State Energy Program Evaluation

Residential On-Site Survey Form - Prescriptive Site ID #__________

Site ID #:

SiteID

Site Strata:

Survey Date:

Contact Information:

Owner Name:
Occupant Name (if different from owner)
Owner Phone:	Tenant Phone:	Email:
Address 1:
Address 2:
City: Zip:
Mailing Address:
City: Zip:

* Mailing address is only needed if different from building address

Survey Tracking Information

Surveyor Name:	Travel Mileage:
Start Time:	Finish Time:	Total Time (mins): (Onsite, QC, Travel)

Scheduling Notes:

Month/Year of Home Performance Assessment	Month/Year of Home Performance Work Completion
Number of Year Round Occupants	Change in number of occupants over the past 12 months?
Any significant changes to household energy consumption over the past 12 months?	Y / N (if yes, please document the changes below)

Site & Survey Notes (Please note any changes to the household’s energy usage or occupancy over the past 12 months):

Background Information

Dwelling Information

Dwelling type
Year Built
Number of stories

Utility Information

	Electric	Natural Gas
Utility
Account Number
Meter Number

Installed Measures

	Measure Description	Quantity	Energy Savings	Units of Savings	Total Customer Cost
EE Measure 1
EE Measure 2
EE Measure 3
EE Measure 4
EE Measure 5
EE Measure 6
EE Measure 7
EE Measure 8

Interview & Introduction

Hello, my name is [NAME] and I work with KEMA Inc. I am working on behalf of [Sponsor] to conduct an independent assessment of energy-efficiency technologies installed under the &Program. I am here to meet with [FirstName1 LastName2] to discuss energy-using technologies in this home. (Show letter, identification and business card.) During my visit I’d like to ask a few questions about your home’s general characteristics and then would like walk through to note the number and type of lighting fixtures and visually inspect heating, cooling, and water heating equipment. The survey should take no more than 300 minutes to complete. Do you have any questions regarding my visit?

The U.S. Department of Energy (DOE) would like to inform each individual that the information requested here is being solicited under the statutory authority of Title III of the Energy Policy and Conservation Act of 1975, as amended, which authorizes DOE to administer the State Energy Program (SEP). This information is being sought as part of a national evaluation of SEP, the purpose of which is to reliably quantify Program accomplishments and help inform decisions on future operations. The sole use of the information collected will be for an analysis of national-level Program impacts. Disclosure of this information is voluntary and there will be no adverse effects associated with not providing all or any part of the requested information.

Cooling Equipment –Inventory

	Primary	Secondary
C1. Cooling Type C = Central Air Conditioning CO=Cooling coil HPA = Heat Pump – air HPG= Heat Pump - ground R = Room air conditioning N = No AC OTH = Other (describe) DK= Don’t Know	C CO HPA HPG R N DK OTH________________ [If N or DK skip to CV1]	C CO HPA HPG R N DK OTH________________ [If N or DK skip to CV1]
C2. Size	tons / kBtu / kW	tons / kBtu / kW
C3. Manufacturer
C4. Model Number
C5. Serial Number
C6. Estimated Age <1 year old 1-4 years old 5-10 years old 11-15 years old 16-20 years old >20 years old Don’t Know	1 2 3 4 5 6 7	1 2 3 4 5 6 7
C7. Manufacturer Date
C8. Efficiency (from yellow sticker)	SEER / EER	SEER / EER
C9. Space Served	Serves home or apartment only Serves more than one home or apartment	Serves home or apartment only Serves more than one home or apartment
C10. Frequency of Use All summer Quite a bit Only a few times when needed Not at all Don’t know	1 2 3 4 5	1 2 3 4 5

* If Type = Room AC, note the quantity in the notes section

Notes:

Cooling Equipment – Verification of Installed Measures (repeat set of questions for each type of equipment installed under the program)

	Installed Equipment
CV1. Cooling Type Installed C = Central Air Conditioning E = Evaporative coolers (swamp coolers) HPA= Heat Pump – air HPG=Heat Pump - ground R = Room air conditioning DK = Don’t Know OTH = Other (describe)	C E HPA HPG R DK OTH________________
CV2. Quantity
CV3. Efficiency (from yellow sticker)	SEER / EER
[If CV2not equal to quantity in tracker, else skip to CR1] CV4. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
CV5. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused	Y N DK REF

Notes:

