Buy American AFFIDAVIT - Reinvestment Fund
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Pennsylvania Green Energy Loan Fund
Buy American Affidavit
|1. Borrower |
|Legal Name of Borrower: |FEIN: |
|Address: - Street: |DUNS Number: |
|City: |State: |Zip: - |SAM Number: |
|Main Telephone: - - |Website: |NAICS Number: |
|2. Contact Person |
|Contact Person Name: |Contact Person Title: |
|Contact Person Phone: |Contact Person Email: |
|3. Proposed Energy Project |
|Project Name: |
|Project Address: Street: |City: |
|County: |State: |Zip: |
|Owner of Building: |Is building owner the federal, state | Yes No |
| |or local government: | |
|Brief Project Description: |
|4. Compliance with the Buy American Act |
|Based upon the guidance provided by the U.S. Department of Energy and the Pennsylvania Department of Environmental Protection, I have |
|determined that my project (select one of the following): |
| |Is not subject to the Buy American provisions because it does not involve a “public work.” All GELF energy projects except |
| |those involving buildings owned by the federal, state or local government should check this box. If this box is checked, skip |
| |Part 5 and proceed to Part 6. |
| |Is a “public work” subject to the provisions of the Buy American Act and MEETS the requirements of Act because all of the iron,|
| |steel and manufactured goods in the project are of domestic origin. If this box is checked, skip Part 5 and proceed to Part 6.|
| |Is a “public work” subject to the provisions of the Buy American Act and has been granted an exception by the US DOE for the |
| |foreign iron, steel and manufactured goods in the project under one of the three exceptions to the domestic-source requirement |
| |(non-availability, unreasonable cost, and inconsistent with the public interest). If this box is checked, complete Part 5 and |
| |Part 6 and attach a copy of the US DOE exception letter. |
| |Is a “public work” subject to the provisions of the Buy American Act and a written exception request has been submitted (date: |
| | ) to US DOE requesting an exception for the foreign iron, steel and manufactured goods in the project under one of the |
| |three exceptions to the domestic-source requirement (non-availability, unreasonable cost, and inconsistent with the public |
| |interest). If this box is checked, complete Part 5 and Part 6 and attach a copy of the exception request letter that was |
| |submitted to US DOE. |
| |Is a “public work” subject to the provisions of the Buy American Act and a written exception request has not been submitted to |
| |US DOE requesting an exception for the foreign iron, steel and manufactured goods in the project under one of the three |
| |exceptions to the domestic-source requirement (non-availability, unreasonable cost, and inconsistent with the public interest).|
| |If this box is checked, complete Part 5 and Part 6. |
| |The written exception request will be submitted by: [date]. |
|5. Foreign Origin of Iron, Steel and Manufactured Goods |
|List all iron, steel and/or manufactured goods in the project that are of foreign origin. If this project is a “public work” (i.e. a |
|building owned by a government), the project will need to seek U.S. Department of Energy approval based on one or more of the three listed |
|exceptions (non-availability, unreasonable cost, and inconsistent with the public interest). |
|Description of Material(s) |Name and Address of |Cost ($) |
| |Foreign Manufacturer/Supplier | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
|6. Certification |
|I certify that the information I have provided in this form is true and correct and that I am authorized to prepare, sign, and submit this |
|form on behalf of the Borrower. |
| |
|I certify that the Borrower will comply with the Buy American Act in this project financed by the Pennsylvania Green Energy Loan Fund and |
|will notify GELF of any changes in the project that may affect the project’s compliance with the Buy American Act. |
| |
|I acknowledge that: the information provided by me on behalf of the Borrower is material and important; the Commonwealth of Pennsylvania |
|shall rely upon this information in submitting reports to the federal government pursuant to the American Recovery and Reinvestment Act; |
|and the Commonwealth shall treat any misstatement, omission or misrepresentation as fraudulent concealment of the true facts, punishable |
|pursuant to 18 Pa.C.S. §4904. |
| |
| |
| |
|____________________________________________________ |
|(signature) |
|Name: | |
|Title: | |
|Date: | |
Please return this completed form with an original signature to:
PA Green Energy Loan Fund
Reinvestment Fund
1700 Market Street - 19th Floor
Philadelphia, PA 19003
PaGELF@
Please submit any questions by email to PaGELF@.
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