5900-76 Qualified Product Information Form for Light Commercial

OMB Control No. 2060-0528

Approval Expires XX/XX/XX

United States

ENVIRONMENTAL PROTECTION AGENCY

Washington, DC 20460

Qualified Product Information Form for

Light Commercial Air Source Heat Pumps & Central Air Conditioners (ASHP/CAC)

Office of Atmospheric Programs

ENERGY STAR^® product information form for use by ENERGY STAR qualified light commercial ASHP/CAC partners (Companies who have joined ENERGY STAR for light commercial ASHP/CAC by signing a Partnership Agreement)

Use this form to report only those products that are sold under your company’s brand name. If your firm sells its models to another company that uses its own brand name, that company must join the program and report its own products. Information from this form will be added to the list of ENERGY STAR qualified Light Commercial ASHP/CAC products. If you need additional space, please copy this form.

Company Name: ________________________________ Product Contact Information:___________________ (As listed in Partnership Agreement) (For public requesting product information)

Name: _________________________________________________

Tested by: ______________________________________

(Name of Firm or Self-Tested)

Tel: _______________________ Fax: _______________________

Email: _________________________________________________

Additions to Qualifying Products List:

Manufacturer Name (Trade Name)	Product Family Name1	Product Type2	Capacity (Btu/h)	SEER/ HSPF3 Rating	EER4/ IPLV Rating	COP Rating	ARI Certified and Listed? (Yes/No)	Model Series5

Is the ENERGY STAR label:

__in the product literature?(required)__ on your Internet site?(required)__on the top/front of the product?(recommended)

If answer to any of the above is No, explain why: _________________________________________________________________________________________________

_________________________________________________________________________________________________

Please sign below:

Signature: ________________________________________ Date: __________

Printed Name: _____________________________________

Thank you for your assistance. The Qualifying Products List is available through the ENERGY STAR Hotline (1-888-STAR-YES/1-888-782-7937)

The public reporting and recordkeeping burden for this collection of information is estimated to average 4.85 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, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 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.

1 Product Family Name is a series name, such as ‘Presidential’ or ‘Elite.’

2 Specify product type according to the product types listed in Section IV.C Table 1 and Table 2 of the Eligibility Criteria

(i.e., Air-Source Air Conditioner or Air-Source Heat Pump, and Split Unit or Packaged Unit).

3 HSPF ratings are only necessary for Air-Source Heat Pumps.

4 There is no EER component required for Air-Source Air Conditioners and Air-Source Heat Pumps under 65,000 Btu/h.

5 Simplify model series information when possible (e.g., “Models beginning with...”).

Please submit your completed QPI Form to ENERGY STAR for Light Commercial ASHP/CAC

Email: lchvac@icfi.com, Fax: (202) 862-1144

1725 Eye St., NW, Suite 1000, Washington, DC 20006

ENERGY STAR, US EPA, 1200 Pennsylvania Ave., MC 6202J, Washington, DC 20460 USA

Toll-free number 1-888-STAR-YES; Web site: http://www.energystar.gov

ENERGY STAR is a registered US mark.

EPA Form No. 5900-76