National Energy Services Framework
Appendix 3: Application Form for Technical
Assistance
October 2013
4th draft working document
Sustainable Energy Authority of Ireland – National Energy Services Framework
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List of Contents
1. Lead Client Organisation ...........................................................................................................................3
1a. Client organisation ..............................................................................................................................3
1b. Bank details of client organisation ......................................................................................................3
1c. Details of main EPC/EPRP project suppliers (if known at this stage) .................................................4
1d Route to project development ..................................................................................................................4
2. Project Summary .......................................................................................................................................5
2a. Project location(s) ...............................................................................................................................5
2b. Technical description of project ..........................................................................................................5
2c. Projected Annual Energy Costs ..........................................................................................................6
2d. Projected Annual Savings ...................................................................................................................6
3. Project Costs (Stage 3 and 4) ...................................................................................................................7
3a. Overview of costs and funding ............................................................................................................7
3b. Itemised estimates of eligible costs (as per section 1.4 of Appendix 2 the Guide to Technical
Assistance) ................................................................................................................................................7
3b1. External specialist costs ....................................................................................................................7
3b2. Material and equipment costs ...........................................................................................................8
4. Project Timescale, Work Plan and Constraints .........................................................................................8
4a. EPC/EPRP estimated project timescale (complete at appropriate for public or private sector
milestones) ................................................................................................................................................8
Where to send this form? ..........................................................................................................................9
5. Declaration of Lead Client Organisation .................................................................................................10
Appendix 3.1................................................................................................................................................11
Appendix 3 Application for Technical Assistance v1.3
Sustainable Energy Authority of Ireland – National Energy Services Framework
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Reference (for SEAI internal use only)
1. Lead Client Organisation
Table 1a is to be completed for the lead Client Organisation for the proposed project. Where
the project includes other Client Organisations, their details, roles and signatures must be
completed in Appendix 3.1. Please ensure you have read the Framework and Appendix 2
Guide to Technical Assistance before completing this application form.
NOTE: Where separate business entities within a corporate group are participating in the
project, then each such entity should be entered as a Client Organisation in Appendix A. Only
costs incurred / paid for by such companies as are listed in Appendix A will be eligible for
Technical Support payment.
1a. Client organisation
Lead Client Organisation
Company Registration
Number
VAT no. (if
applicable)
Principal Business Activity
Contact Name
Signature
Position
Address
County
Telephone
Fax
Mobile
Is the proposed project a grouped EPC/EPRP
project? (Yes/No)
Email
If Yes, complete Appendix 3.1
1b. Bank details of client organisation
Lead Client Organisation
Bank Name
Bank Branch / Address
Account Name
Account Sort Code
-
Account Number
Email address for
remittance advice
Appendix 3 Application form for Technical Assistance
-
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1c. Details of main EPC/EPRP project suppliers (if known at this stage)
Where known, please provide details of all significant suppliers of services to the Project
Supplier
Role
Contact
Name
Contact
Number
Contact Email
1d Route to project development
Have you read the National Energy Services
Framework? (Yes/No)
Have you read Appendix 2 Guide to Technical
Assistance (Yes/No)
Is the proposed project an EPC project? (Yes/No)
Is the proposed project an EPRP project? (Yes/No)
Is the proposed project an Exemplar project?
(Yes/No)
Appendix 3 Application form for Technical Assistance
If Yes, Please submit a
completed Stage 1 & 2
Workbook
If Yes, Please submit a
completed Stage 1 & 2
Workbook
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2. Project Summary
Project Title
2a. Project location(s)
(If there is more than one location please provide details of all locations: name of building/ facility/ service, address)
2b. Technical description of project
Provide a technical description of the proposed project, including energy savings projected and any technical innovation elements.
Outline the demonstration value and the potential for replication either within your organisation, among your peers, and/or in other
sectors.
