Energy Efficiency Disclosure Form printable pdf download

Energy Efficiency Disclosure Form for Rental Units in Maine

Address of Rental Unit: _____________________________________________

This rental unit ___ meets/___ does not meet/___partially meets (check one)

the minimum energy efficiency guidelines suggested below for rental units

in Maine.

You can expect your energy bills to be lower if your dwelling is insulated and has efficient appliances. There are

several factors that affect energy costs. The areas below are the most important ones and indicate where this

dwelling exceeds, meets, or falls below minimum efficiency guidelines suggested for Maine. The bold items below

are suggested minimum guidelines.

Heating Systems

Space Heat

Tested heating system efficiency (minimum: 82%) ____% ___ unknown

Test date: _______

Exposed pipes or ducts in unheated crawl space insulated? ___ yes ___ no

Heating fuels: ___ oil ___ natural gas ___ propane ___ kerosene ___ wood ___ electric ___ other

Water Heat

___ yes ___ no

Accessible domestic hot water pipes insulated?

Fuels: ___ oil ___ natural gas ___ propane ___ solar ___ electric ___ other

Insulation

Walls

Insulated? (minimum: cavity filled) ___ filled ___ partially filled ___ no insulation ___ unknown

Insulation thickness: ___ less than 3” ___ 36” ___ more than 6”

Ceiling

Insulated? (minimum: R38 or cavity filled) ___ filled ___ partially filled ___ no insulation ___ unknown

Insulation thickness: ___ inches or R____

Floors over unheated areas

Insulated? (minimum: R21 or cavity filled) ___ filled ___ partially filled ___ no insulation ___ unknown

Basement wall

Insulated? (minimum: 2’ below grade) ___ yes ___ no ___ unknown

Windows and Doors

Windows (minimum: 2 panes of glass) ___ single pane ___ single + storm ___ double (DG) ___ DG + lowe

___ (DG + lowe + argon gas) ___ triple or better

Doors (minimum: insulated or with storm) ___ insulated ___ storm ___ insulated + storm ___ neither

Appliances

Refrigerator (minimum: post1995) ___ yes ___ no ___ unknown ___ Energy Star rated

Gas stove (suggested electronic ignition) ___ electronic ignition ___ pilot light ___ no gas stove

You have the right to obtain a 12month history of electricity used by this rental unit by calling your local electric

company. If this unit uses natural gas, you have the right to obtain a 12month history of natural gas used by the

unit by calling your local natural gas company.

For further information about energy efficiency, contact Efficiency Maine, 18663762463

Signatures: Landlord: _______________ Tenant: _________________ Date: _______

This information is accurate to the best of the landlord’s knowledge.

Other comments about the unit’s efficiency: ___________________________________________________

Available on the Maine Public Utilities Commission or Maine State Housing Authority

web pages ( or )

May 12, 2006

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Energy Efficiency Disclosure Form

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