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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