Form DOE Form XXX DOE Form XXX Save Energy Now Pledge Annual Report Form

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Overview

Annual Form
Instructions

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Sheet 1: Annual Form

		Save Energy Now LEADER Pledge Annual Reporting Form
		Please provide data requested in white cells only. Shaded cells are calculated based on user input.
	Company Name:
	Company Contact Name:
	Address:
	Phone:
	E-mail Address:
	NAICs of Partipating Plants:
	Year of reported data:
	Base Year:
	Is this portion of the pledge entity located in the US?
		Baseline Year	Current Year
	Number of Participating Plants Included in Current Year of Pledge:
	Primary Energy Consumed, MMBtu/yr:	Baseline Year	Current Year
	Electricity
	Natural gas
	Distillate or Light Fuel Oil (#1, 2, & 4)
	Residual or Heavy Fuel Oil (# 5, 6, Navy Special & Bunker C)
	Coal
	Coke
	Blast Furnace Gas
	Wood Waste
	Other Gas (please specify)
	Other Liquid (please specify)
	Other Solid (please specify)
	Total Primary Energy Consumed, MMBtu/yr:	0	0
	Adjustment for Baseline Primary Energy, +/- MMBtu/yr*:
	Adjusted Baseline of Primary Energy, MMBtu/yr:	0
	Current Year Energy Savings for Cumulative Actions Since Baseline Year, MMBtu/yr**:		0
		Annual Change In Energy Intensity for Current Year, %:		*Please refer to the Energy Intensity Matrix for
		Total Change In Energy Intensity, %:		a calculator to determine changes in intensity.
	*Justification for baseline adjustment for the current year (250 word max):
	**Description of energy efficient technologies, strategies, and practices employed during year to decrease intensity (250 word max, please):

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Sheet 2: Instructions

Instructions for Completing the Annual Report Form

Reporting Form Field

Instructions

Company Name:

Provide the name of the organization that has committed to the SEN Pledge

Company Contact Name:

Provide the name of the person with the organization who is responsible and knowlegable of this information.

Address:

Provide the address for the organizational contact.

Phone:

Provide the phone number for the organizational contact.

E-mail Address:

Provide the email address for the organizational contact.

NAICs of Partipating Plants:

Provide the 6-digit North American Industry Classification Codes for the plants that are under the scope of the pledge effort. To find your NAICS code, please visit: http://www.naics.com/search.htm

Year of reported data:

Identify the current reporting year, in YYYY format.

Base Year:

Identify the base year for your pledge agreement, in YYYY format.

Is this portion of the pledge entity located in the US?

Yes or No. Report data for the portion of the pledge entity in the United States separately from the portion outside of the United States. Submit a a separate form for each. All data reported below should be for this portion of the pledge entity. The pledge entity is defined by the boundaries choosen to be part of the voluntary agreement. See the Frequently Asked Questions (FAQs) for additional information.

Number of Participating Plants Included in Current Year of Pledge:

Identify the number of plants that are represented in your current pledge year.

Primary Energy Consumed, MMBtu/yr:

Provide the primary energy consumed, by fuel type, for the pledge entity, for the baseline and current years. Exclude energy used as a feedstock. For additional information, see the following documents: Steps to Develop a Baseline, Frequently Asked Questions.

Total Primary Energy Consumed, MMBtu/yr:

This number is calculated by the spreadsheet. It represents the total primary energy consumed by the pledge entity, for the current reporting year.

Adjustment for Baseline Primary Energy, +/- MMBtu/yr*:

Identify the baseline adjustment required to estimate energy savings for energy-saving actions taken since the baseline year. DOE estimates savings according to the following: Total Primary Energy Use in Baseline Year + Adjustments to Baseline - Total Primary Energy Use in Current Year = Energy Savings in Current Year.

Adjusted Baseline of Primary Energy, MMBtu/yr:

This number is calculated by the spreadsheet using the following equation: Total Primary Energy Use in Baseline Year + Adjustments to Baseline = Adjusted Baseline.

Current Year Energy Savings for Cumulative Actions Since Baseline Year, MMBtu/yr**:

This number is calculated by the spreadsheet using the following equation: Total Primary Energy Use in Baseline Year + Adjustments to Baseline - Total Primary Energy Use in Current Year = Energy Savings in Current Year. It represents an estimate of the energy savings in place from cumulative actions taken since pledge inception.

Annual Change In Energy Intensity for Current Year, %:

Provide the change in energy intensity experienced in current year, as compared to the previous year.

Total Change In Energy Intensity, %:

Provide the total change in energy intensity since the baseline year.

Justification for baseline adjustment for the current year:

Briefly describe the rationale behind your adjustment to the baseline for the pledge entity. Reasons might include plant addition or removal from pledge program, weather interactions, increases in production. For additional information, see the following documents: Steps to Develop a Baseline, Frequently Asked Questions.

Description of energy efficient technologies, strategies, and practices employed during year to decrease intensity:

Briefly describe, in general, the range of technologies, strategies and practices employed during the current year that resulted in a reduction in energy-intensity. Identify systems and if possible, plants that were impacted. Optional details: approximate energy savings (in $ or Btu), type of fuel, geographic location, industry, and additional descriptive details about the projects.

This data is being collected to implement the congressional directive from the Energy Policy Act of 2005, section 106, requiring the Secretary of Energy to submit a report to Congress that evaluates the success of the voluntary agreements no later than June 30, 2012, and June 30, 2017. The report must provide independent verification from a sample of the energy savings estimates provided by participating firms. ITP will collect annual information on primary energy use and energy savings from participating entities through the duration of the program. The data you supply will be used for program evaluation and will be aggregated will all other participants for the report to Congress.

Public reporting burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Office of Energy Efficiency and Renewable Energy, Paperwork Reduction Project (1910-XXXX), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910-XXXX), Washington, DC 20503.

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.

Submission of this data is voluntary.