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Warning Text %XTableStyleMedium9PivotStyleLight16`ASheet1ÖSheet2`Sheet3# _Toc518722614<  ;8fffP0@ZR3 A@@   63Item Description Sales TaxCost of Item(s)Item No.Electricity Storage DevicesEligible Cost ElementsIneligible Cost Elements#(B) TOTAL INELIGIBLE PROJECT COSTS:!(A) TOTAL ELIGIBLE PROJECT COSTS:%(C) = (A) + (B) = TOTAL PROJECT COST:"Planning & Feasibility Study CostsEngineering & Design Costs)Ineligible Self-Generation Equipment Cost6Buildings to house and/or support generation equipmentDAmount representing the total cost to install the generating system.U along with the Proof of Project Advancement or Incentive Claim documentation.vINSTRUCTIONS: Refer to the Self-Generation Incentive Program Handbook before completing and then submitting this form `SECTION 1: ELIGIBLE PROJECT COSTS (refer to SGIP Handbook for further definitions and examples):# ^6Permitting Costs (air quality, building permits, etc.)5Construction & Installation Costs (labor & materials)!>Interconnection Costs - Electric (customer side of meter only)!9Interconnection Costs - Gas (customer side of meter only)1Warranty Cost (if not already included in Item 4)<Maintenance Contract Cost (only if warranty is insufficient)$Other Eligible Costs (Itemize Below)oSECTION 2: PROJECT COSTS CONSIDERED NOT ELIGIBLE (refer to SGIP Handbook for further definitions and examples):2 m2Fuel Supply Costs (digesters, gas gathering, etc.);Thermal Load Costs (new absorption chillers, boilers, etc.)@Interconnection Costs - Electric (work on utility side of meter)!;Interconnection Costs - Gas (work on utility side of meter)!"$%(Warranty Costs (beyond SGIP requirement)4Maintenance Contract Costs (beyond SGIP requirement)&Other Ineligible Costs (Itemize Below)bSelf-Generation Equipment Costs (generator, ancillary equipment) - fill out appropriate line below  Fees/PermitsBWaste Heat Recovery Costs (not including thermal application eqp.)  Feasibility & Engineering DesignInstallation CostsBalance of PlantHOST CUSTOMER FACILITY ADDRESS:Gasline Installation Costs5Metering, Monitoring and Data Acquisition System Cost+Air Emission Control Equipment Capital Cost8.a8.b8.cBFuel Gas Clean-up Equipment (on-site renewable fuel projects only)-Cost of Bond to Certify Use of Renewable Fuel18.a18.b18.c:7 ;89RB<u>?c@s ccBOUj_ KU g2ɀ MV^gl  dMbP?_*+%xu&C&"Arial,Bold"&14Self-Generation Incentive Program Project Cost Breakdown Worksheet and Final Project Cost Affidavit&CPage &P of &N&?'?(?)?M\\ES-DC-ATRIUM\RICOH MP 2352-O  odX,10DRH/:nxTے0 :ݶ?#*@n)bˀ$?#j?MY/9`@s1k(?qaJ|Jqؤ IXoRֹre>Tge<{Q3Me}2{ye>~Z4D&[C{VL6yc hM\}:b]ZeVS.; sBV[HO\`e/1oz GzC"JX,??uu&C&"Arial,Bold"&14Self-Generation Incentive Program Project Cost Breakdown Worksheet and Final Project Cost AffidavitcU} UU} @} 8A} %@} B} C}  CM M@ NHOLP LQ LR LS xLT U V @W @X Y Z [ \ ] ^ _ `abcdefghijkl Me M' MN OOK P P PKQMNNNOM RPRIIIJKSPIIIJKTQRSRT UfUg Uh Ui UjUVpqrqsV ~ Wt? 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The Parties executed a Reservation Request Form ( RRF ) that references the SELF-GENERATION INCENTIVE PROGRAM CONTRACT ( Contract ) which in turn references this Affidavit. In order to meet the requirements of the Contract, Section 3.0. Parties attest that the statements in the following paragraphs are true. 1. At the time the incentive payment is made, System Owner is the owner of the self generation unit(s) which comprise the Project and all the statements below are true and correct: * System Owner incurred all Eligible Project Costs referenced below, * Project is operating as intended according to Contract, * There are no post-sale agreements or agreements which go into effect after the initial sale is made which allow the seller or installer to use the self generation unit(s) which comprise the Project in a sales or promotion campaign. * Eligible Project Costs are paid for in full except for an amount, which does not exceed the amount of incentive funding to be provided by Contract. 2. A description of Project includes the following information: Project Address: City, State ZIP Generating or Energy Storage Technology: Generating Capacity: 3. Costs to Project as referenced below are defined in the SGIP Handbook and are identical to the costs submitted by Parties to Program Administrator in the Final Project Cost Breakdown Spreadsheet. Total Eligible Project Cost: $ Total Ineligible Project Cost: $ Total Project Costs: $ 4. The following list includes all Other Incentives and Rebates, which assisted or may assist in the funding of Project. Source Amount 1. $ 2. $ Total $ Each of the undersigned certifies under penalty of perjury that the foregoing is true and correct and that each is duly authorized to sign this Affidavit. 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