SMART-E LOAN PROGRAM PROPOSAL COVER SHEET

Date of Energy Proposal:______Contractor Company:______

Section 1 (to be completed by loan applicant/owner)

# Units in Building  1  2  3  4  _____ Complex Name (if applicable) ______

Electric Utility Company Electric Utility Account No. Gas Company Gas Co Account No.

______-______-______-______-______Street Address (include Apt or Unit #, if applicable): City ZIP ______, CT ______Owner Occupied  Yes  No # of Occupants in Building: ______Email: ______Selected Lender: ______Section 2 (to be completed by Contractor(s)): Indicate upgrade and/or installation measures using project codes from attached sheet. Code Contractor License # Manufacturer / Model # Cost

Section 3 (to be completed by Contractor) Existing Heating System: Existing Domestic Hot Water Heater: Type:  Furnace  Steam Boiler Type:  Freestanding Tank  Indirect Tank  Hot Water Boiler  Other ______ Tankless  Other ______

Fuel:  Natural Gas  Oil Fuel:  Natural Gas  Oil  Propane  Electricity  Other ______ Propane  Electricity  Other ______

Existing Windows:  Single-Pane  Double-Pane

Date of Construction of Building (according to Town Assessor’s Office): ______Regardless of building age, Contractor must fill out the SHPO form, available in the Contractor Portal (mark box for exempt if building < 50 years old) If using “Other” measure code please explain: ______

Total Proposed Energy Savings (% per year) ______

Total Cost of Proposed Project: ______Total Amount to be Financed: ______ACKNOWLEDGEMENT / DISCLOSURE SECTION

I certify that I have read and understand the program requirements and that I must use proceeds I obtain through a Smart-E loan to install energy-related measures based on, or non-materially modified from, the individual contractor(s)’ proposal(s), which are submitted with this Loan Intake Form for eligibility approval. I understand that my contractor must submit this sheet, along with a proposal for energy upgrades to the Clean Energy Finance and Investment Authority (CEFIA) for technical approval. I am aware that I must receive membership approval or credit pre-approval at my selected Participating Lender before my contractor submits the proposal for technical approval. A list of Participating Lenders, including a summary of applicable fees and charges, can be obtained at www.EnergizeCT.com/SMARTE. However, I understand that receipt of a loan is contingent upon the eligibility of the measures proposed for financing, and I must obtain a signed, itemized proposal from an approved contractor.

The actual amount of the Loan will be determined by the actual costs of all approved measures. The loan amount may be net of any additional state rebates from the Connecticut Energy Efficiency Fund and/or CEFIA.

I understand that completing an Intake Form does not guarantee approval for a loan or membership in a participating lending institution. Loans must be provided directly by a Participating Lender. I understand that I should not complete any measures listed in my application or otherwise rely on the funds of the Loan until I receive a formal commitment from a Participating Lender.

CEFIA is a “public agency” for purposes of the Connecticut Freedom of Information Act (“FOIA”). Information received pursuant to this proposal will be considered public records and will be subject to disclosure under the FOIA, except for information falling within one of the exemptions in Conn. Gen. Stat. Sections § 1-210(b) and § 16-245n(d), which may be withheld at CEFIA’s discretion.

I have read, understood, and agree to the Terms and Conditions above.

Loan Applicant signature(s) Date MEASURE # MEASURE 0 00_Other 1 01_Other: Asbestos Remediation 2 02_Other: ENERGY STAR appliances 3 03_Other: ENERGY STAR QIV incentive 4 04_Other: Mold Remediation 5 05_Other: Roof Repair 6 06_Other: Structural Remediation 7 Air Sealing Air Source Heat Pump 8 Must meet or exceed ENERGY STAR: 14.5 SEER, 12 EER, 8.2 HSPF for split systems: 14 SEER , 11 EER, 8.0 HSPF for single packaged systems Central AC 9 Must meet or exceed ENERGY STAR: 14.5 SEER, 12 EER, for split systems: 14 SEER, 11 EER for single packaged systems 10 Duct Sealing Ductless Mini-Split Heat Pump 11 Must be ENERGY STAR: meet or exceed 14.5 SEER, 12 EER, 8.2 HSPF with inverter driven outdoor compressor 12 Energy Efficient Zone Heating Controls 13 Energy Efficient Lighting Systems Ground Source Heat Pump GLHP Closed Loop Water to Air 17.1 EER, 3.6 COP 14 DX Direct Expansion Refrigerant 16.0 EER, 3.6 COP Water to Water 16.1 EER, 3.1 COP Heat Pump Water Heater 15 Energy Factor (EF) of 2.0 or greater, ENERGY STAR High Efficiency Insulation - all heating types 16 Final R-Value must be >=38 (attic only). Ceiling must be <=30, walls <=4. No basement ceilings, below grade walls or interior walls High Efficiency Window AC Units PTAC/PTHP 8,000 BTU or Below: 12.5 EER – 3.0 COP 8,100 BTU to 10,000 BTU: 12.0 EER – 2.9 COP 17 10,100 BTU to 12,000 BTU: 11.5 EER – 2.9 COP 12,100 BTU to 13,000 BTU:11.0 EER – 2.9 COP 13,100 BTU and above: 10.0 EER – 2.8 COP Hot Air Furnace - Biomass 18 ASME Certified, 85% AFUE Hot Air Furnace - Natural Gas 19 ENERGY STAR: AHRI rated 95% AFUE, Performance EAE of 2% or lower Hot Air Furnace - Oil 20 86% AFUE, Performance EAE of 2% or lower Hot Air Furnace - Propane 21 ENERGY STAR AHRI rated 95% AFUE, Performance EAE of 2% or lower Hot Water Boiler - Biomass 22 ASME Certified 85% AFUE Hot Water Boiler - Natural Gas 23 90% AFUE with temperature reset or purge control Hot Water Boiler - Oil 24 86% AFUE with temperature reset or purge control Hot Water Boiler - Propane 25 90% AFUE with temperature reset or purge control Indirect Water Heater - Natural Gas 26 attached to ENERGY STAR Boiler of AFUE of 90% or greater Micro CHP 27 Contact CEFIA for technical requirements Micro fuel cell 28 Contact CEFIA for technical requirements 29 Natural Gas Conversion of code efficiency equipment (Burner and CIAC, if applicable) On-Demand Tankless Water Heater - Natural Gas 30 ENERGY STAR: EF of 0.82 or greater On-Demand Tankless Water Heater - Propane 31 ENERGY STAR: EF of 0.82 or greater 32 RE_Electric Vehicle Recharging Station 33 RE_Natural Gas Vehicle Refueling Station Replacement Windows - All heating fuels 34 ENERGY STAR U-factor < or = 0.30. Not for unconditioned spaces 35 Smart Meters Solar Photovoltaic System 36 Must meet CEFIA’s standards for rebates Solar Photovoltaic Islanding Inverters 37 Please contact CEFIA for technical standards Solar Photovoltaic Battery Back-up 38 Please contact CEFIA for technical standards 39 Solar Hot Water Heater 40 Steam Boilers - all fuels 41 Weather Responsive Controls - Natural Gas 42 Weather Responsive Controls - Oil 43 Weather Responsive Controls - Propane Wind System (Residential) 44 Please contact CEFIA for technical standards