5900-254 Certification Error 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 "Delisted Product_[Company Name]_[Model 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 neccessary.
Section I: Product and Shipping Information
Partner Name (company):			Date Last Manufactured:
Delisted Model Number (from EPA letter):			Date of Last Sales Shipment (labeled units):
Delisted Model's Brand Name:			Recipient of Last Sales Shipment (labeled units):
Original Equipment Manufacturer (OEM):			Destination of Last Sales Shipment (labeled units):
Model's ENERGY STAR Product Category:			Units Shipped in Last 6 months (labeled units):
Delisted Product Notification Date:			Total Units Manufactured (labeled units):
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, retailers, consumers, and other affected organizations (e.g., utilities), that the model(s) is/are no longer ENERGY STAR certified. 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., 03/15/12
CFL 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: Additional Model Numbers
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 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