ࡱ>  bjbjT~T~ 866&-BB8eT{:tV%%%H9999999;>99%%5:"""X%%9"9""V6F8%\WU,|69K:0{:76g?g?,F8g?F8X"99( z{:g?B K: State of New Mexico - Energy, Minerals and Natural Resources Department 1220 S. St. Francis Dr., Santa Fe, NM 87505  HYPERLINK "http://www.cleanenergynm.org" www.cleanenergynm.org (505) 476-3310 Geothermal Ground-Coupled Heat Pump System Certification Application (FORM 1) Geothermal Ground-Coupled Heat Pump Tax Credit - 3.3.32 and 3.4.19 New Mexico Administrative Code (NMAC) Project No.  FORMTEXT       For department use only Form version date: 9/15/10Taxpayer Information * indicates required information* Name  FORMTEXT      * Social Security Number or Corporate Number FORMTEXT       (Will be kept confidential)* Mailing Address (Address, City, Zip Code) FORMTEXT        FORMTEXT      * Telephone  FORMTEXT      Email FORMTEXT      Contractor Information * Name  FORMTEXT      * License No. FORMTEXT      * Mailing Address FORMTEXT      * License Classification FORMTEXT      * Telephone  FORMTEXT      Email FORMTEXT       Geothermal Ground-Coupled Heat Pump System (System) Information * Project Location  FORMTEXT      * County FORMTEXT      * Residential System (please check one) FORMTEXT      * Commercial System (please check one) FORMTEXT      * System Description FORMTEXT      * System Cost$ FORMTEXT      Applicant AgreementThe applicant named above and signing this statement agrees that all information provided in this application package is true and correct to the best of the applicant s knowledge. The applicant has read the certification requirements of 3.3.32 or 3.4.19 NMAC. The applicant understands that there are annual aggregate state tax credit limits in place for these systems and that the department must certify the system documented in this application package before the applicant is eligible for a state tax credit. Furthermore, the applicant agrees to: make any changes the department requires to the system for compliance with 3.3.32 or 3.4.19 NMAC; operate the system for a minimum of five years after department certification or, if the residential, business, or agricultural enterprise where the system is located is sold or transferred to another party within five years after the departments certification of the system, the sale or transfer agreement shall require the systems continued operation or maintenance for energy production for no less than the balance of the five-year period remaining; provide for the systems regular maintenance for a minimum of five years with the applicants own resources or through a contractor; and allow the division or its authorized representative to inspect the system that is described in the application package, from the application packages submittal to three years after the department has certified the system, upon the division providing a minimum of five days notice to the applicant.   FORMTEXT      * Taxpayer Signature* Date System Monitoring OptionsOptional: taxpayer may indicate interest in the following no-cost monitoring options for the system, if these options are made available, to assist with evaluation of state-wide tax credit benefits (select all that apply):  FORMCHECKBOX  add energy monitoring equipment to the system  FORMCHECKBOX  analysis of system performance and operation  FORMCHECKBOX  analysis of taxpayer utility bill records. Checklist - System Certification Application Please review the following list to make sure you have provided all attachments required in the application package. For assistance on system certification requirements, see the Geothermal Ground-Coupled Heat Pump Tax Credit rules, 3.3.32 and 3.4.19 NMAC, and other information available