DOE F 220.78 Nema Design C and IEC Design H Motors

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Overview

Certification
Branding CC#
Input

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Sheet 1: Certification

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

Version 5.3

DOE F 220.78

NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)

Product Type:

NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)

Status of This Certification Sheet

No Data

5.3

Overall Status of Template

No Data

Click here for instructions for completing this form

Each Manufacturer or Private Labeler is legally required to certify the compliance of the products it distributes in commerce. This party is the "Certifier" on this form. This certification may be submitted by the Certifier or by a Third Party Representative. This party is the "Submitter" on this form.

Certifier - Party Legally Obligated to Certify Compliance

Submitter - Party Submitting This Report

The party responsible for certification is (select one only):

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

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Certifier 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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Compliance Statement

Select one of the options for 'Submitter - Party Submitting This Report' above

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.

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Sheet 2: Branding CC#

NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)		NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)						Version 5.3
5.3	Complete either Section 1 OR Section 2 below. This template should be used to submit models for a SINGLE Compliance Certification Number, whether already assigned or requested. Section 3 is optional.						Status of This Sheet	No Data
							Overall Status of Template	No Data
		Please complete either Section 1 or Section 2			Click here for instructions for completing this form
Section 1. To be completed if a Compliance Certification Number has already been assigned.
	A.	Enter the Compliance Certification Number that applies to all of the electric motors covered by this Compliance Certification. This must be in the form of CCnnnx where n is a number and x is either the letter A or B.
	B.	Enter the name(s) to be marked on the electric motors to which this Compliance Certification applies:
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Section 2. To be completed if a Compliance Certification Number is being requested.
	A.	Enter each brand name, trademark, or other label name for which the Certifier requests a Compliance Certification Number:
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	B.	List all other names, if any, under which the Certifier distributes electric motors:
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Section 3. To be completed if the Certifier wants to request modifying the brand, trademark or label names
associated with any existing Compliance Certification Number. Any change will not take effect until
confirmation is received from the Department of Energy.
		Compliance Certification Number	Brand(s)	Add	Delete
		Note: The Compliance Certification Number must be in the form of CCnnnx where n is a number and x is either the letter A or B.

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Sheet 3: Input

NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)	NEMA Design C and IEC Design H Motors (effective Jun 1, 2016)						Version 5.3		· Please enter your data in the columns shaded in gray below, using a separate line for each model. · Click on the column heading for instructions on how to complete cells in that column. · Cells highlighted in yellow indicate an "Error." "Error" means that information is missing or there is an issue with the entry. · If the "Status" for a row is "Error," you can see an explanation in the columns to the far right.
5.3
	Status of This Input Sheet		No Data			Overall Status of Template	No Data
	Certification Report				Click here for instructions for completing this form				The cells below provide an explanation for "Errors".			The cells below provide an explanation for "Errors".
Line No.	Status	Motor Horsepower	Number of Poles	Open or Enclosed Motor	Least Efficient Basic Model - (Model Number(s))	Nominal Full Load Efficiency	Nominal Full Load Efficiency Determined by Actual Testing?		Motor Horsepower Status	Number of Poles Status	Open or Enclosed Motor Status	Least Efficient Basic Model - (Model Number(s)) Status	Nominal Full Load Efficiency Status	Nominal Full Load Efficiency Determined by Actual Testing? Status
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