	Replaced Equipment
CR1. Cooling Type Replaced C = Central Air Conditioning E = Evaporative coolers (swamp coolers) H= Heat Pump (heats & cools) R = Room air conditioning DK = Don’t know REF = Refused OTH = Other (describe) NO=no cooling equipment replaced	C E H R DK REF OTH________________ NO [If NO, DK, REF, skip to H1]
CR2. Quantity
CR3. Efficiency (from yellow sticker)	SEER / EER
CR4. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
CR5. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6

Notes:

Heating Equipment –Inventory

	Primary	Secondary
H1. Fuel Type N=Natural gas B= Bottled gas/propane E=Electric O=Oil K=Kerosene W=Wood S=Solar G=Geothermal OTH=Other (describe)_________ NO=No heating system DK=Don’t know	N B E O K W S G OTH _____________ NO DK [If NO or DK skip to HV1]	N B E O K W S G OTH _____________ NO DK [If NO or DK skip to HV1]
H2. Heating Type Central forced air furnace Steam boiler (upright radiators or baseboards) Hot water boiler (upright radiator or base boards Baseboard, wall heaters without fans or ceiling cables Wall heaters with fans Air source heat pump Ground source heat pump Direct vent space heaters Un-vented space heaters Portable heaters Fireplace inserts Stoves Other _____________ No heating system Don’t know	1 2 3 4 5 6 7 8 9 10 11 12 13_____________ 14 15	1 2 3 4 5 6 7 8 9 10 11 12 13_____________ 14 15
H3. Input Capacity	kBtuh / kW / GPH	kBtuh / kW / GPH
H4. Output Capacity	kBtuh / kW	kBtuh / kW
H5. Manufacturer
H6. Model Number
H7. Serial Number
H8. Estimated Age <1 year old 1-4 years old 5-10 years old 11-15 years old 16-20 years old >20 years old Don’t know	1 2 3 4 5 6 7	1 2 3 4 5 6 7
H9. Manufacturer Date
H10. Efficiency *	AFUE / COP	AFUE / COP
H11. Space Served	Serves home or apartment only Serves more than one home or apartment	Serves home or apartment only Serves more than one home or apartment
H12. Frequency of Use	Everyday 3-5 days per week 1-2 days per week Only a few days a year Don’t know Refused to answer	Everyday 3-5 days per week 1-2 days per week Only a few days a year Don’t know Refused to answer

* If efficiency not available for electric equipment, note volts and amperage from nameplate. (For non-electric equipment, note input and output values).

Notes:

Heating Equipment – Verification of Installed Measures (repeat set of questions for each type of equipment installed under the program)

	Installed Equipment
HV1. Heating Type Installed G = Natural gas boiler W =Wood pellet boiler H= Heat pump (heats & cools) DK = Don’t know OTH = Other (describe)	G W H DK OTH________________
HV2. Quantity
HV3. Fuel type N=Natural gas B= Bottled gas/propane E=Electric O=Oil W=Wood S=Solar OTH=Other (describe)_________	N B E O W S OTH____________________
[If HV2 not equal to Quantity in Tracker, else skip to HR1] HV4. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
HV5. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused	Y N DK REF

Notes:

	Replaced Equipment
HR 1. Heating Type Replaced G = Natural gas boiler W =Wood pellet boiler F=Furnace DK = Don’t Know REF = Refused OTH = Other (describe) NO=No heating equipment replaced	G W F DK REF OTH________________ NO [IF NO, DK, REF, skip to WH1]
HR 2. Condition of replaced equipment G= Good F= Fair P=Poor I=Inoperable DK=Don’t know REF=Refused	G F P I DK REF
HR 3. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused	1 2 3 4 5 6

Notes:

