Maryland FY18 CHP Program

MEA CHP Grant Program

Attachment C - Groundbreaking Report and Disbursement Request
Reporting Information

PLEASE NOTE: Your participation in this grant program requires you, the grantee, to submit this progress report at the conclusion of ground-breaking activities, regardless if payment is requested.

Failure to submit a properly completed Attachment B Quarterly Status Report on a quarterly basis may result in a significant delay in your financial reimbursements.
Acknowledgement*

I Understand

PART I: Groundbreaking Checklist

Groundbreaking Invoice Project Checklist Requirements
Please verify that you have the following documents ready to upload on the final page of this form. A file will be required, unless otherwise noted, for all items in this checklist.

If you have any questions regarding the requirements, please contact CHP Program Manager Brandon Bowser at BrandonW.Bowser@Maryland.gov or via phone at (443) 306-0304.

NOTE: This form must be submitted with an invoice from the Grantee. The invoice should be on the Grantee’s letterhead or standard invoicing document.
Checklist Requirements

PART II: Grantee Information
Organization (Grantee) Name*
Federal Tax ID Number*
MEA Grant Number*
Your MEA Grant number can be found on your Grant Agreement
County Where Grant Work is Occuring*
Organization Information
Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code
Congressional District **
**Find your Congressional and MD Legislative Districts at www.mdelect.net
MD Legislative District **
**Find your Congressional and MD Legislative Districts at www.mdelect.net
Grantee Point of Contact Information
Name*

First NameLast Name
Title
E-mail*
Phone Number*

Area CodePhone Number

PART III: Reporting Period and Grantee Invoice
Reporting Period
Month*
Year*
Grantee Invoice
Grant Award Total Dollar Amount*
As indicated in Section 3 of the Grant Agreement.
Invoice Amount for Total Reimbursement requested from MEA*
Note: Groundbreaking reimbursement is 30% of the total grant award amount.
Grantee Invoice Number

PART IV: Supporting Documentation Upload
Reimbursement Invoice*

Upload a File
For Grantee reimbursement, an invoice must be issued to MEA and needs to be placed on the Grantee’s letterhead or standard invoicing document and contain the Grantee invoice number, MEA Grant number, Grantee federal tax identification number, location and system address of the CHP system being installed, and Grantee contact information. The Grantee’s organization name must be the same as what is listed on the submitted IRS Form W9. The invoice should be billed to: Maryland Energy Administration - CHP Program, 1800 Washington Blvd, Suite 755, Baltimore, MD 21230. Cancelof
Developer/Contractor/Manufacturer Invoice(s)*

Upload a File
Copy of developer/vendor/manufacture invoice (issued to Grantee) providing proof of costs incurred equal to or greater than 2x the total reimbursement request from MEA as provided above. Cancelof
Copy of Finalized Design Drawings*

Upload a File
Please submit as a .PDF Cancelof
Manufacturer Cut/Data Sheets

Upload a File

Cancelof
Executed Agreement between Grantee and 3rd Party Owner or Contractor Agreement ***

Upload a File
**Copy of executed agreement between Grantee and third-party owner of the CHP system. If the CHP system is owned by the Grantee, a copy of the executed agreement between the Grantee and contractor. Cancelof
IRS Form W9 For Grantee **

Upload a File
**Signed IRS W9 from the Grantee unless already submitted. Note: A new IRS Form W9 is required if Grantee address has changed. Cancelof
Certificate(s) of Insurance (COIs) **

Upload a File
**Insurance policy certificate(s) indicating MEA as an additional insured pursuant to the requirements of Section 10 of the Grant Agreement, if not already submitted. Cancelof
All Applicable Federal, State, and Local Permits **

Upload a File
**Copy of all required permits, as required by all Federal, Sate, and Local authorities having jurisdiction. Cancelof
Utility Interconnection Agreement

Upload a File

Cancelof
Utility CHP Incentive Approval Letter **

Upload a File
** For CHP projects receiving Utility incentives, a copy of the utility approval letter Cancelof
Utility CHP Incentive Monthly Progress Report **

Upload a File
** For CHP projects receiving Utility incentives, a copy of the most recent Utility monthly progress report and support documentation Cancelof
Five-year Warranty and/or Service Agreement **

Upload a File
** For CHP projects not receiving utility incentives only. Cancelof
Project Team Organizational Chart

Upload a File
Project team organizational chart with contact information Cancelof
Commissioning Plan

Upload a File
Copy of commissioning plan to include at a minimum the construction phase, acceptance phase, and post-acceptance phase Cancelof

Part VI: Signature

By signing this invoice, I affirm that the CHP project for which this award was executed is in compliance with all terms, conditions, and requirements of the Grant Agreement. For FY20 Projects only: I affirm that all activities funded through the Program award have been completed in compliance with section 9-20B-05 of the State Government Article which requires that at least 80% of workers participating in a project or program that receives money from the Strategic Energy Investment Fund ("SEIF") must reside within 50 miles of the project or program. As the SEIF funds a statewide program, MEA will determine compliance based on whether at least 80% of workers participating in a SEIF-funded project reside in Maryland, or within 50 miles of Maryland’s borders. In addition, and if applicable to my organization, I affirm that this project also complies with §14-416 and §17-303 of the State Finance and Procurement Article.
Signature - Please use your mouse or finger to digitally sign below*
Printed Name*

First NameLast Name
Date

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

MEA CHP Grant Program

PART I: Groundbreaking Checklist

PART II: Grantee Information

Organization Information

Grantee Point of Contact Information

PART III: Reporting Period and Grantee Invoice

Reporting Period

Grantee Invoice

PART IV: Supporting Documentation Upload

Part VI: Signature