DOE F 413.39 50001 Ready Self-Attestation Form

DOE HQ F 413.39 (11/2021)

50001 Ready Self-Attestation Form

OMB Control# 1910-5177 Exp. Date:

PROJECT NAME:

Project Location (City, State/Province):

Project Scope:

Organization Name:

This document is for energy management teams using the 50001 Ready Navigator tool to attest to the U.S. Department of Energy that they have successfully implemented a 50001 Ready energy management system. This document must be signed by an energy management representative with the responsibility and authority to make this attestation and top management representative. The undersigned hereby declare that the energy management team for the facility covered by the above Project has completed all 25 tasks in the Navigator tool, including energy performance calculations, and is continuing to incorporate energy management into its everyday organizational practices.

Energy Management Representative Signature

Executive / Top Management Signature

Printed Name

Printed Name

Title

Title

Email and Phone

Email and Phone

Date

Date

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the U.S. Department of Energy (DOE) through the 50001 Ready Navigator energy management system implementation tracker.

1. AUTHORITY. 42 U.S.C. 7010 et seq.; 50 U.S.C. 2401 et seq.; Public Law 95-91; and Executive Order 9397, Numbering System for Federal Accounts Relating to Individual Persons.

2. PURPOSE(S). The information contained on this form is used in administering the 50001 Ready Navigator energy management system implementation tracker. This collection documents a username and password to login to the tool where users can go through a set of 25 tasks, worksheets, and templates to evaluate energy performance using internal audits and management reviews. While it is voluntary to provide login information, you must provide a login and other information when applying to DOE to recognize the steps they have completed. This collection is to provide organizations an internationally recognized framework to manage and improve their energy performance.

3. ROUTINE USES. The information may be disclosed to an appropriate Federal, State, or local agency in the event the information indicates a violation of law and in the course of an administrative or judicial proceeding. In addition, this information may be transferred to an appropriate Federal, State, and local agency to the extent relevant and necessary for a DOE decision or to an appropriate Federal agency to the extent relevant and necessary for that agency’s decision about you.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION. It is voluntary that you furnish the requested information. If the information is not furnished, you may still access the 50001 Navigator tool and utilize the templates and steps. However, if you wish to track your progress or apply to DOE to recognize the steps you have completed, the information must be furnished.

OMB DISCLOSURE STATEMENT

This data is being collected to facilitate delivery of technical assistance and other program services. The data you supply will be used to evaluate the effectiveness of investments in energy management systems and to improve the usefulness of Federal technical assistance and recognition programs.

Public reporting burden for this collection of information is estimated to average < 30 minutes 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, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project OMB control number 1910-5177, 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 OMB control number 1910-5177, 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 voluntary.

DOE HQ F 413.39 (11/2021)

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