Water Heating Equipment –Inventory

		Primary			Secondary
WH1. Fuel Type N=Natural gas B= Bottled gas/propane E=Electric O=Oil K=Kerosene W=Wood S=Solar G=Geothermal OTH=Other (describe)_________ NO=No heating system DK=Don’t know	N B E O K W S G OTH _____________ NO DK [If NO or DK skip to WHV1]			N B E O K W S G OTH _____________ NO DK [If NO or DK skip to WHV1]
WH2. Equipment Type: Traditional water heater tank Whole house tankless system or instantaneous Heat pump water heater High efficiency gas storage water heater Indirect tank attached to a boiler Other _____________ Don’t know Refused to answer		1 2 3 4 5 6________________ 8 9			1 2 3 4 5 6________________ 8 9
WH3. Manufacturer
WH4. Model Number
WH5. Serial Number
WH6. Manufacture Date
WH7. Quantity
WH8. Size: Tank Capacity/Volume in Gallons
WH9. Rated Input Capacity
WH10. Rated Input Capacity Units: (W=kW or B=kBtuh)		W B			W B
WH11. Location Garage Attic Conditioned space Outside closet Mechanical room/closet Other _____________		1 2 3 4 5 6__________________			1 2 3 4 5 6__________________
WH12. Location dimensions (W x D x H)
WH13. Is water heater less than 8’ away from all DHW fixtures?		Y N			Y N
WH14. Estimated Age <1 year old 1-4 years old 5-10 years old 11-15 years old 16-20 years old >20 years old Don’t know			1 2 3 4 5 6 7			1 2 3 4 5 6 7
WH 15. Water Heater wrap		Y N DK			Y N DK
WH16. Hot water pipes insulated		Y N DK			Y N DK
WH17. Water heater timer visible?		Y N DK			Y N DK

*Select solar water heater back-up fuel [N = natural gas, E = electricity, F = fuel oil, P = propane]

Notes:

Water Heating Equipment – Verification of Installed Measures (repeat set of questions for each type of equipment installed under the program)

		Installed Equipment
WHV1. Fuel type N=Natural gas B= Bottled gas/propane E=Electric O=Oil S=Solar DK = Don’t know OTH=Other (describe)_________		N B E O S DK OTH____________________
WHV2. Quantity
WHV3. Temperature setting	______________ Don’t know Refused
[Ask If WHV2 not equal Quantity in Tracking, else skip to WHR1] WHV4. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused		1 2 3 4 5___________________ 6 7
WHV5. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused		Y N DK REF

Notes:

Water Heating Equipment – Replaced Equipment

		Replaced
WHR1. Fuel Type N=Natural gas B= Bottled gas/propane E=Electric S=Solar G=Geothermal OTH=Other (describe)_________ NO=No heating system DK=Don’t know REF=Refused		N B E S G OTH _____________ NO DK REF
WHR2. Equipment Type: Traditional water heater tank Tankless or instantaneous hot water heater Other _____________ Don’t know Refused to answer	1 2 3________________ 4 5
WHR3. Temperature setting	______________ Don’t know Refused
WHR4. Is a clothes washer present? Y= Yes N= No DK=Don’t know	Y N DK
WHR5. Do you wash clothes in warm or hot water? A=Always S=Sometimes N=Never DK=Don’t know REF=Refused	A S N DK REF
WHR6. Is a dishwasher present? Y= Yes N= No DK=Don’t know	Y N DK

Notes:

Lighting Inventory

Record information on all interior and exterior lighting sockets on the attached sheets. Refer to bulb shape code list.

Fixture Group Information
F1. Fixture Group #	_____	_____	_____	_____	_____	_____	_____	_____	_____
F2. Location (Room Type)
F3. Control Type	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T	S D L 3 M P T
F4. Fixture Type
F5. Total # of Fixtures
Lamp Information
L1. Lamps per Fixture
L2. Watts per Lamp
L3. Lamp Type	I C F H L O	I C F H L O	I C F H L O	I C F H L O	I C F H L O	I C F H L O	I C F H L O	I C F H L O	I C F H L O
L4. Lamp Shape
L5. Base Type	SM SS P O	SM SS P O	SM SS P O	SM SS P O	SM SS P O	SM SS P O	SM SS P O	SM SS P O	SM SS P O

* I = Incandescent, C = Compact Fluorescent, F = Fluorescent, H = Halogen, L = LED, O = Other

SM = Mini Screw SS = Standard Screw P = Pin O = Other

S = Switch D = Dimmer L = Photocell 3 = Three-way M = Motion P = Photomotion T = Timer

Notes:

