Form PFN-3400-3 Incentive Manager Questionnaire

					OMB Control No. 2060-0528
					Approval expires: Pending Approval
EEPS Incentive Data Collection
Instructions
Welcome to the ENERGY STAR Incentive Management Portal. This tool updates the incentive data in the ENERGY STAR Rebate Finder, Home Improvement Savings Tool, and DIME. Thank you for helping keep these tools up to date! The more accurate and relevant our information is, the better we can promote your program offerings to your customers and to retailers and manufacturers who may be interested in collaborating with you more closely. We appreciate your input and thank you for your continued support of ENERGY STAR! Please fill in each yellow field below with information that accurately captures the incentive information for each incentive you offer.
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0528). Responses to this collection of information are voluntary (Section103(g) of the Clean Air Act). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to take ___ hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.
Organization Name:
Section I: Incentive and Product Information
State:			Product:
Are all Certified Models Eligible for the Incentive?			Incentive Beneficiary (General or Low income?)
Incentive Type:			Incentive Amount:
Incentive Start Date:			Incentive End Date:
Program Web Address:			Customer Hotline:
Incentive Recipient (Customer or trade ally?)			Sector (Residential or Commercial?)
Visibility in ENERGY STAR Tool Types (consumer, partner, or both?)			Fuel Type Requirement?
Section II: Contact Information
Point of Contact Name:
Contact Email:
Contact Phone Number:
Section III: Service Territory
Please fill in the information below with details on what areas the incentives are available in. Incentive Service Area should be listed as a series of zip codes seperated by commas. If the incentive applies to an entire state, fill in cells B27 and F26.
Incentive Service Area Name:			Incentive Service Area Description:
Does this Incentive Service Area correspond to an income-based incentive offering only (Y/N)?			Status for use in Incentives (Active/Disabled):
Does this Incentive Service Area apply to customers of only a specific fuel type or types?			Which state does this Incentive Service Area apply to?
Should this Incentive Service Area apply to the entire state?			Incentive Beneficiary (General or Income Qualified)
List of Zip Codes where incentive is available
Section IV (Conditional): Incentive Beneficiary
The fields below should be filled out only for Income Qualified Incentives
Program Focus
Energy Audit Required (Y/N)?			Retrofit or New Construction?
Detailed Eligibility Criteria
Program Eligibility Criteria
Percent Min			Percent Max
Section V (Conditional): Tiered Incentives
The fields below should be filled out only for tiered incentives. Incentives that cannot be expressed as simple numeric ranges can be indicated in the "Other Amount" custom field.
Tiered Incentive Basis
Incentive Range
Minimum Incentive Amount			Maximum Incentive Amount
Other Amount
Section V (optional): Additional Comments
Use this section to provide EPA with relevant information not included elsewhere in this form.
EPA Form No. PFN-3400-3