Form DOE Form No 540.2 DOE Form No 540.2 U.S. Department of Energy Loan Guarantee Program for Pro

DOE FORM NO: 540.2 FORM APPROVED EFFECTIVE DATE: 03/08

OMB NO. 1910-5134 EXPIRATION DATE: 03/11

U.S. Department of Energy Loan Guarantee Program for Projects that Employ Innovative Technologies

This form is for use by 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. (Social Security numbers are requested for purposes of verifying whether the Applicant has any tax delinquent accounts with the IRS as required by OMB Policy Circular A-129.) After completing this form, please print two copies and send to the address below. It is highly recommended that all mail be sent via Express Mail. Full Applications should be uploaded using Fed Connect at www.fedconnect.net. For more information on the program, please visit our website at http://www.lgprogram.energy.gov.

If you need assistance or have any questions please contact the Loan Guarantee Program Office by email at [email protected]

Submit Completed Form to:

Director

U.S. DOE Loan Guarantee Program

1000 Independence Ave, SW

Washington, DC 20585-0121

In reference to DOE Solicitation No. __________________________________________

Invitation No. (if applicable)­________________________________________________

GENERAL INFORMATION

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

Email DUNS Number NAIC Number

Project Location – City State 9 Digit Zip Code

PROJECT SPONSORS (ASSET HOLDERS) WITH EQUITY OF 5 PERCENT OR MORE

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

DOE FORM NO. 540.2 FORM APPROVED EFFECTIVE DATE: 03/08

OMB NO. 1910-5134 EXPIRATION DATE: 03/11

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

Organization Name Federal Tax ID or Social Security No.

Contact Last Name First Name Position/Title

Phone Number Fax Number

Address

City State 9 Digit Zip Code

DOE FORM NO.: 540.2 FORM APPROVED EFFECTIVE DATE: 03/08

OMB NO. 1910-5134 EXPIRATION DATE: 03/11

SUMMARY OF LOAN GUARANTEE REQUEST

Requested Period of Guarantee	yrs	Total Project Costs*	$
Equity*	$	Proposed Guaranteed Amount*	$
Debt*	$	Requested Loan Guarantee to Debt Instrument	%
Debt to Equity Ratio	:	Requested Loan Guarantee to Total Project Costs	%

* Please indicate dollars in millions

CATEGORY OF PROJECT

Category	Description	Check Box
1	Renewable Energy Systems
2	Advanced Fossil Energy Technology (including coal gasification meeting the criteria in paragraph 1703 (d) of Title XVII
3	Hydrogen fuel cell technology for residential, industrial or transportation Applications
4	Advanced nuclear energy facilities
5	Carbon capture and sequestration practices and technologies, including agricultural and forestry practices that store and sequester carbon
6	Efficient electrical generation, transmission and distribution technologies
7	Efficient end-use energy technologies
8	Production facilities for fuel efficient vehicles including hybrid and advanced diesel vehicles
9	Pollution control equipment
10	Refineries, meaning facilities at which crude oil is refined into gasoline

RESTRICTIONS ON DISCLOSURE AND USE OF INFORMATION

Title XVII of the Energy Policy Act of 2005 authorizes the collection of this information. The primary use of this information is by the Loan Guarantee Program Office of the Department of Energy in their review of applications for loan guarantees under Title XVII. Additional disclosures of this information may be made as required by law. Where the information provided is a social security number, the provision of the information is voluntary but failure to disclose may result in disapproval of the application.

All information collected will be handled in accordance with the Freedom of Information Act (5 U.S.C. 552) and all applicable laws.

Patentable ideas, trade secrets, proprietary, or confidential 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 specifically identifies and marks such data in accordance with the following provisions:

1. Applicant hereby discloses that (fill in the blank below in this Application Form with the specific Application Sections containing proprietary data):

“Sections ___ of this Application contain data which 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 is issued a loan guarantee under Title XVII of the Energy Policy Act of 2005 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, other than such data that have been properly reasserted as being trade secret or proprietary in the loan guarantee agreement. This restriction does not limit the Government’s right to use or disclose data obtained without restriction from any source, including the applicant.”

2. Include the following legend on the first or cover page of each document or electronic file submitted that contains such data (be sure to specify the page numbers from such document or electronic file that contains the proprietary data):

“The data contained in pages _____ of this document or electronic file which hereby forms a part of the 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 is issued a loan guarantee under Title XVII of the Energy Policy Act of 2005 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, other than such data that have been properly reasserted as being trade secret or proprietary in the loan guarantee agreement. This restriction does not limit the Government’s right to use or disclose data obtained without restriction from any source, including the applicant.”

3. Include the following legend on each page of a document or electronic file containing such data (a) as a header on the page or (b) to specifically identify and mark each line or paragraph on the page containing such data:

“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.”

BURDEN DISCLOSURE STATEMENT

This data is being collected to support Applications for loan guarantees from the Department of Energy under Title XVII of the Energy Policy Act of 2005 (22 USC 16511, et seq.). The data you supply will be used for the review of business and credit risks relating to projects which qualify for loan guarantees under Title XVII.

Public reporting burden for this collection of information is estimated to average 10.36 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 the Office of the Chief Information Officer, Records Management Division, IM-23, U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget, OIRA, 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 required to obtain a guarantee of the repayment of principal and interest on loans relating to projects that qualify for such guarantees under Title XVII of the Energy Policy Act of 2005 (22 USC 16511, et seq.).

CERTIFICATION

The undersigned certifies that the data and information submitted and the representations made in this Application and any attachments to this 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