State of New Mexico - Energy, Minerals and Natural ...



|State of New Mexico - Energy, Minerals and Natural Resources Department | |

|1220 S. St. Francis Dr., Santa Fe, NM 87505 (505) 476-3310 |Project No.       |

|Geothermal Ground-Coupled Heat Pump System Certification Application (FORM 1) | |

|Geothermal Ground-Coupled Heat Pump Tax Credit - 3.3.32 and 3.4.19 New Mexico Administrative Code (NMAC) |For department use only |

| |Form version date: 9/15/10 |

|Taxpayer Information * indicates required information |

|* Name |      |* Social |      |

| | |Security Number | |

| | |or Corporate Number |(Will be kept confidential) |

|* Mailing |      |

|Address (Address, City, Zip |      |

|Code) | |

|* Telephone |      |Email |      |

|Contractor Information |

|* Name |      |* License |      |

| | |No. | |

|* Mailing |      |* License |      |

|Address | |Classification | |

|* Telephone |      |Email |      |

| Geothermal Ground-Coupled Heat Pump System (System) Information |

|* Project Location |      |* County |      |

|* Residential System |      |* Commercial System |      |

|(please check one) | |(please check one) | |

|* System |      |* System |$      |

|Description | |Cost | |

|Applicant Agreement |

|The applicant named above and signing this statement agrees that all information provided in this application package is true and correct to the best of the|

|applicant’s knowledge. The applicant has read the certification requirements of 3.3.32 or 3.4.19 NMAC. The applicant understands that there are annual |

|aggregate state tax credit limits in place for these systems and that the department must certify the system documented in this application package before |

|the applicant is eligible for a state tax credit. Furthermore, the applicant agrees to: |

|make any changes the department requires to the system for compliance with 3.3.32 or 3.4.19 NMAC; |

|operate the system for a minimum of five years after department certification or, if the residential, business, or agricultural enterprise where the system |

|is located is sold or transferred to another party within five years after the department’s certification of the system, the sale or transfer agreement |

|shall require the system’s continued operation or maintenance for energy production for no less than the balance of the five-year period remaining; |

|provide for the system’s regular maintenance for a minimum of five years with the applicant’s own resources or through a contractor; and |

|allow the division or its authorized representative to inspect the system that is described in the application package, from the application package’s |

|submittal to three years after the department has certified the system, upon the division providing a minimum of five days notice to the applicant. |

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|* Taxpayer Signature |* Date |

|System |Optional: taxpayer may indicate interest in the following no-cost monitoring options for the system, if these options are |

|Monitoring |made available, to assist with evaluation of state-wide tax credit benefits (select all that apply): |

|Options |add energy monitoring equipment to the system |

| |analysis of system performance and operation |

| |analysis of taxpayer utility bill records. |

|Checklist - System Certification Application |

| |

|Please review the following list to make sure you have provided all attachments required in the application package. For assistance on system certification|

|requirements, see the Geothermal Ground-Coupled Heat Pump Tax Credit rules, 3.3.32 and 3.4.19 NMAC, and other information available through the website at |

|, or contact the Energy, Minerals and Natural Resources Department (EMNRD) at (505) 476-3310. |

|Geothermal Ground-Coupled Heat Pump Systems |

|3.3.32 and 3.4.19 NMAC - Required attachments |

| |Copy of a current property tax bill to the taxpayer for the residence, business, or agricultural enterprise where the system is located. |

