RD-4288-6 Repowering Assistance Program Payment Request

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Form Approved - OMB No. 0570-0066
Form RD 4288-6
(05-11)

U.S. DEPARTMENT OF AGRICULTURE
Rural Development - Energy Division

REPOWERING ASSISTANCE PROGRAM - REPORTING FORM
This form is to be completed by Biorefineries that have been approved for participation in the Repowering Assistance Program. For the
purpose of verifying compliance with the fossil fuel reduction and energy production requirements, each biorefinery must make available
and provide for the metering of all power and heat producing boilers, containment vessels, generators and any other equipment related
to the production of heat or power required to displace fossil fuel loads with renewable biomass.
See Page 3 for Privacy Act and Public Burden Statements.

Part A- Project Information
1. Name of Biorefinery:

2. Agreement Number (from Form RD 4288 - 5):

3. Mail Address (Regular Mail):

4. Congressional District:

5. IRS Tax Identification Number:

6. Contact Person:

7. Contact Person's Title:

8. Telephone No. (Include Area Code)

9. Period for annual report (Enter beginning and ending dates for period):
From

to

Part B, Reporting
1. Date of completion of the repowering project. (Enter the date on which the biorefinery began the use of biomass as a replacement
for fossil fuels.)

2. Description of the repowering project, as completed. (Describe the equipment installed, including manufacturer's name, rated capacity,
type of energy produced (steam, direct heat, process heat, electricity, etc.), amount of energy expected to be produced by the repowering
project, and percentage of Biorefinery's total energy needs to be generated by the repowering project.)

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Page 2 of 3

3. Describe the metering equipment used to determine the production of usable energy from renewable biomass. (include the
type of device(s) and the equipment manufacturer's name and model number, the Serial Number(s) of the equipment, the type of
energy measured (steam, electricity, etc.), and the units of measure.)
3c. Model
3d. Serial number
3f. Units of
3b. Manufacturer's name
3e. Type of energy
3a. Type of
number

device

measured

measure

4. Actual total costs that are eligible project costs for the Repowering Assistance Program. (Total project costs minus any
costs associated with the production of energy that will be sold.)

5. In Blocks 5a through 5g provide documentation for the amount of energy production (MMBTU). (For each type of energy production,
provide meter reading at the beginning and end of the period and show how the readings were converted to MMBTU.)

5a. Type of
energy
produced

5b. Serial Number of meter
used to record energy
production

5c. Meter
reading at end
of period

5d. Meter reading
at beginning of
period

5e. Energy produced (5c 5d), give units of
measurement

5f. Energy
produced in
MMBTU

Total energy production for period specified in Block 9 of Part A

5g. For each different unit of measurement shown in Block 5e, provide an example calculation showing the conversion of the
measured values to MMBTU.
1.

2.

3.

4.

6. Provide the amount of each type of biomass feedstock used in the production of energy.
1.

(tons, or other applicable units) of

2.

(tons, or other applicable units) of

3.

(tons, or other applicable units) of

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7. Provide the amount and type of energy produced or purchased by the Biorefinery that is NOT derived from the repowering
project.
Concurrent period meter
readings or shipments
Natural Gas
Propane
Electric
Coal
Fuel Oil

Serial Number of meter
or bin or tank location

Meter reading at end of
period

Meter reading at
beginning of period

Unit consumption in
gallons, tons, Kwh etc.

Part C- Certification
CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included in this form is true and correct
and that I am in compliance with all Repowering Assistance Program requirements including applicable Federal and State
certifications.
1. BIOREFINERY
A.
(BIOREFINERY NAME)
B. By:
(SIGNATURE)

(Date (MM-DD-YYYY))

C. Title:

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq. ), as amended.
The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L.110-234). The information will be used to
complete the terms of an agreement between the Biorefinery and the Agency. Furnishing the requested information is voluntary, however, without it, eligibility to enter into an
agreement with the Agency cannot be determined. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law
enforcement agencies and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 15 USC 714m, 18 USC
286, 287, 371, 641, 651, 1001, 1014; and 31 USC 3729, may be applicable to the information provided.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number The valid OMB control number for this information collection is 0570-0066. The time required to complete this information collection is
estimated to average 1.5 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. RETURN THIS COMPLETED FORM TO: USDA RURAL DEVELOPMENT-ENERGY DIVISION, REPOWERING
ASSISTANCE PROGRAM 1400 INDEPENDENCE AVENUE, SW, STOP 3225, WASHINGTON, DC 20250-3225.
The U. S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political
beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of
program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA,
Director, Office of Civil Rights, Room 326-W Whitten, Building, 1400 Independence Avenue, SW, Washington, D,C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an
equal opportunity provider and employer.

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