through the website at  HYPERLINK "http://www.cleanenergynm.org" www.cleanenergynm.org, or contact the Energy, Minerals and Natural Resources Department (EMNRD) at (505) 476-3310.Geothermal Ground-Coupled Heat Pump Systems 3.3.32 and 3.4.19 NMAC - Required attachments FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Copy of a current property tax bill to the taxpayer for the residence, business, or agricultural enterprise where the system is located.Copy of invoice(s) of itemized equipment and labor costs for the system.Copy of the systems design schematic and technical specifications.Photographic record of the system after installation is completed.Documentation of the manufacturers listed coefficient of performance and efficiency ratio for the ground-coupled heat pump unit(s)Copies of Manufacturer or supplier of system components and their model numbersContractor or Installer documentation of IGSHPA Accredited Installer Workshop CertificationDocumentation of the total geothermal ground-coupled heat pump system sizeCompleted Geothermal Ground-Coupled Heat Pump System Installation FormTaxpayer and Contractor Statement of Understanding (3rd page of Geothermal Ground-Coupled Heat Pump System Installation Form)Copy of the written final inspection approval from the building code authority or, if inspection approval cannot be obtained, the applicant shall provide the necessary information on the system installation form in place of obtaining the inspection approval. Help - Application Package SubmittalGeneral InformationSubmit the application package to EMNRD after the system is completely installed and operating. Copies are adequate for any documents submitted to EMNRD in the application package. Use the Geothermal Ground-Coupled Heat Pump System Certification Application form as the first page of the application package. Taxpayers are encouraged to submit application packages in a timely manner. Mail applications to the attention of ECMD Geothermal Ground-Coupled Heat Pump Tax Credit Administrator or email to EMNRD as directed at  HYPERLINK "http://www.cleanenergynm.org" www.cleanenergynm.org . ECMD is EMNRD Energy Conservation and Management Division.Taxpayer InformationProvide contact information so that EMNRD may communicate with you about your application. The email address is not required but, if available, would expedite communication. The Social Security Number is required and is important in EMNRDs reporting to the New Mexico Taxation and Revenue Department on taxpayer eligibility for the tax credit. It will be filed as confidential information.Contractor InformationProvide contact information so that EMNRD may communicate with the contractor, if needed. The Email address is not required but, if available, would expedite communication. The contractor license number and classification is required so that EMNRD may verify licensing of the contractor. If the system is homeowner installed, select the box and leave the contractor information blank.Geothermal Ground-Coupled Heat Pump System InformationProvide the location of the system by either the address, which could be the same as the taxpayer mailing address, or a brief description of the physical location if an address is not available, to enable EMNRD to locate the system for inspection purposes. Also provide the county where the system is located. Please indicate whether the tax credit application is for a residential or commercial system. Provide a brief description of the system, such as describing the open or closed system, vertical or horizontal application, or lake or pond applications. Provide the systems complete net installation cost, including equipment, materials and labor, excluding the items listed in 3.3.32.13 NMAC, which should agree with the total amount shown on an attached invoice that itemizes components and labor charges of the installed system. 