Room Types	Fixture Types	Lamp Types	Lamp Descriptions
Basement	Ceiling fixtures	CF-I-A	Compact fluorescent integrated – Use code from below
Bathroom – 1	Ceiling Fan	CF-Mini	Any CFL with mini screw base
Bathroom – 2	Floor Lamp	CF-PIN-Base	Compact fluorescent type all, non-integrated ballast (pin base)
Bathroom – 3	Other	F-12	T-12 Fluorescent
Bathroom – Master	Architecturally Integrated (built into furniture)	F-4	T-4 Fluorescent
Bedroom – 1	Garage Door Opener	F-5	T-5 Fluorescent
Bedroom – 2	Wall mount	F-8	T-8 Fluorescent
Bedroom – 3	Recessed can	F-CIR	T-12 or T-8 Circular
Bedroom – 4	Torchiere	F-OTH	Other Tube Fluorescent not listed above
Bedroom – Mster	Chandelier / Hanging	F-TUBE-UNK	Unknown fluorescent tube lamp
Breakfast Nook	Table lamps	HAL-MR	MR-16 pin based halogen
Closet	Track lighting	HAL-PAR	Halogen Parabolic Reflector
Dining Rm	Under Cabinet	HAL-QTZTUB	Halogen quartz tube
Family Room	Exterior – post	HAL-OTH	Other Halogen lamp not listed above
Garage	Exterior – walkway	I-DEC	Decorative screw based incandescent
Hall	Exterior – wall mount	I-FLOOD	Flood/PAR screw based incandescent
Kitchen	Control Types	I-GLO	Globe style screw based incandescent
Laundry Rm	Switch	I-Mini	Any incandescent with mini screw base
Living Rm	Dimmer	I-OTH	Other screw based incandescent
Office	Motion	I-STD	Standard screw based incandescent
Other	Photocell	I-UNK	Unknown type screw based incandescent
Exterior Porch	Photo/motion	HEAT LAMP	Relatively high wattage incandescent lamp commonly found in bathrooms
Exterior – Other	Timer	SSL	Any Solid State Lamp
Rec Rm
Wattage
888 – three way
999 – unknown

[Ask If F5 not equal to Quantity in Tracker, else skip to DW1] LV1. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused	1 2 3 4 5___________________ 6 7
LV2. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused	Y N DK REF

Appliance Verification

Dishwasher
DW1. Did you replace an existing dishwasher? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF [If N, DK, REF then skip to DW5
DW2. Estimated Age of replaced dishawasher <1 year old 1-4 years old 5-10 years old >10 years old Don’t know Refused		1 2 3 4 5 6
DW3. Was the replaced dishwasher working? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF [If N, DK, REF, skip to DW5]
DW4. Condition of replaced dishwasher G= Good F= Fair P=Poor DK=Don’t know REF=Refused			G F P DK REF
[ Ask If quantity not equal to quantity in tracker, else skip to CW1] DW5. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused			1 2 3 4 5___________________ 6 7
DW6. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF
Clothes Washer
CW1. Did you replace an existing clothes washer? Y= Yes N= No DK=Don’t know REF = Refused			Y N DK REF [If N, DK, REF skip to CW4]
CW2. Estimated Age of replaced clothes washer <1 year old 1-4 years old 5-10 years old >10 years old Don’t know Refused		1 2 3 4 5 6
CW3. Was the replaced clothes washer working? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF
CW4. Do you have a clothes dryer?		Y N DK REF [If N, DK, REF skip to CW6]
CW5. Fuel type of clothes dryer: E=Electric N=Natural Gas OTH=Other (specify)_________ DK=Don’t know REF=Refused		E N OTH_________ DK REF
[Ask if quantity not equal to quantity in tracker, else skip to R1] CW6. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused			1 2 3 4 5___________________ 6 7
CW7. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF
Refrigerator
R1. Location of freezer: Freezer on bottom Freezer on top Freezer on side Don’t know Refused		1 2 3 4 5
R2. Through the door ice machine in new refrigerator: Y= Yes N= No DK=Don’t know		Y N DK
R3. Type of defrost: A=Automatic defrost P=Partial automatic defrost M=Manual defrost DK=Don’t know		A P M DK
R4. Plugged in and operating: All the time Special occasions only During certain months Never plugged in Don’t know		1 2 3 4 5
R5. Size: C=Compact S=Standard O=Oversized DK= Don’t know		C S O DK
R6. Did this refrigerator replace an existing refrigerator Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF [If N, DK, REF, skip to R14]
R7. Location of freezer for replaced refrigerator: Freezer on bottom Freezer on top Freezer on side Don’t know Refused		1 2 3 4 5
R8. Through the door ice machine in replaced refrigerator: Y= Yes N= No DK=Don’t know REF=Refused		Y N DK REF
R9. Through the door ice machine in replaced refrigerator: Y= Yes N= No DK=Don’t know REF=Refused		Y N DK REF
R10. Estimated Age of replaced refrigerator <1 year old 1-4 years old 5-10 years old >10 years old Don’t know Refused	1 2 3 4 5 6
R11. Has the replaced refrigerator been removed from the home? R=Removed from home S=Still have it DK=Don’t know REF=Refused		R S DK REF [If S, DK, REF, skip to R13]
R12. How did you dispose of your old refrigerator? Took it recycler or scrap dealer Took it to a landfill or threw away Sold or gave it to a private party Sold it to a used refrigerator/freezer dealer Hired someone to pick it up Utility program hauled it away Left it behind when moved Other (specify)_________ Don’t know Refused		1 2 3 4 5 6 7 8__________________ 9 10
R13. Was the replaced refrigerator working? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF
[If quantity not equal to quantity in tracker, else skip to I1] R14. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused			1 2 3 4 5___________________ 6 7
R15. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF

