Form Pon 2439 - Initial Incentive Payment Form - New York State Energy Research And Development Authority

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Initial Incentive Payment Form - PON 2439
65% of Approved Incentive Amount
Attachment D
Eligible Installer: _______________________________________Wind Project Number: ________________
Billing Address for Eligible Installer:
Installation Company’s Federal Identification Number: _________________________________________
Customer Name: ___________________________________________________________________________
Installation Address:
Date All Equipment is Delivered to Customer Site:
Total Approved Incentive Amount $
Initial Incentive Payment Requested (65% of Total Approved Incentive) $
Note: It is NYSERDA’s goal to see wind energy systems installed in a timely manner, in general, all the wind energy
system components should be delivered to the customer’s site within 120 days of the NYSERDA Purchase Order date. If
this is not possible, NYSERDA must be contacted to establish a reasonable schedule. Otherwise, the reservation will
become void 120 days after the NYSERDA Purchase Order date.
This form must be completed to receive 65% of the approved incentive value for this customer’s wind energy system.
Please attach a copy of the equipment packing slip(s) for the turbine, tower, and balance of system, signed by the
customer, to indicate that the all system components have been delivered to a customer’s site and copies of the concrete
delivery slips or other equivalent approved documentation.
Checklist: (This form will be returned if the following are not included)
 Itemized packing slip for all system components signed by customer.
 Concrete Delivery Slips or other approved documentation.
Certification Statement-
I certify that all information provided in this form, including all attachments, are true and correct to the best of
my knowledge.
Customer Signature ___________________________________________ Date _______________________
Installer Signature ____________________________________________ Date _______________________
All Forms and Attachments should be sent to:
New York State Energy Research and Development Authority
PON 2439 – Attachment D
17 Columbia Circle
Albany, NY 12203-6399
FAXED FORMS WILL NOT BE ACCEPTED.
Forms and attachments may alternatively be e-mailed to SmallWind@nyserda.ny.gov.
For Internal Use Only
Date Received by NYSERDA
Completed Form and All Required Attachments
Yes
No
Approved __________________________________________________________________ Date _____________________
Denied
__________________________________________________________________ Date _____________________

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