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| |Copy of invoice(s) of itemized equipment and labor costs for the system. |

| |Copy of the system’s design schematic and technical specifications. |

| |Photographic record of the system after installation is completed. |

| |Documentation of the manufacturer’s listed coefficient of performance and efficiency ratio for the ground-coupled heat pump unit(s) |

| |Copies of Manufacturer or supplier of system components and their model numbers |

| |Contractor or Installer documentation of IGSHPA ‘Accredited Installer Workshop’ Certification |

| |Documentation of the total geothermal ground-coupled heat pump system size |

| |Completed Geothermal Ground-Coupled Heat Pump System Installation Form |

| |Taxpayer and Contractor Statement of Understanding (3rd page of Geothermal Ground-Coupled Heat Pump System Installation Form) |

| |Copy of the written final inspection approval from the building code authority or, if inspection approval cannot be obtained, the applicant shall |

| |provide the necessary information on the system installation form in place of obtaining the inspection approval. |

|Help - Application Package Submittal |

|General Information |

|Submit the application package to EMNRD after the system is completely installed and operating. |

|Copies are adequate for any documents submitted to EMNRD in the application package. |

|Use the “Geothermal Ground-Coupled Heat Pump System Certification Application” form as the first page of the application package. |

|Taxpayers are encouraged to submit application packages in a timely manner. |

|Mail applications to the attention of “ECMD Geothermal Ground-Coupled Heat Pump Tax Credit Administrator” or email to EMNRD as directed at |

| . ECMD is EMNRD Energy Conservation and Management Division. |

|Taxpayer Information |

|Provide contact information so that EMNRD may communicate with you about your application. The email address is not required but, if available, would |

|expedite communication. |

|The Social Security Number is required and is important in EMNRD’s reporting to the New Mexico Taxation and Revenue Department on taxpayer eligibility for the|

|tax credit. It will be filed as confidential information. |

|Contractor Information |

|Provide contact information so that EMNRD may communicate with the contractor, if needed. The Email address is not required but, if available, would expedite|

|communication. |

|The contractor license number and classification is required so that EMNRD may verify licensing of the contractor. |

|If the system is homeowner installed, select the box and leave the contractor information blank. |

|Geothermal Ground-Coupled Heat Pump System Information |

|Provide the location of the system by either the address, which could be the same as the taxpayer mailing address, or a brief description of the physical |

|location if an address is not available, to enable EMNRD to locate the system for inspection purposes. Also provide the county where the system is located. |

|Please indicate whether the tax credit application is for a residential or commercial system. |

|Provide a brief description of the system, such as describing the open or closed system, vertical or horizontal application, or lake or pond applications. |

|Provide the system’s complete net installation cost, including equipment, materials and labor, excluding the items listed in 3.3.32.13 NMAC, which should |

|agree with the total amount shown on an attached invoice that itemizes components and labor charges of the installed system. |

|Applicant Agreement |

|Sign and date the application form, which includes taxpayer agreement regarding truthfulness of the information provided, knowledge of the 3.3.32 or 3.4.19 |

|NMAC rules governing system certification, annual aggregate tax credit limits, system maintenance, and EMNRD inspection of the system. |

|Attachments |

|Property Tax Bill: provide a current property tax bill to prove that the taxpayer owning the system also owns the home, facility, or land where the system is |

|located. |

|Invoice: provide a contractor’s invoice (or homeowner-generated invoice for homeowner-installed systems) to document the complete cost of the installed |

|system. See 3.3.32.13 NMAC, for costs that are not allowed. |

|Taxpayer and Contractor Statement of Understanding: provide Taxpayer and Contractor Statement of Understanding signed by the contractor and the owner of the |

|system. If the system is installed by the homeowner, the statement does not need to be included. |

|Design: provide a schematic of the system installation, including specifications, component model numbers, and other information specific to its type, as |

|required. Additional attachments may be included if information cannot be shown entirely on the schematic. |

|Photographs: provide up to four photographs that show the system’s: 1) general site location and 2) above ground system components. |

|System Installation Form: provide a copy of this form completed with signatures from the contractor (if contractor installed) and the building code authority.|

|Use Alternative System Installation Approval only if building code authority approval cannot be obtained. Taxpayer may provide signatures on two separate |

|identical forms. |

|Final Inspection Approval: provide copy of building code authority’s written approval document for code compliance. |

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