Form GDO-038 Solar Ambassador Household Intake Form

DRAFT

GDO-038.1 OMB No. 1910-NEW

Exp. xx/xx/xxxx

Solar Ambassador Household Intake Form

Introduction:

The Solar Ambassador Prize, hosted by DOE, is designed to fast-track community efforts to enhance energy resilience by performing outreach and engagement to disadvantaged Puerto Rican households who qualify for residential solar and battery storage systems. The information below is being collected for the purpose of identifying eligible households with an individual with energy dependent disability, with the goal of improving energy resilience and reducing energy burden.

Do you want to proceed? □ Yes, (if ‘Yes’, go to Part A) □ No

Part A: Answer questions 1, 2, and 3 and only proceed if answers to all three questions are ‘YES’.

1. Construction-type Eligibility

Is the house a single-family house (i.e., fully detached house, semidetached (side-by-side) house, row house, or townhouse)?

□ Yes □ No

2. Income Eligibility

Is at least one of the residents of the household enrolled in or receive benefits from one or more of the following government assistance programs: Low-Income Home Energy Assistance Program (LIHEAP), Nutrition Assistance Program (NAP), or Temporary Assistance for Needy Families (TANF).

□ Yes □ No

3. Primary Residence

Is this the primary residence of the homeowner?

□ Yes □ No

Part B: Answer questions 4 and 5 and only proceed if answer to at least one question is ‘YES’.

4. Energy-Dependent Disability Eligibility

Does at least one of the residents of the household qualify as an Individual with an Energy Dependent Disability?

□ Yes □ No

Individual with Energy Dependent Disability: Individuals with disabilities that rely on electricity-dependent or battery-dependent medical equipment or assistive technology to live independently or to assist in performing activities of daily living. This includes individuals who are unable to control body temperature and therefore require heating or cooling systems to prevent injury or death, as well as those that rely on medication that is required to be refrigerated. Below is a non-exhaustive list of examples of medical devices considered to rely on electricity-dependent or rechargeable battery-dependent medical equipment or assistive technology:

• ventilator,

• bilevel positive airway pressure (BiPAP) machine,

• enteral feeding machine,

• intravenous (IV) infusion pump,

• suction pump,

• at-home dialysis machine,

• electric wheelchair,

• electric scooter,

• electric bed equipment in the past 13 months;

• oxygen concentrator equipment in the past 36 months;

• implanted cardiac devices that include left ventricular assistive device (LVAD),

• right ventricular assistive device (RVAD),

• bi-ventricular assistive device (BIVAD),

• total artificial heart (TAH) in the past 5 years.

If your medical equipment is not listed above but fits the definition, please state it here for consideration: _____________________________________________________________________________________

5. Geographic Eligibility (Last Mile Community)

Is the household located in a Last Mile Community (a qualifying census block that has a high percent of very low-income households, and experiences frequent and prolonged power outages)?

□ Yes □ No

Part C: Please proceed only if the homeowner answered ‘Yes’ to all questions in Part A; and ‘Yes’ to at least one question in Part B.

Section 1: Household Data

Installation Physical Address: ________________________ _______________________ ____________________

Street Apt/House # Municipality

Latitude: _________________________________ Longitude: ______________________________________

Name of Homeowner: __________ __________ _______________ ___________

First Name Middle Name Paternal Last Name Maternal Last Name

Homeowner’s Phone number: ( ) _________-____________

Alternate phone number (if identified by the homeowner, someone who lives at or outside the household):

( ) _________-____________

Homeowner’s Email: __________________________________

Section 2: Qualifying Resident Data

Name of Individual enrolled in TANF, PAN, or LIHEAP:

__________ ___________________ ___________________ _______________________

First Name Middle Name Paternal Last Name Maternal Last Name

Name of Individual with energy dependent disability (if applicable):

__________ ___________________ ___________________ _______________________

First Name Middle Name Paternal Last Name Maternal Last Name

Section 3: Document Upload
Proof of enrollment in Low-Income Home Energy Assistance Program (LIHEAP), Nutrition Assistance Program (NAP), or Temporary Assistance for Needy Families (TANF): Certificate letter from the Department of the Family
Proof of Individual with Energy Dependent Disability living in household, please provide the following:   Photograph of ONLY the electrical medical devices (avoid pictures where the individual is visible)  AND Letter verifying benefits status (i/e Social Security Administration/SSA, Medicare, Medicaid, Veteran Affairs/VA)  Benefits verification links: For SSA, Medicare/Medicaid verification: Get benefit verification letter | SSA For VA: Download VA Benefit Letters | Veterans Affairs
Proof of Home Ownership, please provide one of the following: Copy of property deed, Copy of notarized affidavit of ownerships. If multiple owners, affidavit needs to be signed by all. Property tax receipts for the last year, Utility bills for an account under the homeowner’s name for the last 4 months
Proof of most recent electric bill LUMA electric bill

