001-FY16-07/15

Local Government Energy Audit Program Registration Form

July 1, 2015 – June 30, 2016The Local Government Energy Audit Program provides funds to subsidize the cost of an energy audit and

encourage the implementation of the recommendations in the energy audit report.

The first step to enrolling in the Local Government Energy Audit Program is to submit this form, the Facility DataForm(s), and one of the following, whichever is applicable:

A. A copy of a resolution passed by your local governing body.B. A copy of a tax exemption letter from the Internal Revenue Service indicating that your organization is

exempt from Federal income tax under section 501(c)(3).

Next, you should begin to develop your RFP while the Program Manager processes this form, the Facility Data Form(s), and either A or B from above.

A. You are required to receive confirmation and approval from the Program Manager before contacting any ofthe pre-qualified energy auditing firms.

Application Eligibility Checklist (The applying entity must check one of the following to be eligible.)

A local government under the Local Public Contracts Law

A local government under the Public School Contracts Law

A county college under the County College Contracts Law

A New Jersey State College or State University

A nonprofit charitable organization exempt from taxation under Section 501 (c)(3) of the Internal Revenue Code

AND, must be able to assert the following:

This applying entity has not already met the program cap of $100,000 this calendar year through the LGEA Program for eligible buildings. The applying entity has previously applied and been approved for the LGEA Program:

Yes

No

Applicant Contact Information (Please complete the information below for the primary contact for this application.)Applying Entity Tax ID

Primary Contact Name Title County

Address City State Zip

Phone Fax E-mail

How did y rogram? Advertisement Internet Search Mailer Video

Tradeshow/Event Word of Mouth Radio Contractor Other __________________________________________________________

Designated Representative (if applicable)Company Name

Contact E-mail

Contact Name

Contact Phone

NAICS Code

001-FY15-07/14

The program is designed to be a first-come, first-served program in terms of the budget, which means applications that are reviewed and complete will be funded on a rolling basis while designated funds last. However, if there are more applications seeking funds than there are remaining funds, the following criteria will be used to prioritize the applications.

Does this applying entity meet the following prioritization criteria:a. The local government agency has completed the registration process with Sustainable Jersey, and the governing body of the local government agency has passed a resolution stating their intent to seek “certification” according to the Sustainable Jersey criteria.

b. The agency is actively participating in a state, national or other sustainability certification or implementation program that has rigorous and verified criteria for establishing what can be done to be sustainable. This includes actions and strategies addressing issues such as sustainable community creation, energy efficiency, greenhouse gas reduction, sustainable/green design, and/or high performance buildings.

Yes, this entity does meet one or more of these criteria.

No, this entity does NOT meet one or more of these criteria.

Prioritization Criteria

Other Funding Sources

Please mail, fax, or e-mail your completed application to:New Jersey's Clean Energy Program c/o TRC Energy Services

900 Route 9 North, Suite 404 • Woodbridge, NJ 07095Phone: 866-657-6278 • Fax: 732-855-0422 • E-mail: LGEA@NJCleanEnergy.com

For further questions, please call 866-657-6278 x4 or visit our website at NJCleanEnergy.com/LGEA

Application AuthorizationAuthorization section should be signed by the Mayor, Business Administrator, Executive Director, or some comparable decision-maker at the applying entity.

I have read the Program Guidelines and understand the Program rules and procedures. I will not hold the Administrator or Program Manager responsible for work performed by a third party

Applicant Representative Signature

Application Representative Printed Name

Applicant Representative Title

Date Submitted

Staff Use Only: Date Received: _______________________________________

ACKNOWLEDGEMENT – I have read, understood and am in compliance with all rules and regulations concerning this incentive program. I certify that all information provided is correct to the best of my knowledge, and I give the Program Manager permission to share my records with the New Jersey Board of Public Utilities, and contractors it selects to manage, coordinate or evaluate the Local Government Energy Audit Program, including the release of electric and natural gas utility billing information, sharing of ENERGY STAR® Portfolio Manager data and access, as well as make available to the public non-sensitive information. I allow reasonable access to my property to inspect the existing conditions of the facility or facilities in order to determine eligibility for incentives under the guidelines of New Jersey’s Clean Energy Program. This arrangement supersedes all other communications and representations.

Acceptance into the Program is dependent on approval of the Scope of Work and cost proposal. Acceptance into the Program does not guarantee approval of the energy audit report. The applicant and selected auditing firm must meet all Program rules to receive incentive funds from the Program. Neither the Commercial/Industrial Program Manager nor the Administrator is responsible for work performed by third parties.

Check the box if an Energy Savings Improvement Program (ESIP) will be a source of funding. ESIP allows government agencies to pay for energy related improvements using the value of the resulting energy savings.

Check this box if the Energy Resilience Bank (ERB) will be an anticipated source of financing. The ERB is being utilized to develop or enhance distributed energy resource techologies at critical facilities that were directly or indirectly impacted by Superstorm Sandy or other eligible disasters.