New Jersey Edison Innovation Clean Energy Manufacturing Fund. Eligibility Intake Form and Instructions. Intake Form Accepted on a Rolling Basis

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1 New Jersey Edison Innovation Clean Energy Manufacturing Fund Eligibility Intake Form and Instructions Intake Form Accepted on a Rolling Basis

2 Edison Innovation Clean Energy Manufacturing Fund Renewable Energy & Energy Efficiency The New Jersey Board of Public Utilities (BPU) Funding Opportunity Administered by the New Jersey Economic Development Authority (EDA) Eligibility Intake Form and Instructions Thank you for your interest in the Edison Innovation Clean Energy Manufacturing Fund Program. The Funds awarded through this program are public funds. Therefore, any information submitted to the EDA by the Applicant in response to the Clean Energy Manufacturing Fund is subject to public disclosure requirements. Please refer to the Solicitation for more information regarding public disclosure requirements and procedures for the submission of documents. Please submit completed Eligibility Intake Form via to as well as one (1) original copy mailed to the following address: CEMF Eligibility Intake Form New Jersey Economic Development Authority 36 West State Street P.O. Box 990 Trenton, New Jersey If you need assistance completing an Adobe Acrobat Form, click here. Please check that you have read the Clean Energy Manufacturing Fund Solicitation, in full, before completing the Intake Form. 1

3 Edison Innovation Clean Energy Manufacturing Fund Eligibility Intake Form All Edison Innovation Clean Energy Manufacturing Fund (CEMF) Applicants must first submit an Eligibility Intake Form to help determine applicant program eligibility. For detailed information about CEMF, please refer to the Solicitation guidelines located at Applicants will be notified as to whether or not they are eligible under the threshold criteria by within 14 business days of EDA s receipt of the fully completed Eligibility Intake Form. Applicants that are notified of meeting eligibility requirements may then move forward to complete the online Application. A FINDING OF ELIGIBILITY IS NOT A GUARANTEE OF FUNDING BY THE EDA AND THE BPU. PLEASE REFER TO THE SOLICITATION GUIDELINES FOR A FULL EXPLANATION OF APPLICATION CRITERIA. Name of NJ EDA Officer, if applicable Project Title (10 Word Maximum) Project Site Mailing Address Applicant Organizational Legal Name Federal Employer s ID Number/(FEIN) Doing Business As Name Name of Authorized Representative Title Holding Company Name Headquarter Business Address City/Town County State Zip Code Telephone Number Fax Number Year Established Contact address Applicant Web Address Number of existing W-2 jobs NAICS No. /SIC No. Ownership Structure State of Incorporation/Year Full-time Part-time Corporation Partnership Sole Proprietorship LLC Other Brief Summary of Company s Business and Subject Facility (including location of existing and proposed manufacturing facility). Eligible Class I Renewable Energy/Energy Efficiency Technology Category (check all that apply): Solar Photovoltaic Wind Energy Renewably Fueled Fuel cells Wave Tidal Sustainable harvested biomass Methane gas from landfills Energy Efficiency Other qualifying technology (Please explain) State the proposing team's individual and combined technical expertise that would enable successful completion of this project. How will the manufacturing project contribute to the cost competitiveness of Class I renewable energy and/or energy efficiency technologies including economic, environmental or other benefits to New Jersey ratepayers from use of product? (No longer than 400 words) 2

4 Provide an assessment of how the energy efficiency (EE) or renewable energy (RE) technology, system or equipment will aid the State in achieving the goals established in the Governor s Energy Master Plan (EMP) and the NJDEP Global Warming Response Act (GWRA) Report. This should include the number of potential jobs to be produced by the deployment and use of the EE or RE technology, system, equipment and the potential reduction in NJ rate payer costs to achieve the goals of the EMP and GWRAct reports. This should include how, if any, current EE or RE incentives could be reduced or eliminated in the future consistent with the objectives set forth in the Electric Discount and Energy Competition Act (EDECA) to transform the EE and RE market place to be able to operate without incentives. List all sources of proposed project funding including the projected amount of CEMF requested and general fundraising plan description for the Subject Facility (sources of committed and available capital). (No longer than 400 words) For expansion of an existing Subject Facility, list annual amount of output/capacity as of the end of the most recent fiscal quarter. For all development and expansion projects, explain planned expansion of employees and output/capacity at the Subject Facility within 24 months of proposed funding. Has the applicant or owners with a 10% or more interest ever received financial assistance from the New Jersey Economic Development Authority or any other state agency for funding? If yes, please list Agency and describe type of assistance. 3

5 Has the applicant, or any related individual or entity: been, within the last five years, a party in litigation involving laws governing hours of labor, minimum wage standards, discrimination in wages or child labor? been, or is now, charged with, convicted of, under indictment, on parole, on probation or a plaintiff in, any criminal or civil offense other than a minor motor vehicle violation? been, or is now, subject to, or has pending, any disciplinary action by any administrative, governmental or regulatory body? been, or is now, subject to any order resulting from any criminal, civil or administrative proceedings brought against such persons or parties by any administrative, governmental, or regulatory agency? been, or is now, denied any license by any administrative, governmental or regulatory agency on the grounds of moral turpitude? been, or is now, informed of any current or on-going investigation with respect to possible violations by such persons or parties of state or federal securities, anti-trust or criminal laws? been, or is now, denied a business-related license or had it suspended or revoked by any administrative, governmental or regulatory agency? been, or is now, disbarred, suspended or disqualified from contracting with any federal, state or municipal agency? been, or is now, in receivership or adjudicated bankrupt? been, or is now, in default on a personal or business loan? been, or is now, in default on any tax payments? If Yes to any of the above, please provide explanation below: 4

6 Verification and Acknowledgement I verify that I am authorized to commit my organization and to make this Eligibility Intake Form on behalf of the organization. I certify that the above information is correct and that the statements made herein, including all attachments and exhibits, are true and correct to the best of my knowledge. I understand that this Eligibility Intake Form or a subsequent Application may be disqualified if it does not contain all required information. I understand that all materials submitted as part of the Application are subject to disclosure. I acknowledge and agree that the EDA and the BPU have no obligation, and retain the sole discretion to fund or not to fund the Application set forth herein, and that the EDA s receipt of the Eligibility Intake Form, Application, and my receipt of letter of eligibility does not imply any promise of funding at any time. Signature Name (print) Title Date Submission Instructions: Please send Eligibility Intake Form via to EdisonCEMF@njeda.com as well as one (1) hard copy via postal or other delivery service to the address set forth below: CEMF Eligibility Intake Form New Jersey Economic Development Authority 36 West State Street P.O. Box 990 Trenton, NJ