Form 18d - Energy Conservation Improvement Fund Program Grant Distribution
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1Energy Conservation Improvement
FORM
18D
Fund Program Grant Distribution
PLEASE DO NOT WRITE IN ThIS SPACE
RESET
PRINT
Nebraska Identification Number
Federal Identification Number
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name Doing Business As
Name
Legal Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
1 Enter the total amount of distribution you are requesting for grants approved under the Low-Income
Home Energy Conservation Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
By signing this form, I certify that all purchases and installations of eligible energy conservation improvements at all eligible persons’ residences have
been verified, and that all grants for which the utility is seeking distribution have been approved . Under penalties of law, I declare that I have examined this
form, and to the best of my knowledge and belief, it is correct and complete .
sign
here
Authorized Signature
Date
Telephone Number
Title
E-Mail Address
INSTRUCTIONS
WhO MAY FILE. Every participating entity which has funded and maintained an Energy Conservation Improvement Fund
subaccount, and has approved eligible grants under the Low-Income Home Energy Conservation Act, may file to obtain
distribution for such grants.
WhEN TO FILE. Participating entities may file this form with the Nebraska Department of Revenue no more than once
per month.
There must be sufficient funds in your Energy Conservation Improvement Fund subaccount in order to receive distribution
of any amount entered on line 1 of this form. Only those remittances into your subaccount, which are received on or before
the 15th day of the preceding month (and any appropriate matching state funds), will be available for distribution of the
amount claimed on line 1.
DIRECT DEPOSIT. To have distributions deposited directly into your checking or savings account, it is necessary to be
actively enrolled in the State Treasurer’s Automated Clearing House (ACH) program. If you wish to enroll in this program,
the
State Treasurer’s ACH form
is available at
FOR NEBRASKA DEPARTMENT OF REVENUE USE ONLY
Total Distribution Approved as Requested
Distribution as Adjusted
Distribution Disapproved
COMMENTS:
Authorized Signature
Date
Mail this form to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
6-489-2009 Rev . 6-2009
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