Authorization Form For A Third Party Representative To Submit Certification Report(S) - U.s Department Of Energy Page 2
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2AUTHORIZATION FORM for a Third Party Representative to Submit Certification Report(s) –
Consumer Products & Commercial and Industrial Equipment ‐‐ Continued
Part II: Compliance Statement (to be completed by Authorizing Official)
I, the Authorizing Official identified above, certify that:
1. I am aware of the penalties associated with violations of (1) the Energy Policy and Conservation
Act (Pub. L. No. 94‐163), as amended by Pub. L. No. 95‐619, Pub. L. No. 100‐12, Pub. L. No. 100‐
357, and Pub. L. No. 102‐486 (the Act) and the regulations thereunder, and (2) 18 U.S.C. § 1001,
which prohibits knowingly making false statements to the Federal Government;
2. I am responsible for all information in the certifications report(s) submitted to DOE via CCMS by
the third party organization identified above;
3. The third party organization identified above will submit to DOE via CCMS certification reports
only in accordance with 10 C.F.R. Parts 429, 430, and 431 and the Energy Policy and
Conservation Act, as amended;
4. The basic models listed in all certification reports submitted to DOE via CCMS by the third party
organization identified above comply with the applicable conservation standard(s);
5. All required testing has been conducted in conformance with the applicable test requirements
prescribed in 10 C.F.R. Parts 429, 430 and 431, as appropriate, or in accordance with the terms
of an applicable test procedure waiver; and
6. All information reported in all certification report submitted to DOE via CCMS is true, accurate,
and complete.
Signature: ________________________________________________________ Date: ______________
Name (typed or printed):________________________________________________________________
Paperwork Reduction Act and OMB Burden Disclosure Statement
OMB Control Number: 1910‐1400
Expiration: November 30, 2017
These data are being collected for manufacturers to certify compliance with DOE's energy conservation, water
conservation, or design standards. The data you supply will be used by the Department to monitor compliance
with the energy conservation, water conservation, and design standards and testing requirements for the
consumer products and commercial and industrial equipment mandated by the Energy Policy and Conservation
Act, as amended, and DOE regulations.
Under this Office of Management and Budget control number, the public reporting burden for collection of
information in the certification process is estimated to average 30 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Of this total time, DOE estimates that third party
authorization will have an average public reporting burden of 0.2 hours. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to
Office of the Chief Information Officer, Records Management Division, IM‐23, Paperwork Reduction Project (1910‐
1400), U.S. Department of Energy, 1000 Independence Ave. SW, Washington, DC, 20585‐1290; and to the Office of
Management and Budget (OMB), OIRA, Paperwork Reduction Project (1910‐1400), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be
subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number.
Submission of this data is mandatory.
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