Form 5900-254 Non-disputable Partner Response Form

Partner Response Form
Instructions
To submit Product Control Measures, complete Sections I, II, III, IV, and V below. Fields highlighted yellow are required. Click on each field for additional instructions. EPA will not accept Partner Response Forms that do not include a representative signature at the bottom. Save your completed form as "Testing Failure_[Company Name]_[EPA Case Number]" and submit the form to [email protected]. EPA will review your submittal, and notify you once the form is approved or if additional information is necessary.
Section I: Product and Shipping Information
Partner Name (company):			Date Last Manufactured:
EPA Case Number (from EPA letter):			Date of Last Sales Shipment (labeled units):
Original Equipment Manufacturer (OEM):			Recipient of Last Sales Shipment (labeled units):
Test Failure Notification Date:			Destination of Last Sales Shipment (labeled units):
Tested Unit's Brand Name:			Units Shipped in Last 6 months (labeled units):
Model's ENERGY STAR Product Category:			Total Units Manufactured (labeled units):
Disqualified Model Number (from EPA letter):			Is the model promoted by an energy efficiency program and/or utility? (If yes, provide name[s])
Section II: Contact Information
Point of Contact at Your Company:			Original Equipment Manufacturer (OEM):
Title:			OEM Contact:
Email:			Title:
Phone:			Email:
Additional Contacts: Name (Email)			Phone:
Section III: Certification of Product Control Measures (PCM)
For the model numbers in Sections I and V, the company named in the Partner Name field of Section I is undertaking the following measures. Note: If you seek to deviate from the proposed measures after EPA has approved them, you must notify EPA prior to making any changes.
1) Inform the distribution chain that the model(s) is/are not ENERGY STAR certified: EPA requires that you inform all downstream parties to whom you directly sold the model as ENERGY STAR certified in the last two years, including distributors, online and in-store retailers, consumers, and other affected organizations (e.g., utilities), that the model(s) is/are no longer ENERGY STAR certified. Specifically, the following statement must be included in all communications: "This product failed verification testing and has been disqualified from ENERGY STAR." Use the table below to submit a list of these entities. Note: If you need additional rows, please submit along with this form a word document listing the other organizations contacted. Enter "N/A" for any unused rows.
Organization Name:		Organization Type:		Proposed or Actual Completion Date:
e.g., Big Box Store		e.g., National Retailer		e.g., 3/15/2012
CFL and ILL products only: If the distribution chain you've listed above includes one or more of the product retailers identified in EPA's testing failure email to your organization, you must include the EPA-provided contact(s) for that/those retailer(s) as part of your downstream notice that the model(s) is/are no longer ENERGY STAR certified. By checking the box at right, you indicate you have or will contact the applicable contact(s) by the completion date(s) listed above.
2) Remove the ENERGY STAR mark from all:		Applicable?	Proposed or Actual Completion Date:	Number of Units:
	a) Affected Units: (within your control)
		Applicable?	Proposed or Actual Completion Date:	Number of Units:
	b) Unit Packaging: (within your control)
		Applicable?	Proposed or Actual Completion Date:	URL of Modified Website:
	c) Website References to Model(s):
		Applicable?	Proposed or Actual Completion Date:	Example of Modified Marketing Material:
	d) Marketing Materials: (e.g., spec sheets)
Section IV, Part 1: Additional Model Numbers
If submitting for windows, doors, and skylights products, proceed directly to Section IV, Part 2
Use this section for affected family models. Fill out a new form for any models requiring different actions or estimated completion dates from those entered in Section III.
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Additional Model #:		Units Shipped in Last 6 Months:		Date of Last Sales Shipment:
Section IV, Part 2: Affected Product Options
Complete this section only if submitting for windows, doors, and skylights products
Use this section to identify all affected product options within the product line of the model number entered in Section I.
Identify affected product options of failed model(s) List the National Fenestration Rating Council (NFRC) Certified Products Directory (CPD) number for any product options qualified on the same basis as the product that failed testing. For example, affected product options may be grouped with or otherwise share components or other product features with the product that failed testing, and a result of the issue(s) identified during verification testing, the affected product options would also fail to meet the ENERGY STAR requirements. Any affected product options you elect to identify below will need to be reviewed and confirmed by NFRC prior to EPA review of your submittal. Please include with your response a written confirmation letter from an NFRC representative. If you need additional rows, submit with this form a supplementary document listing the additional affected product options. Enter "N/A" for any unused rows. If no additional product options are affected by this failure, provide an explanation in Section V.
Product Line Number:		CPD # of Affected Product Option:		Explanation: (optional)
Section V (optional): Additional Comments
Use this section to provide EPA with relevant information not included elsewhere in this form.
Representative Signature
As a representative of this company, I hereby certify on its behalf as to the actions taken or to be taken by it, as described above. Failure to implement these actions as indicated, or to inaccurately certify as completed, may result in partnership suspension or termination, or the loss of other ENERGY STAR program benefits. I understand that intentionally submitting false information to the U.S. government is a criminal violation of the False Statements Act, Title 18 U.S.C. section 1001.
	Name (First & Last)		Date	I agree to the above statement
OMB Control No. 2060-0528