OMB Control No. 2060-0528 Approval Expires 03/31/2011

Energy Star® product information form for use by Energy Starqualified geothermal heat pump partners

(Companies who have joined Energy Starfor geothermal heat pumps 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 geothermal heat pump 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. 5900-74

OMB Control No. 2060-0528 Approval Expires 03/31/2011

Company Name: Product Contact Information

(As listed in Partnership Agreement)(For public requesting product information)

If above listed company is not the originalName:

equipment manufacturer (OEM), whatTel:

is the name of the OEM?Fax:

E-mail:

Tested By:

(Name of Firm or Self-Tested)

DateTested:

Additions to Qualifying Products List:

Brand Name / Model Name / Product Type[1] / Water Heating[2] / Test Standard[3] / COP Rating / EER Rating / Model Number[4]

Check to confirm that themanufacturer limited warranty is provided for all models above (Note:all parts and labor must be covered for a minimum of two years, and a minimum of five years for the major refrigerant circuit components, as specified in Section IV of the Eligibility Criteria.)

Labeling Requirements:

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

In product literature?(required) On Internet site? (required)

On product packaging? (recommended) On the top/front of the product? (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 Qualified Product Information Forms one of the following ways:

Email:

Fax: (202) 862-1144

US Mail/Overnight Express: ICF International,1725 Eye Street 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 .

Thank you for your assistance. The Qualifying Products List is available through the Energy Star Hotline

(1-888-STAR-YES/1-888-782-7937) and Web site (

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. 5900-74

[1] Please specify product type according to the product types listed in Section III, Tables 1-3 of the Eligibility Criteria.

(i.e., Closed Loop Water-to-Water, Open Loop Water-to-Water, Closed Loop Water-to-Air, Open Loop Water-to-Air, DGX).

[2] Please specify the means of domestic water heating offered, if applicable (i.e., provided through the use of a desuperheater or demand water heating model).

[3] Please specify the test standard that testing was performed in accordance with (i.e., ISO 13256-1, ISO 13256-2, or AHRI 870).

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