Secondary Contact Name. Position: Address: E mail: City: Phone: State: Zip: Fax: Please indicate if the following Forms, Returns and Fields need to be documented as state exceptions: Yes, we support No, we do not support Form 600S Consolidated Returns Returns with PDF Attachments TP’s E-Mail address and authorization Field Preparer information and authorization Field Direct-Deposit ACH-Direct Debit Withdrawal Attach an additional sheet to list Federal limitations, additional Georgia limitations and other information Will you be seeking a paper forms certification from GA? Yes No Print Name: Title: Signature: Date: Send the completed Compliance Agreement to xxxxxxxxxx.xxxxxx.xxxxxxxxx@xxx.xx.xxx Rev 8/15 2 Compliance Agreement Supplemental Form Additional Georgia Limitations: Federal Limitations:
Secondary Contact Name. Title: E-Mail Address: Mailing Address: City: State: Zip: County: Telephone (Day): Fax: Facility Location (if different from above): (Evening): Project Name: Address: City: State: Zip: County: Alternative Contact Information (if different from the Interconnection Customer) Contact Name: Title: E-Mail Address: Mailing Address: City: State: Zip: Telephone (Day) Fax: (Evening) Application is for: New Generating Facility Capacity Change to a Proposed or Existing Generating Facility Change of Ownership of a Proposed or Existing Generating Facility to a new legal entity Change of Control of a Proposed or Existing Generating Facility of the existing legal entity. Equipment Substitution Other Please provide additional information regarding the proposed change(s): Will the Generating Facility be used for any of the following? Net Metering? Yes No To Supply Power to the Interconnection Customer? Yes No To Supply Power to the Utility? Yes No To Supply Power to Others? Yes No (If yes, discuss with the Utility whether the interconnection is covered by the NC Interconnection Standard.) Is the Generating Facility owned by the Interconnection Customer or Leased from an Electric Generator Lessor in NC? Owned Leased NCUC Docket No.:
Secondary Contact Name. Title: E-Mail Address: Mailing Address: City: State: Zip: County: Telephone (Day): Fax: (Evening): Contact (if different than Interconnection Customer) Name: E-Mail Address: Address: City: State: Zip: County: Telephone (Day): Fax: (Evening): Owner(s) of the Generating Facility: Generating Facility Information Facility Location (if different from above): Address: City: State: Zip: County: Utility: Account Number: Is the Generating Facility owned by the Interconnection Customer or Leased from an Electric Generator Lessor in NC? Owned Leased NCUC Docket No.: Inverter Manufacturer: Model: Nameplate Rating (each inverter): kW (AC) (each inverter) kVA (AC) (each inverter) Volts (AC) (each inverter) Single Phase: Three Phase: System Design Capacity1: kW (AC) (system total) kVA (AC) (system total) 1 Total inverter capacity. For photovoltaic sources only: Total panel capacity: kW (DC) (system total) Maximum Generating Capacity Requested:2 _(calculated)3_ kW (AC) For other sources: Maximum Generating Capacity Requested:2 kW (AC) Prime Mover Information (Refer to U.S. EIA Form 860 Instructions, Table 2 Prime Mover Codes and Descriptions at xxxxx://xxx.xxx.xxx/survey/form/eia_860/instructions.pdf) 2 At the Point of Interconnection, this is the maximum possible export power that could flow back to the Utility. Unless special circumstances apply, load should not be subtracted from the System Design Capacity. 3 For a photovoltaic installation, the Utility will calculate this value as the lesser of (1) the total kW inverter capacity and (2) the total kW panel capacity (no DC to AC losses included, for simplicity). Prime Mover Code Prime Mover Description Energy Source Information (Refer to U.S. EIA Form 860 Instructions, Table 28 Energy Source Codes and Heat Content at xxxxx://xxx.xxx.xxx/survey/form/eia_860/instructions.pdf) Fuel Type Energy Source Code Energy Source Description Is the equipment UL 1741 Listed? Yes No If Yes, attach manufacturer’s cut-sheet showing UL 1741 listing Estimated Installation Date: Estimated In-Service Date: The 20 kW Inverter Process is available only for inverter-based Generating Facilities no larger than 20 kW that meet the codes, standards, and certification requirements of Attachments 3 and 4 of the North Carolina Interconnection Procedures, or the Utility has reviewed the design or tested the proposed Generating Facility and is satisfied that it is safe to operate. List components of the Generating Facility equipment package that are cur...
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Secondary Contact Name Please identify the individual who will be secondarily responsible for all TIPS matters and inquiries for the duration of the contract.
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Secondary Contact Name. Title: Email: Phone Number: Email to xxxxxxxxxxx@xxxxxxxxxxxxx.xxx This material was prepared by Alliant Health Solutions, a Quality Innovation Network – Quality Improvement Organization (QIN – QIO) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS
Secondary Contact Name. Title: Email: Phone Number: Email to xxxxxxxxxxx@xxxxxxxxxxxxxx.xxx
Secondary Contact Name. Email Address: Mailing Address: Phone Number(s): Please initial next to each statement to show your understanding of the maintenance agreement. All maintenance/upkeep of cigarette litter bins, provided by Keep South Carolina Beautiful (KSCB), is the sole responsibility of the volunteer. Recycling cigarette butts with pre-paid postage, provided by KSCB, is required to receive cigarette litter bins. KSCB will replace receptacles in the event they are stolen or damaged due to natural disasters. KSCB will not dispose of any cigarette butts collected in the receptacles. KSCB will not install or remove receptacles. Before installation of bins, a cigarette litter butt count will be done and submitted to KSCB. After installation a count will need to be done after 6 months and after 1 year of the bin being installed. Report is submitted back to xxxxxxx@xxxxxxxxxxxxx.xxx.
Secondary Contact Name. Relationship: ❑ Family ❑ Friend ❑ Caregiver ❑ Neighbor ❑ Legal Guardian ❑ Other or ❑ Organization, specify: Phone: Work: Home: Cell: E-‐mail:
Secondary Contact Name. Title: SC Generator Interconnection Request 2
Secondary Contact Name. Position: Address: E mail: City: Phone: State: Zip: Fax: Please indicate if the following Returns and Fields need to be documented as state exceptions: Yes, we do support No, we do not support Partnership Returns with more than 100 partners Returns with PDF Attachments TP’s E-Mail address and Authorization Field Preparer information and Authorization Field Federal Limitations: More State Limitations: *Developer ID should be 10 characters. If you established a Developer ID last season, please do not change it. You can use the first 10 characters of your software name for the Developer ID. If you have more than one software product, you can use 10 characters of each of your product names. Will you be seeking a paper forms certification from GA? Yes No By: Title: Date: Only 2 contacts will be accepted. GA DOR will be authorized to release testing information only to the contacts listed.
Secondary Contact Name. Email: Phone: Fax: Mailing address: Name: Email: Phone: Fax: Mailing address: Part 5: GENERAL PROVISIONS Indemnification Agency shall be responsible for damages caused by the negligence of its directors, officers, agents, employees and duly authorized volunteers occurring in the performance of this agreement. Loyola shall be responsible for damages caused by the negligence of its directors, officers or employees occurring in the performance of this agreement. It is the intention of Agency and Loyola that the provision of this paragraph be interpreted to impose on each party responsibility for the negligence of their respective directors, officers, employees and duly authorized volunteers.