To Start the Grant Process with Energy Improvement Matters (EIM, LLC), Complete Form And

REAP Grant Intake Form for Energy Improvement Matters

For Retro-Fitting a Business to a Central Boiler System

Paperwork must be received by March 1 2013 to be prepared in time for the 2013 grant cycle. To start the grant process with Energy Improvement Matters (EIM, LLC), completethis form and return itto EIM.Send a check for $600 for grant writing and energy audits. Make checks payable to EIM at 7545 Chablis Circle, Indianapolis, IN 46278. By completing this application, the applicantalso agrees to pay EIM 1% of the total project amount, if and only if you winthe grant. The REAP grant pays you 25% of eligible project costs if you win.

Name of Applicantor Businessto be listed on the grant application (full legal name as on taxes)

______

Principal person to contact: ______

Person who will sign the grant application: ______

Tax ID # (if sole proprietor, your SSN works)______DUNS#______

Phone______Fax______

E-mail (very helpful for quick communication)______

Business address______

Location of proposed equipment ______

Type of business (as taxes are filed): circle one: Sole Proprietor; LLC; C Corp; S Corp

List names and addressesof business partners filing taxes under this name (i.e.: wife, brother, parent; partner) ______

Describe your operation (PLEASE provide all info).

What type of farm or company do you have?

Years you have been in this business:______

Years you have operated equipment similar to what you are requesting:______

If this grant is for a farm, please describe your farm in terms of total acreage farmed and what you produce.

How many full-time employees do you have?______

How have you learned about energy efficient equipment? ______

___ Met with dealers

___ Investigated independently on-line

___ Attended farm shows and meetings

Educational level ___ High school___ Trade school___ Associate Degree___ BS ___ MS

(This is used to tell the grant reader that you will be able to operate the equipment if you receive the grant.)

How do you think this equipment would benefit your farm or business? (Check all that apply): _____ It would allow me to keep up with increasing capacity needed to advance my business;_____ It would save money in operating costs by reducing fuel bills; _____ It would increase the quality of my products.

Other things for which you are proud and make you a good applicant:

Dealershipwhere you will purchase equipment (please use a separate paper if you have multiple dealers for different equipment). ______

Dealer contact (sales person) ______

Phone number:______E-mail:______

Fax:______

Equipment (make and model # if possible) that you wish to purchase ______

(Please use a separate paper as needed.) Fuel(circle): LP; Natural Gas; Electric

Bank you will work with (required) ______

Contact person______

Phone number______E-mail______

Fax:______

Description of Current/Existing equipment

1.Current heating system description

Manufacture______Model ______Qty____BTU output______Propane or Natural gas

2. Fuel Type for existing equipment (circle): Liquid propane Natural Gas Electricity

3. Fuel cost (cents/gal):______Total cost last year______

4. Electricity Cost (cents/KWH):______Total Cost last year ______

Description of the NEW system

What Central Boiler will be installed:______

1. Other than the boiler what equipment will be installed: ______

______

2. What will be your source of fuel ______What is it’s cost per ton ______

5. What will happen to any equipment (i.e. furnaces or tube heaters) being replaced? Circle and/or explain:

It will be properly disposed of in an environmentally sound manner.
We will keep it to use as a back-up system.
We will “repurpose” it. Explain:
We will try to sell it or trade it in to the dealer.
Other: (Explain)

6. Comment on your current equipment’s performance:

Energy Improvement Matters (EIM, LLC)

7545 Chablis Circle, Indianapolis, IN46278

Phone: 317-228-0134; Fax: 1-866-286-0343