Compliance Statement Energy/Water Conservation Standards for Appliances

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DOE F 220.39 (Expiration Date: February 3, 2014)
Single

Product Type:

4.2

Single Package Vertical Air Conditioners and Heat
Pumps

Version 4.2

Status of This Certification Sheet

No Data

Overall Status of Template

No Data

Submitter Information
I am a(n) (check one only):
Domestic Manufacturer
Please enter required data

Importer
Third-Party Representative
The third-party representative includes industry organizations submitting on behalf of their members, foreign manufacturers who do not
import and are submitting on behalf of their importers, private labelers submitting on behalf of an importer or domestic manufacturers,
third-party testing organizations submitting on behalf of a manufacturer, etc.

Submitter Information (Required for all submissions):
Company Name:

Please enter required data

Company Address:

Please enter required data

Contact Name:

Please enter required data

Contact Telephone Number:

Please enter required data

Contact Fax Number:

Please enter required data

Contact email address:

Please enter required data

For importers, the U.S. Customs and
Border Protection importer
identification number (OPTIONAL):

Third Party-Representatives (If Submitter is not a Third-Party Representative, skip to Certification
If the submitter is a third-party representative, provide the following information on each company on whose behalf you are certifying.
Note: Please complete an additional template if you are certifying on behalf of more than five companies.
If you are a Third-Party
Representative, for how many
companies on whose behalf are you
certifying? (Maximum of 5)

1.

Company Name:
Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:

Select all that apply
(at least one):

For Importer - U.S. Customs and Border
Protection importer identification number
(OPTIONAL):
For Private Labeler - Provide all of the
brand name(s):

2.

Company Name:

Domestic Manufacturer
Importer - OPTIONAL: Provide U.S. Customs and Border Protection
importer
identification number below
Private Labeler - Provide all of the brand name(s) below

Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:

Select all that apply
(at least one):

Domestic Manufacturer
For Importer - U.S. Customs and Border
Protection importer identification number
(OPTIONAL):

Importer - OPTIONAL: Provide U.S. Customs and Border Protection
importer
identification number below
Private Labeler - Provide all of the brand name(s) below

For Private Labeler - Provide all of the
brand name(s):

3.

Company Name:
Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:

Select all that apply
(at least one):

Domestic Manufacturer
For Importer - U.S. Customs and Border
Protection importer identification number
(OPTIONAL):

Importer - OPTIONAL: Provide U.S. Customs and Border Protection
importer
identification number below
Private Labeler - Provide all of the brand name(s) below

For Private Labeler - Provide all of the
brand name(s):

4.

Company Name:
Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:

Select all that apply
(at least one):

For Importer - U.S. Customs and Border
Protection importer identification number
(OPTIONAL):

Domestic Manufacturer
Importer - OPTIONAL: Provide U.S. Customs and Border Protection
importer
identification number below
Private Labeler - Provide all of the brand name(s) below

For Private Labeler - Provide all of the
brand name(s):

5.

Company Name:

Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:

Select all that apply
(at least one):

For Importer - U.S. Customs and Border
Protection importer identification number
(OPTIONAL):
For Private Labeler - Provide all of the
brand name(s):

Domestic Manufacturer
Importer - OPTIONAL: Provide U.S. Customs and Border Protection
importer
identification number below
Private Labeler - Provide all of the brand name(s) below

Certification
Compliance Statement
SELECT SUBMITTER TYPE AT THE TOP OF THIS WORKSHEET

Type your full name to signify
compliance (required):
Enter your email address (required):
Date (MM/DD/YYYY) (required):

Please enter required data
Please enter required data
Please enter required data

OMB Control Number: 1910-1400
Paperwork Reduction Act Statement
OMB Burden Disclosure Statement
This data is being collected for manufacturers to certify compliance to DOE's energy conservation, water conservation, or design standards. The
data you supply will be used by the Department to monitor compliance with the energy conservation, water conservation, and design standards
and testing requirements for the consumer products and commercial and industrial equipment mandated by the Energy Policy and Conservation
Act, as amended.
Public reporting burden for this collection of information is estimated to average 20 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 Office of the Chief Information Officer, Records Management Division, IM-23, Paperwork Reduction Project (1910-1400),
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 (1910-1400), 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 mandatory.

Product Type:
Single P
4.2
Status of This Input
Sheet

Version 4.2

Single Package Vertical Air Conditioners and
Heat Pumps
No Data

Overall Status of Template

No Data

Certification Report
· Please enter your data in the columns shaded in gray below, using a separate line for each model.
· Click on the column heading for instructions on how to complete cells in that column.
· Cells highlighted in yellow indicate an "Error." "Error" means that information is missing or there is an issue with the entry.
· If the "Status" for a row is "Error," you can see an explanation in the columns to the right of the Status column.· Reports
submitted with errors cannot be processed and will be returned for resubmission.

Line
No.

Status Manu-facturer

For Third-Party
Representatives,
Company Number
From Certification
Sheet

Brand Name(s)

Basic Model
Number

Individual Model
Number Covered
by Basic Model

Action

Product
Class

Is the Certification
Sample Size for this Basic Model
(Number of Based on a Waiver
Units
of DOE's Test
Tested)
Procedure
Requirements?

Date of Test
Procedure
Waiver, if
Applicable

Is the Certification based
upon any Exception
Relief from an Applicable
Standard by DOE's Office
of Hearing and Appeals?

Date of
Exception
Relief, if
Applicable

Is Certification
based on an
Alternate Way of
Determining
Measures of Energy
Conservation?

