Form RD 9004-1 RD 9004-1 Repowering Assistance Program - Application

Form Approved - OMB No. 0570-XXX

Form RD 9004-1		U.S. DEPARTMENT OF AGRICULTURE	For Agency Use Only
(04/09)		Rural Development – Energy Division	Agreement Number
REPOWERING ASSISTANCE PROGRAM - APPLICATION
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1995 ( 44 U.S.C. 3501 et seq.), as amended. The authority for requesting the following information is Section 9001 of the Food, Conservation, and Energy Act of 2008 (P.L. 110-234). The information will be used to complete the terms of an Agreement between the owner of an eligible biorefinery (Biorefinery) and the Agency. Furnishing the requested information is voluntary, however, without it, eligibility to enter into an Agreement with the Agency cannot be determined. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 15 USC 714m; 18 USC 286, 287, 371, 641, 1001, 1014; and 31 USC 3729, may be applicable to the information provided. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0570-XXXX. The time required to complete this information collection is estimated to average 24 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. RETURN THIS COMPLETED FORM TO: USDA RURAL DEVELOPMENT-ENERGY DIVISION, REPOWERING ASSISTANCE PROGRAM, 1400 INDEPENDENCE AVENUE, SW, STOP 3225, WASHINGTON, DC 20250-3225.

1. Operating name of Biorefinery
2A. Mail Address (Regular Mail)		2B. Congressional District
3. IRS Tax Identification Number		4A. Contact Person
4B. Contact Person’s Title		5. Telephone No. (Include Area Code)
6. FAX No. (Include Area Code)		7. E-Mail Address
8. DUNS Number:	9. Are the Certification(s) required by the applicable Notice or regulations as amended attached? (Check one) ______ yes ______ no		10. Is the Feasibility Study required by the applicable Notice or regulations as amended attached? (Check one) ______ yes ______ no

______________________________________________________________________________________________________________

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

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Part A - Provide the information specified in Table A, either in the spaces provided or on attached pages.

Table A. Biorefinery Information

1. What is the typical operating schedule for the Biorefinery?

____________hours/day; ___________days/year

2. Electric use data. (Provide information on the electric service to the Biorefinery; typical consumption, peak and average demand; monthly and seasonal use patterns, etc.)

3. Fuel use data. (Provide information on the current fuel use for boilers and process heaters, including fuel type, costs, and use patterns)

4. Thermal loads. (Provide information on existing thermal loads, including type (steam, hot water, direct heat), conditions (temperature, pressure), and use patterns)

5. Existing equipment. (Provide information on the existing heating and cooling equipment, including type, capacities, efficiencies and emissions)

6. Site-specific data. (Provide information on other site-specific issues, such as expansion plans or neighborhood considerations that might impact the proposed new system design or operation)

7. Biofuel production. (Provide information on the liquid transportation fuels production; type, gallons per year)

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8. Projected Return on Investment. (Provide information on the projected return on investment demonstrated by calculating actual base energy use costs for the 24-month period prior to submission of the application, or based on engineering, design, and site plans for biorefineries with less than 24 months of operating data)

9. Projected Reduction of Fossil Fuel. (Provide information on the projected reduction in fossil fuel use based on actual fossil fuel use for the 24-month period prior to submission of the application, or at least 12-months of actual data and on engineering, design, and site plans for biorefineries with less than 24 months of actual operating data)

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Part B - Provide the information specified in Table B, either in the spaces provided or on attached pages.

Table B. Repowering Project Information

1. a. Identify the sources and uses of funds.

b. Identify the total project costs.

2. List costs that are eligible project costs for the Repowering Assistance Program. (Eligible project costs include only those costs that are for equipment, construction and engineering services for renewable biomass systems used to replace fossil fuels used to produce heat or power to operate the biorefinery. Thus, if the renewable biomass system will also be used to generate heat or power that is to be sold, the percentage of costs associated with that activity must be deducted from the total repowering project cost.)

3. Dollar amount of Repowering Assistance to be requested. (Based on planned energy production from renewable biomass and calculated using a payment amount of $0.50 per Million Btu. Maximum payment amount is the lesser of $5 million dollars or 50 percent of the eligible project cost.)

4. Provide information on the expected schedule of the repowering project. (Give the estimated date the repowering project will be initiated, the estimated calendar time to complete the project, the projected completion date, and the projected date by which full energy production will be reached.)

5. Percentage of energy produced from renewable biomass that will be used for:

_________ steam production; ___________ direct heat; __________ process heat; _________ electricity generation;

6. Will production of energy from renewable biomass be uniform throughout the year? If not, describe seasonal and other variations.

7. Type(s) of renewable biomass feedstock to be used. (If more than one type of biomass feedstock is expected to be used, give the estimated percentage of each type.)

8. Provide an estimate of the number of jobs created, saved, or lost as a result of the repowering project.

___________ jobs created; ____________ jobs saved; ____________ jobs lost

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Part C - Certification of Biorefinery Documentation and Acceptance

CERTIFICATION AND ACCEPTANCE

I certify that, to the best of my knowledge and belief, the information included with this Application is true and correct, that the Biorefinery reported is an eligible Biorefinery that was in existence on or before June 18, 2008, and that the Biorefinery is producing liquid transportation fuels from an eligible renewable biomass feedstock. I certify that the Biorefinery does not receive Title I payments for biomass used as feedstock in this repowering project.

1. BIOREFINERY

A. __________________________________________________________________________________________________________

(PRODUCER NAME)

B. By: _______________________________________________________________________________________________________

(Officer, Member, Partner, Proprietor)

C. Title: ______________________________________________________________________________________________________

D. Date ______________________________________________________________________________________________________