Form DOE-LGP-FORM 01 V. DOE-LGP-FORM 01 V. U. S. Department of Energy Loan Guarantee for Projects t

FORM APPROVED
OMB NO. ________

U.S. Department of Energy Loan Guarantee for Projects that Employ Innovative
Technologies
This form is for use of Applicants seeking a U.S. Department of Energy Loan Guarantee pursuant to Title
XVII of the Energy Policy Act of 2005, Public Law 109-58 (22 USC 16511, et seq.) and is governed by 10
CFR Part 609. After completing this form, please print two copies. Next, click on the “Submit by Email”
button above to submit this data electronically. Select “Other” to save this data in an electronic format.
Email this file to the Loan Guarantee Program Office at [email protected]. Upload supporting
documentation using DOE’s Industry Interactive Procurement System (https://e-center.doe.gov) and submit
two hard copies to the address below. It is highly recommended that all hard copies be sent via Express
Mail. Please note that Pre-Applications should not exceed 100 pages and Applications should not exceed
___ pages. For more information, please visit our website at http://www.lgprogram.energy.gov.
Mail All Paper Copies to:
Director
U.S. DOE Loan Guarantee Program Office
1000 Independence Ave, SW
Washington, DC 20585-0121

If you need assistance or have any questions please
contact the Loan Guarantee Program Office at (202)
586-8336 or email us at [email protected].

_____ Pre-Application

_____ Application (Check one)

In reference to DOE Solicitation No. ________________________________________________________
If you are submitting an Application, please identify the Invitation No._____________________________
GENERAL INFORMATION
Organization Name
Contact Last Name

First Name

Position/Title

Phone Number

Fax Number

Address
City

State

9 Digit Zip Code

Email

Federal Taxpayer ID

DUNS Number

Project Location – City

State

9 Digit Zip Code

PROJECT SPONSORS (ASSET HOLDERS)
Organization
Name

Contact / Phone

DOE-LGP-FORM 01- v. 03/2007

Address

City

State

Zip
Code

Country

FORM APPROVED
OMB NO. ________

SUMMARY OF LOAN GUARANTEE REQUEST
Requested Period of Guarantee
Equity*

$

Debt*

$

Debt to Equity Ratio

yrs

:

Total Project Costs*
Proposed Guaranteed Amount*
Requested Loan Guarantee to Debt
Instrument
Requested Loan Guarantee to Total
Project Costs

$
$
%
%

* Please indicate dollars in millions

CATEGORY OF PROJECT
Category

Description

1

Renewable Energy Systems
Advanced Fossil Energy Technology (including coal gasification meeting
the criteria in paragraph 1703 (d) of EPAct 2005
Hydrogen fuel cell technology for residential, industrial or transportation
applications
Advanced nuclear energy facilities
Carbon capture and sequestration practices and technologies, including
agricultural and forestry practices that store and sequester carbon
Efficient electrical generation, transmission and distribution technologies
Efficient end-use energy technologies
Production facilities for fuel efficient vehicles including hybrid and
advanced diesel vehicles
Pollution control equipment
Refineries, meaning facilities at which crude oil is refined into gasoline

2
3
4
5
6
7
8
9
10

Check
Box

PRIVACY ACT NOTICE
This information collection provides the following assurance of confidentiality to
respondents, under the Freedom of Information Act (5 U.S.C. 552):
“Patentable ideas, trade secrets, proprietary, or confidentional commercial or financial
information, disclosure of which may harm the applicant, should be included in an
Application only when such information is necessary to convey an understanding of
the proposed project. The use and disclosure of such data may be restricted, provided
the applicant includes the following legend on the first page of the project narrative
and specifies the pages of the Application which are to be restricted:
‘The data contained in pages _____ of this Application have been submitted in
confidence and contain trade secrets or proprietary information, and such data
shall be used or disclosed only for evaluation purposes, provided that if this
applicant receives an award as a result of or in connection with the submission of
this Application, DOE shall have the right to use or disclose the data herein to the
extent provided in the award. This restriction does not limit the government’s

right to use or disclose data obtained without restriction from any source,
including the applicant.’
“To protect such data, each line or paragraph on the pages containing such data must
be specifically identified and marked with a legend similar to the following:
‘The following contains proprietary information that (name of applicant) requests not be
released to persons outside the Government, except for purposes of review and
evaluation.’”
CERTIFICATION
The undersigned certifies that the data and information submitted and the representations
made in this Pre-Application and any attachments to this Pre-Application are true and
correct, to the best of the Applicant’s knowledge and belief after due diligence, and that
the Applicant has not omitted any material facts.
The undersigned further certifies to having full authority to bind the Applicant.
Applicant (Organization Name)
Name of Applicant’s Authorized Officer (will fulfill on-line certification)

Title

Signature of authorized officer (for paper copy only)

Date

DOE-LGP-Form 01-v. 03/2007