Energy Efficiency
Ratio (EER)
(Btu/watt-hour)

Coefficient of
Performance (COP), if
Applicable

Cooling
Capacity
(Btu/hour)

1
2
3
4
5
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72

source.xlsx

Page 4

07/14/2026

Line
No.

Status Manu-facturer

For Third-Party
Representatives,
Company Number
From Certification
Sheet

Brand Name(s)

Basic Model
Number

Individual Model
Number Covered
by Basic Model

Action

Product
Class

Is the Certification
Sample Size for this Basic Model
(Number of Based on a Waiver
Units
of DOE's Test
Tested)
Procedure
Requirements?

Date of Test
Procedure
Waiver, if
Applicable

Is the Certification based
upon any Exception
Relief from an Applicable
Standard by DOE's Office
of Hearing and Appeals?

Date of
Exception
Relief, if
Applicable

Is Certification
based on an
Alternate Way of
Determining
Measures of Energy
Conservation?

Energy Efficiency
Ratio (EER)
(Btu/watt-hour)

Coefficient of
Performance (COP), if
Applicable

Cooling
Capacity
(Btu/hour)

73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100

source.xlsx

Page 5

07/14/2026

The following is a description of each product class:

Product
Class

Single Package
Vertical AC or HP

Cooling Capacity (Btu/h)

Phase

1
2
3
4
5
6

Air Contitioners
Heat Pumps
Air Contitioners
Heat Pumps
Air Contitioners
Heat Pumps

<65,000 Btu/h
<65,000 Btu/h
>=65,000 Btu/h and <135,000 Btu/h
>=65,000 Btu/h and <135,000 Btu/h
>=135,000 Btu/h and <240,000 Btu/h
>=135,000 Btu/h and <240,000 Btu/h

1,3
1,3
All
All
All
All

Instructions for CCMS Reporting Certification & Templates

Single Package V
4.2

You are currently on the Instructions sheet. Please refer to these instructions when completing the Certification
and Input sheets.

Use your mouse, the "Tab" key and/or arrows on your keyboard to navigate through the fillable fields in both the Certification and Input sheets. If all fields
have been completed correctly, the "Status" indicators on the top of the Certification sheet and the top of the Input sheet will show "OK" in green.
- If these indicators read "Error" in red on the Certification sheet, look for an explanation in the column to the right of the entry field.
- If these indicators read "Error" in red on the Input sheet, look for explanations about incomplete/incorrect field entries by looking in the mirrored cells to
the far right of the sheet.
Please go to https://www.regulations.doe.gov/contact-us if you have any questions about the regulations or need help with the template.

Please click on the tab for the
Certification Sheet at the bottom of
the page:
CERTIFICATION INSTRUCTIONS
Step 1

Enter the Submitter Information - required for all submissions.

Submitter Information
I am a(n) (check one only):
Domestic Manufacturer
Importer
Third-Party Representative

Submitter Information (Required for all submissions):
Company Name:
Company Address:
Contact Name:
Contact Telephone Number:
Contact Fax Number:
Contact email Address:
For importers, the U.S. Customs and
Border Protection importer
identification number
(OPTIONAL):

If you are not a Third-Party Representative, skip to the Compliance Statement (Step 3)
Step 2

Enter the Third Party Representative Information

- Third Party Representatives should enter data on the companies for which they are reporting.
- Enter the number of companies for which you are reporting on this copy of the template in the box on the Certification sheet similar to the
one shown below.
- On each copy of the template, you may report for no more than five companies.
- If you need to report for more than five companies, complete as many separate copies of the template as are necessary.
If you are a Third-Party
Representative, for how many
companies on whose behalf are you
certifying? (Maximum of 5)

- For each of the Companies that you are reporting on in this template, you will need to fill out a full section as shown below.
1.

Company Name:
Company Address:
Responsible Person at Company:
Telephone Number:
Fax Number:
Email Address:
Select all that apply
(at least one):

For Importer - U.S. Customer and
Border Protection importer
identification number (OPTIONAL):
For Private Labeler - Provide all of
the brand name(s):

Domestic Manufacturer
Importer - OPTIONAL: Provide U.S. Customs and Border Protection importer
identification number below
Private Labeler - Provide all of the brand name(S) below

Step 3

Compliance Statement

- The Compliance Statement will be different depending on whether you are a Domestic Manufacturer, Importer, or a Third-Party
Representative.
- Review the statement carefully and then, in order to signify compliance, complete the information in the spaces provided below the
statement.
Type your full name to signify
compliance (required):
Enter your email address (required):
Date (MM/DD/YYYY) required:

Please click on the tab for the Input
Sheet at the bottom of the page:
TEMPLATE INSTRUCTIONS
Step 1

Filling out the Template

- Starting on line No. 1, begin entering applicable data in each field.
- Enter a separate line of data for each individual model.
- If you need more than the number of lines available in the template, complete as many additional copies of the template as are necessary.
- At any time you may click on a column heading for a complete explanation of what to enter in each cell.
- If the status at the beginning of the line reads "Error," review your data to verify entries and check the explanation table to the right of the
data entry table for a description of the error.
- Click on the Product Description tab to see a description of the product classes and to determine what number should be entered in the
Product Class field for each line.

Step 2

Completed template

- Lines with an "ok" status have been completed correctly. Be sure your "Overall Status of Template" and "Status of This Input Sheet" reflects
"OK" status as expected.
- Save the template to a local drive for safekeeping. You will upload this template later to DOE via the CCMS application.