Section 4: Verification of Information

(To be completed by Homeowner)

By completing and submitting this Application to the Federal Government, I certify that I have read, understood, and agree to all the terms and conditions of the [Program Name]. By signing below, I represent that the information provided on this Application is true, correct, complete, and contains no misrepresentations. I further agree to provide additional information to and contracted parties to review this Application. I understand false statements or misrepresentations to the Federal Government may result in civil and/or criminal penalties under 18 U.S.C. § 1001.

I hereby authorize LUMA to release my account number and account information. This includes location information for the purpose of allowing [Contracted Party Name] to assess the effectiveness and feasibility of home installation. I further grant [Contracted Party Name] permission to access my electricity usage history and data from LUMA’s website.

I understand I must meet eligibility criteria and requirements for enrollment in PR-ERF, including the stated income limits or Electrically Dependent Disability.

Signature:___________________________________________________________________________________________ Date:___________________________

 

Section 5: Ambassador Statement

(To be completed by Ambassador)

I certify that I aided the homeowner in completing the intake form and uploading the proofs of eligibility facilitated by the homeowner. I certify that no record was kept either in a printed or digital format.

Signature: ___________________________________________________________________________________________

Organization’s name: _____________________________________

Date: ___________________________

Section 6: Rooftop Solar Readiness  (This section is to be completed by the Solar Ambassador during the in-person site visit)
	Yes	No	Unable to assess
Does the house have an intact roof?	□	□	□
Does the house appear to be a single-family dwelling?	□	□	□
Does the house have any tall surrounding vegetation and/or trees that may shade the roof?	□	□	□
Does the household have reliable internet connection?	□	□	□

Solar Ambassador Program Privacy Act Statement

The Privacy Act of 1974 (5 US Code §552a) requires that when the federal government requests information from individuals, we tell them our legal right to ask for the information, why we are asking for it, and how it will be used. The purpose of this information collection is to determine an applicant’s eligibility to receive rooftop solar PV and battery storage systems installation under the Funding Opportunity Announcement DE-FOA-0003096. This program is authorized by the Consolidated Appropriations Act, 2023 (Public Law No: 117-328). 

The U.S. Department of Energy (DOE) Grid Deployment Office (GDO) established the Puerto Rico Energy Resilience Fund (PR-ERF) to administer a program focused on both residential and community-based energy resilience investments. DOE has launched the Solar Ambassadors Prize to partner with local community-based organizations, non-profit, and for-profit entities to assist in collecting information.

We are information on income status, electricity dependency (e.g., you require electricity to operate a medical device), proof of homeownership, rooftop solar readiness and whether your residence is located in a defined census tract. Applicants will also be asked optional questions to help prioritize their application based on the eligibility criteria or target beneficiaries.

This information could be disclosed to the Department of Justice for the purpose of litigating any civil, administrative, or judicial proceeding or criminal prosecution (including the presentation of evidence, disclosures to opposing counsel or witnesses, in discovery, or in settlement negotiations, or in response to a subpoena) where the United States, the Department of Energy (DOE), or its employees (in their official capacities or where the government has decided to represent them) are parties; and to provide information to congressional offices in response to inquiries made at the request of the individuals to whom the information pertains. The full system of records notice with complete description of routine uses may be found under the heading "Routine Uses" in the Federal Register notice of the system of records under DOE-82, Grant and Contract Records for Research Projects, Science Education, and Related Activities, published at 74 Fed. Reg. 994 (January 9, 2009).

Providing this information is voluntary but necessary to process your application for approval to receive program benefits. If you choose to apply for the Solar Ambassador Prize, you must provide all requested information. Failure to provide complete information may delay or prevent processing or review of your application for benefits.

Paperwork Reduction Act Burden Disclosure Statement

This data is being collected to qualify households as eligible to participate in the deployment phase of the Puerto Rico Energy Resiliency Fund (PR-ERF). The data you supply will be used to verify your household’s eligibility and priority to receive rooftop solar and (as applicable) battery storage technologies supported by the PR-ERF.

Public reporting burden for this collection of information is estimated to average one-hour 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, Information Collection Management Program (OMB 1910-NEW), U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC 20585; and to the Office of Management and Budget (OMB), OIRA, Paperwork Reduction Project (OMB 1910-NEW), 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 a mandatory requirement for participation in the deployment phase of the PR-ERF.

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