Demand Response Funds Request

Due to requirements of CORE, OPM requires the following information be submitted prior to submission of an Invoice requesting the transfer of Demand Response funds.

Contractor Name (Your Agency) :

Address:

CORE-CT Vendor ID:

Contact Name:

Phone:

E-Mail:

PROJECT TITLE:

Project Description:

Est. dollar savings:	Est. energy savings: Units:

Annual:	Annual:

One-Time:	One-Time:

Other (describe):	Other (describe):

Project Start Date:	Project End Date:

Project cost ($ requested):

Payment Terms Requested (select one):	Total Up Front

50% Up Front, 50% on completion

Up Front, balance on completion

Other:

Facilities/Sites of Project:

Address(es):

JESTER Building IDs:

Will this project leverage other energy funds? (Explain, e.g., will you apply to through a Utility program for Connecticut Energy Efficiency Funds?)

Submit completed form to: greg.fitzpatrick@ct.gov, or/and supporting documents to: Energy Unit, Office of Policy & Management, 450 Capitol Ave. – MS#52ENR, Hartford, CT 06106-1379.

For OPM Use Only:	Approved / Disapproved; Reason for disapproval:

Contract ID: ___________________________ PO#: _______________________

Disbursement amount: Total Requested; Other: ________________

$ GL Unit Fund Department SID Program Account Project Chartfield1 Budget Ref Year

STATE
OPM20810
13008

Initials: ___________ Date: ____________

Please provide OPM with any documents, drawings, invoices, etc., that will allow OPM to adequately review this project for proper use of Demand Response funds, i.e., for the promotion or installation of energy efficiency improvements at your facilities.

Requirements for Obtaining Demand Response Funding

Gregory Fitzpatrick

2007-05-30

STATE OF CONNECTICUT