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A C !!!!!%!]!^!g!z!!!!'"(")"*"4"y"z"{"|""򾱤~vphhRchX] h%CJ *hO,h%hXhU"h%hAh0h%0hO,hH hHCJh%0CJOJQJaJhhHCJOJQJaJhhU"CJOJQJaJh"jhXCJOJQJUaJh(j$hXCJOJQJUaJhhXCJOJQJaJh$A B C !jdd$IfvkdM%$$Ifl40(`X&064 laf4  !$Ifgd%0$ !$Ifa$gdU"!!!]!$Ifvkd*&$$Ifl40( X&064 laf4]!^!_!!$Ifvkd'$$Ifl40( X&064 laf4!!!("$Ifvkd'$$Ifl40( X&064 laf4(")"*"z"$Ifykd($$Ifl40( X&064 laf4ytYYz"{"|""$Ifykd)$$Ifl40( X&064 laf4ytYY"""""""&#'#(#)#3#W#o#p#q#r##########ɹɍ~zr~eUHhEhhEhB*]phhYYh}U56B*]phh}U56B*]phhXhXH*hXh}U h}Uhvhv hICJ$hEhhYYB*CJOJQJ]ph$hEhh#MB*CJOJQJ]phhYYhYY56CJOJQJhI h0h0h% h%CJ *hO,h%hRchX]hhehX]hhehX6]"""'#$Ifykd*$$Ifl40( X&064 laf4ytYY'#(#)#p#w $IfgdYY$Ifykdj+$$Ifl40( X&064 laf4ytYYp#q#r##$IfykdM,$$Ifl40( X&064 laf4ytlK###$$Ifykd0-$$Ifl40( X&064 laf4ytYY##$$$$$$ %!%5%6%&&&'D'E'o'p'q'''''''''f)ྴxi\Qh^ OJQJaJhhheh?5CJOJQJhheh^ 0JCJOJQJ!j&0h^ CJOJQJU!jhheh^ CJOJQJUhhehlCJOJQJhheh^ CJOJQJhheCJOJQJh^ CJOJQJh^ 5OJQJ\h^ 5CJ$OJQJ\h^ h&CJ h^ CJ hHCJhH hvCJ$$$$ %s$ !$Ifa$gd^ ykd.$$Ifl40( X&064 laf4ytYY %!%5%6%+dkd~/$$Ifl4@)@)0)4 laf4yt^  !$Ifgd^ bkd.$$Ifl4@)@)0)4 laf4yt^ 6%%%m&&'''yk  !$Ifgd^ dkd0$$Ifl4@)@)0)4 laf4yt^  & F !$Ifgdhe & F !$Ifgd^ ''(g)h)(dkd2$$Ifl4@)@)0)4 laf4yt^  & F !$Ifgd^ bkdm1$$Ifl4@)@)0)4 laf4yt^ f)g)h)~)))/*0****+++++=+>+?+A+[+I,c,x,,,,---o-p-q-}-------..vvvfh]hh^ CJOJQJaJhh]hCJOJQJaJhh;CJOJQJaJhhQCJOJQJaJhh*CJOJQJaJhhnCJOJQJaJhhLWCJOJQJaJhhLW5OJQJ\hlCJOJQJh^ CJOJQJh^ 5OJQJ\h^ h^ CJOJQJaJh(h)))0**+~~~ & F !$Ifgd^ bkd2$$Ifl4@)@)0)4 laf4yt^  !$Ifgd^ ++>+?+-bkd3$$Ifl4@)@)0)4 laf4yt^  !$Ifgd^ bkdA3$$Ifl4@)@)0)4 laf4yt^ ?+x,,q-...{m  !$Ifgd^ bkdm4$$Ifl4@)@)0)4 laf4yt^  & F !$Ifgd]h & F !$Ifgd^ ...../;/E/Q/q//////////2LiACKk٥hiorq䞔whih^ >*CJOJQJhhh^ CJOJQJh^ CJOJQJhh^ >*CJOJQJh+pyCJOJQJaJhh| ICJOJQJaJhUh^ >*CJOJQJaJhhlCJOJQJaJhh^ CJOJQJaJhh^ 5OJQJ\h^ )..//*bkd5$$Ifl4@)@)0)4 laf4yt^  & F !$Ifgd^ bkd5$$Ifl4@)@)0)4 laf4yt^ ///kiqA~~~~~~~ & F !$Ifgd^ bkd/6$$Ifl4@)@)0)4 laf4yt^  !$Ifgd^ : provide a current property tax bill to prove that the taxpayer owning the system also owns the home, facility, or land where the system is located. Invoice: provide a contractors invoice (or homeowner-generated invoice for homeowner-installed systems) to document the complete cost of the installed system. See 3.3.32.13 NMAC, for costs that are not allowed. Taxpayer and Contractor Statement of Understanding: provide Taxpayer and Contractor Statement of Understanding signed by the contractor and the owner of the system. If the system is installed by the homeowner, the statement does not need to be included. Design: provide a schematic of the system installation, including specifications, component model numbers, and other information specific to its type, as required. Additional attachments may be included if information cannot be shown entirely on the schematic. Photographs: provide up to four photographs that show the systems: 1) general site location and 2) above ground system components. System Installation Form: provide a copy of this form completed with signatures from the contractor (if contractor installed) and the building code authority. Use Alternative System Installation Approval only if building code authority approval cannot be obtained. Taxpayer may provide signatures on two separate identical forms. Final Inspection Approval: provide copy of building code authoritys written approval document for code compliance.      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