Notes:

Other Measure Verification

Insulation
I1. Did you add insulation to walls, attic/ceiling or both? W= Wall only A=Attic/ceiling only B=Both DK=Don’t know REF=Refused				W A B DK REF [If A skip to I8, if DK, REF skip to SHA1]
I2. Was there existing insulation in walls? Y= Yes N= No DK=Don’t know REF=Refused				Y N DK REF [If N, DK, REF skip to I4]
I3. Previous R value or number of inches in wall insulation:				R Value______ # of inches _________ Don’t know Refused
I4. Current R value or number of inches in wall insulation:				R Value______ # of inches _________ Don’t know Refused
I5. Number of Rooms insulated				Number of rooms _________ Don’t know Refused
[Ask If quantity not equal to quantity in tracker, else if I1= B skip to I8, else skip to SHA1] I6. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused				1 2 3 4 5___________________ 6 7
I7. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused				Y N DK REF
I8. Existing insulation in attic/ceiling? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF [If N, DK, REF skip to I10]
I9. Previous R value or number of inches in attic/ceiling insulation:				R Value______ # of inches _________ Don’t know Refused
I10. Current R value or number of inches in attic/ceiling insulation:				R Value______ # of inches _________ Don’t know Refused
[Ask If quantity not equal to quantity in tracker, else, skip to SHA1] I11. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused				1 2 3 4 5___________________ 6 7
I12. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused				Y N DK REF
Showerhead and Faucet Aerators
SHA1. Quantity showerheads installed through the program			Number _________ Don’t know Refused
SHA2. Where was the showerhead installed? (more than one response allowed) Main shower (one shower in home) Master bathroom shower Guest shower Outdoor shower Other __________ Don’t know Refused				1 2 3 4 5_____________ 6 7
SHA3. Quantity aerators installed through the program			Number _________ Don’t know Refused
IF SHA1 or SHA3 not equal to quantity in tracker, else skip to DT1] SHA6. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused				1 2 3 4 5___________________ 6 7
SHA8. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused				Y N DK REF
Duct testing and Sealing
	DT1. Was the duct system installed or replaced during the time you have lived in the home? Y= Yes N= No DK=Don’t know REF=Refused			Y N DK REF
DT2. Estimated Age <5 years old 5-10 years old 11-20 years old >20 years old Don’t know Refused				1 2 3 4 5 6
Other Equipment Installed Through the Program (repeat as needed)
O1. Type of equipment			­­­[If none, skip to D1]
O2. Quantity installed through the program			Number _________ Don’t know Refused
[IF O2 not equal to quantity in tracker, else skip to D1] O3. Reason quantity differed: No idea Put into storage Installed somewhere else in U.S. Insufficient financial resources to complete Other (describe)_____________ Don’t know Refused				1 2 3 4 5___________________ 6 7
O4. Do you plan to install in the next year? Y= Yes N= No DK=Don’t know REF=Refused				Y N DK REF

Notes:

Housing and Demographic Information

D1. Housing Type: One-family detached One-family home attached to one or more houses Apartment building with 2 apartments Apartment building with 3 or 4 apartments Apartment building with 5 or more apartments Mobile home Boat, RV, van etc. Other____________________ Don’t know Refused to answer	1 2 3 4 5 6 7 8___________________ 9 10
D2. Number of year-round occupants:	_____________ Don’t know Refused to answer
D3. Number of rooms (exclude laundry rooms, foyers, unfinished spaces and garages):	_____________ Don’t know Refused to answer
D4. Square footage:	_____________ Don’t know Refused to answer
D5. Number of floors: 1 floor 2 floors 3 floors More than 3 floors Don’t know Refused to answer	1 2 3 4 5 6
D6. Age of building: Before 1970’s 1970’s 1980’s 1990-1994 1995-1999 2000’s Don’t know Refused to answer	1 2 3 4 5 6 7 8

SEP – Residential On-site M&V - Prescriptive Page 17, Sheet _____ of _____