5900-59 Qualified Product Information Form for Residential Air S

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for

Residential Air Source Heat Pumps & Central Air Conditioners

Office of Atmospheric Programs

ENERGY STAR^® product information form for use by ENERGY STAR qualified ASHP/CAC partners

(Companies who have joined ENERGY STAR for ASHP/CAC 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 ASHP/CAC products. If you need additional space, please copy this form.

Company Name: ________________________________ Product Contact Information (for public requesting product information)

(As listed in Partnership Agreement)

Name: _________________________________________________

Tested by: ______________________________________

(Name of Firm or Self-Tested) Tel: _____________________ Fax:_________________________

Email: _________________________________________________

Additions to Qualifying Products List:

Manufacturer Name (Trade Name)	Product Family Name	Product Type1	Capacity (Btuh)	SEER/ HSPF Rating2	EER Rating	Model Series3

Is product shipped with Energy Star label:

_______ in the product literature? (required) ______ on your Internet site? (required) ______ on the top/front of the product? (recommended)

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

______________________________________________________________________________________________________________________

Please sign below:

Signature: ________________________________________ Date: __________

Printed Name: _____________________________________

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.

1 Please specify product type according to the product types listed in the Energy Star Eligibility Criteria (i.e., Air-Source Heat Pump, Central Air-Conditioner, or Single Package Equipment).

2 HSPF ratings are only necessary for Air-Source Heat Pumps.

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

Please submit your completed QPI Form to ENERGY STAR for ASHP/CAC

Email: [email protected], Fax: (202) 862-1144

1725 Eye St., NW, Suite 1000, Washington, DC 20006

Energy Star, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA

Toll-free number: 1-888-STAR-YES Web site: http://www.energystar.gov

Energy Star is a registered US mark.

EPA Form No. 5900-59