OMB Control No. 2060-0528

Approval Expires 03/31/2011

Energy Star® product information form for use by Energy Star qualified boiler partners

(Companies who have joined Energy Star for boilers by signing a Partnership Agreement)

You may use this form to report only those products that are sold under your company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join the program and report its own products. Information from this form will be added to the list of Energy Star qualified boiler products.If you need additional space, please copy this form.

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC20460USA

Toll-free number: 1-888-STAR-YES Web site:

Energy Star is a registered US mark.

EPA Form No. 5900-60

OMB Control No. 2060-0528

Approval Expires 03/31/2011

Company Name:

(As listed in Partnership Agreement) Product Contact Information

(For public requesting product information)

Name:

Tel:

Fax:

Email:

Tested by:

(Name of Firm or Self-Tested)

Additions to Qualifying Products List:

Manufacturer Name (Trade Name) / Product Family Name / Type
(i.e., Steam or Water) / Fuel Type (e.g. Gas, Oil, etc.) / Provides Hot Water Heating? / AFUE Rating / CAafue Rating[1] / Model Series[2]

Labeling Requirements:

By checking the boxes below, you are confirming that you have reviewed and will meet the labeling requirements outlined in the ENERGY STAR Program Requirements for Boilers once this model has been approved by EPA for qualification. These requirements include:

Product literature (required)Internet site (required) Product packaging (recommended)

If answer to any of the above is No, explain why:

Declaration:

By checking this box, I declare that the information submitted via this form is, to the best of my knowledge, accurate and associated with the products included for qualification in this submittal. I understand that the ENERGY STAR Program will associate all data in this submittal with the products listed in this submittal upon receipt. I understand that if any of the submitted information is found to be inaccurate, the products will be removed from the ENERGY STAR qualified products list. I understand that intentionally submitting false information to the U.S. government is a criminal violation of the False Statements Act, Title 18 U.S.C. section 1001.

Date:

Instructions for Submittal:

Please submit your completed QPI Form using one of the following ways:

Email:

Fax: (202) 862-1144

US Mail/Overnight Express: 1725 Eye St., NW, Suite 1000, Washington, DC20006

QPI forms must be accompanied by a lab report. Additional information about acceptable lab report formats may be found at .

EPA uses this data for internal evaluation purposes - to determine ENERGY STAR qualification.Should data other than that which is destined for the ENERGY STAR qualified product list be made public, it will be done so as aggregated data. If you have concerns regarding providing your data via this form, please email

.

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC20460USA

Toll-free number: 1-888-STAR-YES Web site:

Energy Star is a registered US mark.

EPA Form No. 5900-60

[1] Combination Space-Heating and Water Heating appliances provide both space conditioning (boiler) and hot water heating with one appliance or energy source. The combination appliance circulates hot water from the water heater through a heat exchanger in the air handler. A blower will move the heated air through a standard duct system. In the summer, an air conditioner is connected to the exchanger and the system functions similarly, with cool air being pushed through the ductwork. When the primary heating source of the combined appliance is a residential boiler, the Combined Appliance Annual Fuel Utilization Efficiency (“CAafue”) is the same as the AFUE of the boiler as determined by DOE test procedures specified in 10 CFR 430.

[2] Please simplify model series information when possible (e.g., “All models beginning with...”).