all required supporting documentation must be emailed to:
   VanSalesSupport@mbusa.com
   or mailed within 60 days of completed installation of adaptive equipment to:
   Mercedes-Benz USA Commercial Vans
   303 Perimeter Center North, Suite 202
   Atlanta, GA 30346
   Attn: Field Sales Operations Department
2. Adaptive equipment is defined as equipment that is required by persons with a permanent disability to drive, enter,
   exit and/or be transported safely in a Sprinter or Metris vehicle. Factory-optional equipment is not reimbursable under
   this program, even if ordered in conjunction with adaptive equipment.

1. Conversions to all Sprinter and Metris vehicle models may be reimbursed up to a maximum of $1,500.

1. One (1) reimbursement per customer/entity.

1. The application form must be completed in its entirety and sent in with a valid vehicle registration and the adaptive
   equipment company's itemized paid invoice, as described below. The document must be signed by the customer and
   dealership.

1. Mercedes-Benz Commercial Vans, in its sole discretion, will determine eligibility, interpretation and fulfillment of all
   elements of this program. Any payment or benefits received are subject to the Program Guidelines. Payments made by
   Mercedes-Benz Commercial Vans hereafter constitute good will reimbursements to assist Sprinter and Metris
   purchasers and lessees with the installation of special need mobility equipment. Such payment does not represent any
   approval of the equipment or installation method or otherwise constitute a representation or warranty regarding the
   fitness, quality, appropriateness, effectiveness or suitability for use with Mercedes-Benz Commercial Vans products or
   any other warranty of any type with respect to the equipment or its installation.

1. Eligibility:
   
   1. If purchaser or lessee is an individual, following are the items that must be emailed or mailed to the locations
      identified above:
      • • A copy of the application form
        • Adaptive equipment company's itemized invoice and receipt of payment (cancelled check etc.)
        • Valid vehicle registration
        • Prescription or note from a licensed medical doctor on physician's letterhead stating the specific diagnosis
   2. If an entity such as a non-profit organization, church, assisted living facility and/or nursing home, or a business
      offering services under any of the categories listed in the attached "Industry Titles" addendum, the following are the
      items that must be emailed or mailed to the locations identified above:
      • • A copy of the application form
        • Adaptive equipment company's itemized invoice and receipt of payment (cancelled check etc.)
        • Valid vehicle registration
        • Proof of your active status with your state's agency that regulates charitable organizations OR proof of your 501c3
          status from the IRS OR state business license/permit
   3. Adaptive equipment paid by 3rd party or government programs will not be eligible.

The customer is responsible for submitting this application and documentation within the program time limit. Payment
to the individual customer will be mailed within 6-8 weeks after receipt and approval of application form and all
required documentation.

Application Form

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