DOE F 220.92 Enabled Water Heater Shipments

OMB Control Number: 1910-1400 (Expiration Date: XXXXXX XX, XXXX)

Version 5.1

DOE F 220.92

Grid-Enabled Water Heater Shipments

Grid-Enabled Water Heater Shipments

Status of This Certification Sheet

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Status of Template

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Pursuant to 42 U.S.C. 6295(e)(6)(C)(i) and 10 CFR 429.17(c), manufacturers of grid-enabled water heaters must report the total number of grid-enabled water heater units shipped for sale in the U.S. by the manufacturer for the previous calendar year (i.e., January 1st through December 31st), as well as the calendar year that the shipments cover, starting on or before May 1, 2023 and annually on or before May 1 each year thereafter. This party is the “Reporter” on this form. This report may be submitted by the manufacturer or by a Third Party Representative. This party is the “Submitter” on this form.

Reporter - Party Legally Obligated to Report Shipments

Submitter - Party Submitting This Report

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The party submitting this report is (select one only):

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Reporter Contact Information

Third Party Representative Contact Information, if Applicable

Full Legal Name of Individual

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Full Legal Name of Individual

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Full Legal Name of Company

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Full Legal Name of Company

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Complete Company Mailing Address

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Complete Company Mailing Address

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Phone Number

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Phone Number

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Email Address

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Email Address

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Number of Grid-Enabled Water Heaters Units Shipped for Sale in the U.S. for the Previous Calendar Year (i.e. January 1st through December 31st)

Calendar Year that the Shipments Cover

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Compliance Statement

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Submitter Signature (Type your Full Legal Name)

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Date (MM/DD/YYYY)

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OMB Control Number: 1910-1400 (Expiration Date: XXXXXX, XX, XXXX)

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 35 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.