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 ecoENERGY

CDI-2008 Payment Request Form: Solar Water Heating System

To qualify for receipt of the incentive offered under the ecoENERGY for Renewable Heat program, please print clearly when completing this form and submit it to the address provided in Section H below. After the project has been completed, this Payment Request Form must be signed by the Applicant and must be submitted, along with the Commissioning Report and Schedule D (Ref.: Terms and Conditions and the Contribution Agreement - Article 5).

Section A. Applicant

File Number:
Business Name:
First Name:
Last Name:
Mailing Address:
City:
Province/Territory:
Postal Code:
Telephone: () -
Fax: () -
Email:
Cell: () -

Section B. Supplementary Project Sketches and Photos

Has a sketch been attached to the Commissioning Report?  yes    no
Have photos been sent to NRCan?

If yes, which of the following apply? 		 Yes    No

 sent by electronic mail to ecoenergyrhp@nrcan.gc.ca

 enclosed  

Section C. Project Budget

C1. Actual Costs (excluding taxes)

Please list all costs before taxes. List cost of new equipment only. Do not list recycled or refurbished equipment.

Solar Water Heating System Component Supplier Cost (excluding GST & PST)
Collectors
Collector rack and/or support components
Piping and pipe insulation between the collectors and the auxiliary heater (detail the list)
Solar heat exchanger(s)
Solar heat storage equipment: (detail the list)
Photovoltaic components used to power solar system pump(s)
Solar pump(s)
Solar system controller
Other (explain)
  Equipment Cost Subtotal:
Solar Water Heating System Project Costs Supplier Cost (excluding GST & PST)
Project feasibility, design, and simulation
Building Permit
Other Permits (exclusively for solar system installation): Please list them:
Project management
Installation labour
Shipping
Commissioning
  Project Cost Subtotal:
  TOTAL PROJECT COST:
Total solar system cost per m2 of collector area: $   /m2

C2. Additional Financial Contributions

Have you applied to any of the partner programs?  Ontario     Saskatchewan
 British Columbia 
Did the solar system receive, or is it expected to receive any other funding? If yes, list funding sources below.  yes    no

List all funding from governmental sources other than this program:

Organization Program Name Amount ($)
Total additional governmental funding:

List all supplementary funding from other sources:

Organization Program Name Amount ($)
Total non-governmental funding:

C3. Additional In-kind Contributions

Will the project receive any in-kind contributions?  yes    no

If yes, list all in-kind contributions.
Organization Contribution Amount ($)
Total in-kind contributions:

C.4 Anticipated Incentive from NRCan's ecoEnergy for Renewable Heat program

Complete the following equation using data from the Accepted Collector List with the Dollar Value from the Incentive Rate Table, as they pertain to your completed project.

Performance Factor x Incentive Rate x area = anticipated incentive amount

Performance Factor Incentive Rate Area of Collector (m2) Anticipated Incentive Amount ($)

Section D. Commissioning Date

What date was the system commissioned? // (yyyy/mm/dd)

Section E. Checklist for Attachments

Please ensure that all of the following documents are included with your Payment Request Form.

 Commissioning Report

 Photos

 Schedule D

 Supplementary documents that you deem helpful to enable NRCan to process payment.

Identify all attachments with the file number, Applicant's name, and project location.

Section F. Consent and Signature

I  the Applicant, of (company's legal name as stated in the contribution agreement), duly authorized on behalf of the organization, hereby represent and warrant:

  • that the collector installed is that which is has been identified in section C.4 and has been selected from the program's approved collector list;
  • that I have declared on the ecoENERGY for Renewable Heat program Payment Request Form any and all project funding received or anticipated to be receivable from government sources other than the ecoENERGY for Renewable Heat program; and
  • that the above noted declaration is true and accurate. I understand that if, in the opinion of the Minister (NRCan), there has been a misrepresentation or a breach of this warranty, the Minister (NRCan) could place the company in default of the terms, conditions or obligations of the contribution agreement, and may exercise his right to terminate the agreement and direct us to repay forthwith all or any parts of the monies paid by Canada pursuant to the agreement, and the amount will be a debt due to Canada and may be so recovered.
__________________________
Signature		 ___________
Date		 __________________________
Location

 

Was this Payment Request form completed by the Applicant? If not, complete the section below.  yes    no
This Payment Request form was completed by:
Salutation     Mr.    Ms.
Title:
First Name:
Last Name:
Business Name:
Mailing address:
City:
Province/Territory:
Postal Code:
Telephone: () -
Fax: () -
Email:
Cellphone: () -
Signature: ____________________________________

Date: ____________________________________

Location: ____________________________________

Section G. Submission

Please send completed Payment Request form to:

ecoENERGY for Renewable Heat
Renewable and Electrical Energy Division
Natural Resources Canada
Room 150, 615 Booth Street
Ottawa, Ontario K1A 0E9

For more information, contact:

E-mail: ecoENERGYRHP@NRCan.gc.ca
Tel.: 1 800 O-Canada (1 800 622-6232)
Fax: 613-943-6517

IMPORTANT: MISSING INFORMATION WILL DELAY THE PROCESSING OF YOUR PAYMENT.

 

Date Modified: 2011-02-25

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