Form DOE Form XXX DOE Form XXX REQUEST FOR SPECIAL PRIORITIES ASSISTANCE

Form DOE-XXX Department of Energy Office of Electricity REQUEST FOR SPECIAL PRIORITIES ASSISTANCE READ INSTRUCTIONS BELOW FILL OUT USING COMPUTER		For DOE Use OMB No.1910-xxxx CASE NO.________________________ RECEIVED_______________________ ASSIGNED TO____________________
Submission of a completed application is required to request special priorities assistance. See sections 217.40-44 of the Energy Priorities and Allocations System regulations (10 CFR Part 217). It is a criminal offense under 18 U.S.C. 1001 to make a willfully false statement or representation to any U.S. Government agency as to any matter within its jurisdiction. All company information furnished related to this application will be deemed business confidential under Sec. 705(d) of the Defense Production Act of 1950 [50 U.S.C. App.2155(d) which prohibits publication or disclosure of this information unless the President determines that withholding it is contrary to the interest of the national defense. The Department of Energy will assert the appropriate Freedom of Information Act (FOIA) exemptions if such information is the subject of FOIA requests. The unauthorized publication or disclosure of such information by Government personnel is prohibited by law. Violators are subject to fine and/or imprisonment. OMB Burden Disclosure Statement This data is being collected to implement the Department of Energy’s Energy Priorities and Allocations System regulations, promulgated pursuant to the Defense Production Act of 1950, as amended (DPA).  The data you supply will be used to allow you to request special priorities assistance from DOE to fill a rated order issued pursuant to the DPA and DOE’s implementing regulations. DOE will also use the information to conduct audits and for enforcement purposes. Public reporting burden for this collection of information is estimated to average 32 minutes 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 the Chief Information Officer, Records Management Division, IM-23, 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.
1. APPLICANT INFORMATION
Name and complete address of Applicant (Applicant can be any person needing assistance – Government agency, contractor, or supplier. See definition of Applicant in Footnotes section on last page of this form). Applicant Name________________________________ Address______________________________________ City_______________ State_______ Zip___________ Contact Name_________________________________ Title_________________________________________ Telephone_______________ Fax__________________ Email address_________________________________		If Applicant is not end-user Government agency, give name and complete address of Applicant’s customer. Customer name_________________________ Address______________________________________ City_______________ State_______ Zip___________ Contact Name_________________________________ Title_________________________________________ Telephone______________ Fax__________________ Contract/purchase order no.______________________ Dated________________ Priority Rating___________
2. APPLICANT ITEM(S). If Applicant is not end-user Government agency, describe item(s) to be delivered by Applicant under its customer’s contract or purchase order though the use of the item(s) listed in Block 3. If known, identify Government program and end-item for which these items are required. If Applicant is end-user Government agency and Block 3 item(s) are not end-items, identify the end-item for which the Block 3 item(s) are required. See definition of “item” in Footnotes section on last page of this form.
3. ITEM(s) (including service) FOR WHICH APPLICANT REQUESTS ASSISTANCE
Quantity Pieces, units	Description Include identifying information such as model or part number		Dollar Value Each quantity listed