Manufacturers

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Overview

Certification
Input

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Sheet 1: Certification

OMB Control Number: 3084-0069 (Expiration Date: April 30, 2027)

Version 5.5

Television Sets

Product Type:

Television Sets

Status of This Certification Sheet

No Data

5.5

Overall Status of Template

No Data

Click here for instructions for completing this form

Each Importer and U.S. Manufacturer is legally required to certify the compliance of the products it imports, produces, assembles or manufactures. This party is the "Certifier" on this form. This certification may be submitted by the Importer or U.S. manufacturer 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: 3084-0069 (Expiration Date: April 30, 2027)

Paperwork Reduction Act Statement

OMB Burden Disclosure Statement

This data is being collected for manufacturers to report required information to the Federal Trade Commission. This information is shared with the public for the purpose of encouraging consumers to comparison shop for energy-efficiency household products. Public reporting burden for this collection of information is estimated to average from 2 minutes per year per basic product model to 15 hours per year per manufacturer, 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 Division of Enforcement, Bureau of Consumer Protection, Federal Trade Commission, 600 Pennsylvania Avenue NW, Washington, DC 20580; and to the Office of Management and Budget (OMB), OIRA, New Executive Office Building, Docket Library Room 10102, 725 17th Street NW, Washington, DC 20503, Attn: Desk Officer for the Federal Trade Commission. 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 required by the Federal Trade Commission; submission through CCMS is optional.

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Sheet 2: Input

Television Sets	Television Sets						Version 5.5		· 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.
5.5
		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".				The cells below provide an explanation for "Errors".
														By annual report date
Line No.	Status	Manufacturer	Brand Name(s)	Individual Model Number	Starting Serial Number or Date Code (or other means of identifying date of manufacture)	Action	Sample Size (Number of Units Tested)	Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements?	Date of Test Procedure Waiver, if Applicable	Screen Size (diagonal in inches)	Power Consumed in On Mode (watts)	Power Consumed in Standby Mode (watts)	Annual Energy Consumption (kWh per year)	Link to EnergyGuide Label Website (Enter link or, if submitting link later, enter 'By annual report date')		Manufacturer Status	Brand Name(s) Status	Individual Model Number Status	Starting Serial Number or Date Code (or other means of identifying date of manufacture) Status	Action Status	Sample Size (Number of Units Tested) Status	Is the Certification for this Basic Model Based on a Waiver of DOE's Test Procedure Requirements? Status	Date of Test Procedure Waiver, if Applicable Status	Screen Size (diagonal in inches) Status	Power Consumed in On Mode (watts) Status	Power Consumed in Standby Mode (watts) Status	Annual Energy Consumption (kWh per year) Status	Link to EnergyGuide Label Website (Enter link or, if submitting link later, enter 'By annual report date') Status
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