Attachment III - Attestation Form.docx

Attestation Form Directions:

The Contractor (CFE Supplier) is required to submit both Form A and Form B if the energy attributes associated with the CFE are being attested to the Government by any other entity from any other source other than the Generator itself (e.g., Third Party Marketer).

The Contractor (CFE Supplier) is only required to submit Form B if the energy attributes associated with the CFE are being attested to the Government by only the Generator.

Please see the following two Forms below:

FORM A: CARBON POLLUTION-FREE ELECTRICITY (CFE) ATTESTATION FROM THIRD PARTY MARKETER I, (print name and title)______________________________________________, declare under penalty of perjury, on behalf of (name of CFE Supplier)___________________________________________, that

1) all CFE associated with this invoice and supplied to the Government were generated by eligible CFE generators as defined in the subject Agreement and Implementing Instructions to E.O. 14057;

2) all energy attributes associated with the supplied CFE, including any emissions reduction credits or emissions allowances, represented by the Energy Attribute Certificate (EAC) sales reported in EAC Certificate of Transfer were transferred to the Government (list Agency) __________________________

3) all energy attributes associated with the supplied CFE represented by the EAC sales reported in EAC Certificate of Transfer were not and will not be sold, marketed, or otherwise claimed by a third party; and

4) all energy attributes associated with the supplied CFE represented by the EAC sales reported in EAC Certificate of Transfer will be retired by the CFE Supplier on the Government’s behalf by the following Annual CFE Compliance Year EAC Product

Generating Facility

Address

State

Zip Code eGRID Subregion

MWh Generation

From (date)

To (date)

Fuel Type

I further declare that the EAC products associated with the supplied CFE listed above and reported in the EAC Certificate of Transfer were sold once and only once, and that the electrical energy that was generated with the EACs reported in the EAC Certificate of Transfer was not and will not be separately sold, marketed, or otherwise represented as CFE and was not and will not be used to meet any federal, state, or local renewable energy requirement, renewable energy procurement, renewable portfolio standard, or other renewable energy mandate. As an authorized agent of the aforementioned Company, I have authority to submit this report on the company’s behalf.

Signature

Date

Place of Execution

FORM B: CARBON POLLUTION-FREE ELECTRICITY (CFE) ATTESTATION FROM GENERATOR

Facility Information Name of Facility:

Address of Facility:

eGRID Subregion of Facility:

Facility ID Number[footnoteRef:2]: [2: Please enter Energy Information Administration (EIA) identification number for the generating facility. If the facility does not have an EIA number, please enter the utility-assigned Qualifying Facility (QF) identification number, other identification number or indicate not applicable (N/A).]

EIA, QF, Other (specify) or N/A? (circle one)

Contact Person:

Title:

Telephone:

Fax:

Geothermal

Wind

Solar electric

Hydrokinetic (including tidal, wave, current, and thermal)

Hydroelectric

Marine energy

Nuclear

Renewably sourced hydrogen

Fossil resources with active capture and storage of carbon dioxide emissions that meets EPA requirements[footnoteRef:3] [3: Sec. 603(d) of E.O. 14057]

*For facilities which have added new CFE capacity, please indicate the amount and operational date of the new capacity and the existing capacity.

** List as separate line items MWh for each month or quarter.

CFE GENERATOR ATTESTATION FORM (CONT’D)

Declaration:

I, (print name and title)________________________________________________________________, declare under the penalty of perjury, that the information provided on this form is true and correct to the best of my knowledge.

Further, I declare that the (indicate) ___CFE kilowatt hours/ ___EACs listed above were sold exclusively to (name of the CFE Supplier) _____________________________________________. Further, I declare that 1) all the EACs, including any emissions reduction credits or emissions allowances, represented by the CFE generation listed below were transferred to the CFE Supplier above, 2) to the best of my knowledge, the EACs were not and will not be sold, marketed or otherwise claimed by a third party; 3) the EACs were and will be sold once and only once; and 4) the electrical energy that was generated with the attributes was not and will not be separately sold, marketed or otherwise represented as CFE and was not and will not be used to meet any federal, state or local renewable energy requirement, renewable energy procurement, renewable portfolio standard, or other renewable energy mandate.

Generating Facility

MWh of Generation

From (date)

To (date)

Fuel Type

Further, I declare that the facilities that generated all of the (indicate) ___CFE kilowatt hours/ ___ EACs sold to (name of CFE Supplier) _____________________________________________ are listed above by fuel type.

As an authorized agent of (generating company name) _____________________________, I attest that the above statements are true and correct.

Signature: _____________________________________________Date: __________________________ Place of Execution: _____________________________________________________________________ Address of Generating Company: __________________________________________________________ Phone Number: ___________________________________________