RD 9004-3 Repowering Assistance Program - Payment Request

Form Approved - OMB No. XXXX-XXX

Form RD 9004-3

(enter date form approved) U.S. DEPARTMENT OF AGRICULTURE

Rural Development - Energy Division

REPOWERING ASSISTANCE PROGRAM - PAYMENT REQUEST

This form is to be completed by Biorefineries that have been approved for participation in the Repowering Assistance Program. Participating Biorefineries may request a one-time advance payment at the completion of the repowering project by completing Parts A, B, and E of this form. Subsequent payments may be requested semiannually by completing Parts A, C, D, and E of this form.

See Page 4 for Privacy Act and Public Burden Statements.

Part A:

1. Name of Biorefinery:	2. Agreement Number (from Form RD 9004 - 2):
3. Mail Address (Regular Mail):	4. Congressional District:
5. IRS Tax Identification Number:	6. Contact Person:
7. Contact Person’s Title:	8. Telephone No. (Include Area Code) :
9. Purpose of this submission (Check One):  A. Request a one-time advance payment. (If checked, go to 11)  B. Request a semiannual payment.
10. Period for which semiannual payment is being requested (Enter beginning and ending dates for the 6-month period): From _______________________________ to __________________________
11. Electronic Transfer Funds Number: Bank Name: ____________________________________________________________________ Routing Number: ________________________________________________________________ Account Number: ________________________________________________________________

Form RD 9004-3 (enter date) Page 2 of 4

Part B: One-time Advance Payment Request

Eligible Biorefineries applying for a one-time advance program payment shall complete the following table.

1. Date of completion of the repowering project. (Enter the date on which the biorefinery began the use of biomass as a replacement for fossil fuels.)
2. Description of the repowering project, as completed. (Describe the equipment installed, including manufacturer’s name, rated capacity, type of energy produced (steam, direct heat, process heat, electricity, etc.), amount of energy expected to be produced by the repowering project, and percentage of Biorefinery’s total energy needs to be generated by the repowering project.)
3. Describe the metering equipment used to determine the production of usable energy from renewable biomass. (Include the type of device(s) and the equipment manufacturer’s name and model number, the Serial Number(s) of the equipment, the type of energy measured (steam, electricity, etc.), and the units of measure.)
3a. Type of device	3b. Manufacturer’s name	3c. Model number	3d. Serial number	3e. Type of energy measured	3f. Units of measure
4. Actual total cost of repowering project.
5. Portion of actual total costs that are eligible project costs for the Repowering Assistance Program. (Total project costs minus any costs associated with the production of energy that will be sold.)
6. Maximum dollar amount of Repowering Assistance Program payments that the Biorefinery may request. (Enter the lesser of $5,000,000 or an amount equal to 50 percent of the amount reported in Block B5 of this form.)
7. Dollar amount of Advance Payment requested. (Enter an amount equal to 20 percent of the amount reported in Block B6 of this form.)

Form RD 9004-3 (enter date) Page 3 of 4

Part C: Semiannual Payment Request

Eligible Biorefineries applying for a semiannual program payment shall complete the following table.

1. Enter amount of semiannual payment requested. (Calculate by multiplying $0.50 times the number of Million BTU (MMBTU) of energy produced from renewable biomass systems during the 6-month period in Part A(10). Note that if steam produced by the renewable biomass system is used to generate electricity, either the steam energy or the electric energy may be counted, but not both.)

Payment request ($) = (______________ MMBTU) X ($0.50)

Payment request ($) = _____________________________

2. In Blocks 2a through 2g provide documentation for the amount of energy production (MMBTU) reported in Block C1. (For each type of energy production, provide meter reading at the beginning and end of the period and show how the readings were converted to MMBTU.)

2a. Type of energy produced

2b. Serial Number of meter used to record energy production

2c. Meter reading at end of period

2d. Meter reading at beginning of period

2e. Energy produced (2c -2d), give units of measurement

2f. Energy produced in MMBTU

Total energy production for semiannual period

2g. For each different unit of measurement shown in Block 2e, provide an example calculation showing the conversion of the measured values to MMBTU.

1. _______________________________________________________________________________________________

2. _______________________________________________________________________________________________

3. _______________________________________________________________________________________________

4. _______________________________________________________________________________________________

3. Provide the amount of each type of biomass feedstock used in the production of energy.

1. ________________________ (tons, or other applicable units) of ____________________________

2. ________________________ (tons, or other applicable units) of ____________________________

3. ________________________ (tons, or other applicable units) of ____________________________

4. Provide the amount and type of energy produced or purchased by the Biorefinery that is NOT derived from the repowering project.

Concurrent period meter readings or shipments	Serial Number of meter or bin or tank location	Meter reading at end of period	Meter reading at beginning of period	Unit consumption in gallons, tons, Kwh etc.
Natural Gas
Propane
Electric
Coal
Fuel Oil

Form RD 9004-3 (enter date) Page 4 of 4

Part D: Cumulative Energy Production and Payments

Using the data provided in this form for this semiannual period and all previous semiannual periods, fill in the following table to show cumulative amounts of energy produced from the renewable biomass system and cumulative amounts of payments requested.

1. Enter cumulative amount of payments requested. (Include the amount of all previous payments requested (advance payment request and semi-annual payment requests) and the amount requested with this form.) Cumulative amount of payments requested: $_____________________________________
2. In Blocks 2a and 2b enter the cumulative amount of energy production (MMBTU) from the renewable biomass system. (The values presented on this table should equal sum of the total energy production reported in Block C2f of this form and the total energy production reported on all previous semiannual payment requests.)
2a. Type of energy produced	2b. Energy produced in MMBTU
Total energy production
3. Provide the cumulative amount of each type of biomass feedstock used in the production of energy. 1. ________________________ (tons, or other applicable units) of ____________________________ 2. ________________________ (tons, or other applicable units) of ____________________________ 3. ________________________ (tons, or other applicable units) of ____________________________

Part E: Certification

CERTIFICATION AND ACCEPTANCE
I certify that, to the best of my knowledge and belief, the information included in this form is true and correct and that I am in compliance with all Repowering Assistance Program requirements including applicable Federal and State certifications.
1. BIOREFINERY A. __________________________________________________________________________________________________________ (BIOREFINERY NAME) B. By: ____________________________________________________________________ _____________________________ (SIGNATURE) (Date (MM-DD-YYYY)) C. Title: ______________________________________________________________________________________________________
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 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, 651, 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 XXXX-XXXX. The time required to complete this information collection is estimated to average 2 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.

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.