Intake%20irrigation

2013 Irrigation Equipment Grant Intake for Energy Improvement Matters Details for the 2013 REAP grant cycle have not yet been announced by the USDA. Do not start your project or pay the dealer until you give your completed application to the USDA. To start the grant process with Energy Improvement Matters (EIM, LLC), complete this form and return it to EIM. Send a check for $600 for grant writing and energy audits. Make checks payable to EIM at 7545 Chablis Circle, Indianapolis, IN 46278. By completing this application, the applicant also agrees to pay EIM 1% of the total project amount, if and only if you are declared a winner of the grant. For projects over two-hundred-thousand dollars, there will be an additional up-front fee of three hundred dollars to cover required review by professional engineer.

1. 1. Name of Applicant or Business to be listed on the grant application 2. (full legal name as on taxes) Please print/respond in column on right.

3. 2. Principal person to contact: 4. 3. Principal person who will sign as a representative for this entity and his/her position

4. Tax ID # (if sole proprietor, your SSN works) 5. DUNS# 6. Phone Number(s) 7. Fax Number 8.E-mail (required for quick communication) 11. 9. Business address:

Name: Position: ___ Owner ___ President ___ Partner ___ Member ___ Other (explain)

Educational Level: ___ High School ___ Associate Degree ___ College ___ Trade School ___ MS ___ Other (explain)

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10. Location of each proposed irrigation site (FSA aerial photo is very helpful to show location. Identify and number each site. You may use the back of this page to provide more information if this intake form will be mailed.)

Address: City: State: Zip Code: County: Location pump 1: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

Location pump 2: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

Location pump 3: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

12.

Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com

2013 Irrigation Equipment Grant Intake for Energy Improvement Matters

13. 11.County where equipment will be located 14. 12. Address where we will send you the completed application

15. 13.Type of business (as taxes are filed)

14. List names of partners as on article of incorporation or partnership agreement

Location pump 4: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

Location pump 5: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

Location pump 6: Do you own land? ___Yes Do you pay utility bills? ___Yes

___No ___No

Address: City: State: Zip Code: ___ Sole Proprietor ___ LLC ___ C Corp ___ S Corp ___ Partnership ___ Corp Name

SSN

Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com

Position

2013 Irrigation Equipment Grant Intake for Energy Improvement Matters Describe your operation (PLEASE provide all info) 15. Years you have been farming 16.Years you have operated irrigation equipment 17. What crops do you raise?

___ rice ___ corn ___ beans ___ wheat ___ other (list):

18. Total acreage farmed ( acres) 19. Acreage in irrigation 20. New Equipment is for

___ irrigation system, ___ diesel to electric conversion, ___ both ___other

21. Who is your utility provider for your current irrigation system?

22. Utilities usage and cost for your farm or business for the last 12 months. (You can attach your bills.)

If you can’t provide utility usage, please give us authorization to get it.

We will need your irrigation fuel bills for the last 12 months and/or permission for the bills to be released to EIM, LLC. 1. Last 4 digits of the SSN or EIN of applicant’s account: ____________________ If account is in name other than applicant, please provide last 4 digits of SSN or EIM _____________ 2. I ___________________ give EIM, LLC permission to access my account ______________(account #) in order to obtain my utility bills.

Signature __________________________ Date_______________________________

Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com

2013 Irrigation Equipment Grant Intake for Energy Improvement Matters How do you think this equipment would benefit your farm or business? (Check all that apply): _____ It would save money in operating costs by reducing fuel bills _____ It would increase the quality of the crops/grain. _____It would increase the reliability of the bushels per acre _____ It would be more environmentally friendly (less air pollution than with diesel) _____It would help decrease dependence on foreign oil Other things for which you are proud and make you a good applicant:

Dealership Information (PLEASE provide all info) 23. Where you will purchase equipment? (Dealership name.)

24. Dealer contact (sales person) 25. Phone number 26. E-mail 27. Fax 28. Equipment that you wish to purchase: 29. What will you do with the old equipment?

______ Properly dispose of it in an environmentally friendly way ______ Sell it for scrap ______ Save it for an emergency back-up unit ______ Try to sell it or trade it in

Bank Information (PLEASE provide all info) 30. Bank you will work with 31. Contact person 32. E-mail 33. Phone Number 34. Fax

Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com

2013 Irrigation Equipment Grant Intake for Energy Improvement Matters Describe Current/Existing Equipment.

Type of crop to be irrigated

___corn, ___cotton, ___rice, ___sorghum, ___soybeans, ___other__________________ ___ Flooded ___ Furrow ___ Sprinkler/ Pivot ___ Micro Irrigation ___ or other __________

Type of system?

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Manufacturer and Model Number of Motor Manufacturer and Model Number of Pump How many inches of irrigation water per acre per year PSI of system Depth of casing Size of casing How much fuel did it use? Tell about its efficiency. Refer to owner’s manual if possible Problems you’re having with current equipment?

Fuel Type for existing equipment

___ Liquid propane ___ Natural Gas ___ Electricity ___ Diesel

____$ per gallon ____$ per therm ____$ KW

Fuel cost (cents/gal or cents/ KWH) Does the system have a flow meter?

Does the system have a scheduler?

Age of current equipment Other relevant information

Describe Proposed Irrigation Equipment Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com

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2013 Irrigation Equipment Grant Intake for Energy Improvement Matters Manufacturer and Model Number of Motor Manufacturer and Model Number of pump How many inches of irrigation water per acre per year PSI of system GPM (gallons per minute) of system Depth of casing Size of casing Fuel Type for proposed equipment

___ Liquid propane ___ Natural Gas ___ Electricity ___ Diesel

Fuel cost (cents/gal or cents/ KWH) Does the system have a flow meter?

Does the system have a scheduler?

30. Reason for selecting this equipment

___best price ___best dealer (good service and reputation) ___best equipment for my weather and geographical location ___best warranty ___other

What did you compare it to?

Other relevant information

I agree to the fee structure on this form and believe all information provided is accurate.

Printed name:________________________________ Signature:____________________________________

Please include a quote for all work to be done.

Energy Improvement Matters (EIM, LLC) 7545 Chablis Circle, Indianapolis, IN 46278 Phone: 317-228-0134; Fax: 1-866-286-0343 info@midwesteim.com