RD-4288-6 Repowering Assistance Program Payment Request

Form Approved - OMB No. 0570-XXXX

Form RD 4288-6 U.S. DEPARTMENT OF AGRICULTURE

(2/11) Rural Development - Energy Division

REPOWERING ASSISTANCE PROGRAM – REPORTING FORM

This form is to be completed by Biorefineries that have been approved for participation in the Repowering Assistance Program. For the purpose of verifying compliance with the fossil fuel reduction and energy production requirements, each biorefinery must make available and provide for the metering of all power and heat producing boilers, containment vessels, generators and any other equipment related to the production of heat or power required to displace fossil fuel loads with renewable biomass.

See Page 3 for Privacy Act and Public Burden Statements.

Part A: Project Information

1. Name of Biorefinery:	2. Agreement Number (from Form RD 4288 - 5):
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. Period for annual report (Enter beginning and ending dates for period): From _______________________________ to __________________________

Part B: Reporting

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.)

Form RD 4288-6 Page 2 of 3

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 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.)
5. In Blocks 5a through 5g provide documentation for the amount of energy production (MMBTU). (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.)
5a. Type of energy produced	5b. Serial Number of meter used to record energy production	5c. Meter reading at end of period	5d. Meter reading at beginning of period	5e. Energy produced (5c -5d), give units of measurement	5f. Energy produced in MMBTU
Total energy production for period specified in Block 9 of Part A
5g. For each different unit of measurement shown in Block 5e, provide an example calculation showing the conversion of the measured values to MMBTU. 1. _______________________________________________________________________________________________ 2. _______________________________________________________________________________________________ 3. _______________________________________________________________________________________________ 4. _______________________________________________________________________________________________
6. 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 ____________________________

Form RD 4288-6 Page 3 of 3

7.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

Part C: 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 0570-XXXX. The time required to complete this information collection is estimated to average 1.5 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.