Detail the nature of services for which support is being requested. Please format the supports requested in line with the Appendix 2
Guide to Technical Assistance. Please provide information as a minimum on the technical soltuions propsed, the nature of the
performance guarantee and mechanism, the details on the required financial support will be used for, what elements of Stage 3 the
assistance is required for, the innovative nature of the technologies proposed and/or how the project will be delivered
/contracted/financed.
Appendix 3 Application form for Technical Assistance
Sustainable Energy Authority of Ireland – National Energy Services Framework
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Units
2c.
Projected
Energy Costs
Annual Cost (ex. VAT)
Quantity
(kWh, litres etc)
Existing annual utility costs
Costs (€) and energy usage of the
facility, or facilities, within the
scope of this project:
Electricity
Gas
Others (specify):
(e.g. water if included in scope)
Non-energy costs;
(Maintenance etc)
The above figures are:
Delete as appropriate
2d.
Projected
Savings
a. Accurate
b. Approximate, but based on some assessment
c. Estimates / order of magnitude
Annual Value (ex. VAT)
Cost (€) and quantity.
Electricity
Gas
Others (specify):
Non-energy savings
(e.g. maintenance savings, fuel
switching)
Appendix 3 Application form for Technical Assistance
Quantity
Units
(kWh, litres etc)
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3. Project Costs (Stage 3 and 4)
3a. Overview of costs and funding
Funding
Secured
(Y/N)
Euro (€)
(excl. VAT)
Euro (€)
(incl. VAT)
Sustainable Energy Authority of Ireland
(this Support Application)
€
€
Other Public Bodies (please identify body)
€
€
Own Resources
€
€
Other
Please identify:
€
€
Total Technical Assistance Funding
€
€
Proposed Funding Source Structure
Project
Funding
%
100
3b. Itemised estimates of eligible costs (as per section 1.4 of Appendix 2 the
Guide to Technical Assistance)
Euro (€)
(excl. VAT)
Eligible Costs
Euro (€)
(incl. VAT)
External specialist costs (specify below in 3b1):
€
€
Materials/equipment (specify below in 3b2)
€
€
Total
€
€
VAT (Include here as a cost item. However, VAT may only be
deemed an eligible cost where VAT is not reclaimable by the
participating client organisation/s and there is appropriate
certification from the Revenue Commissioners.)
3b1. External specialist costs
Specify:
Euro (€)
(excl. VAT)
€
€
Specify:
€
€
Specify:
€
€
Specify:
€
€
Specify:
€
€
€
€
Daily rate
(€)
External Specialist Costs
Total
Appendix 3 Application form for Technical Assistance
No. of
Days
Euro (€)
(incl. VAT)
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In the case of costs for material or equipment, state the estimated costs.
(Material purchases must be a specific need for the project.)
3b2. Material and equipment costs
Euro (€)
(excl. VAT)
Materials / Equipment
Euro (€)
(incl. VAT)
Specify:
€
€
Specify:
€
€
Specify:
€
€
Specify:
€
€
Specify:
€
€
Total
€
€
4. Project Timescale, Work Plan and Constraints
4a. EPC/EPRP estimated project timescale (complete at appropriate for public or
private sector milestones)
Estimated milestone dates for
the project (DD/MM/YYYY)
Stage of Development
Timing of Technical
Assistance Payment
Stage 1: Get organised
Stage 2: Initial Appraisal
Stage 3: Detailed Appraisal
Stage 4: Procurement –
Competitive
Dialogue
50%
Invitation to Tender*
and
Completed Stage 3 – Workbook &
Documents
 Technical File and Baseline Data

Risk Assessment
Tender Evaluation
Award of
Contract


and
Copy of the Signed Contract
Completed Stage 4 – Workbook &
Documents
Commencement of
Contract
Appendix 3 Application form for Technical Assistance
50%
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*For private sector organisations who are not undergoing a tendering process, a letter confirming the
equivalent milestones is required.
For EPRP projects 100% of the Technical Assistance will be paid at the end of the Procurement stage at
the Award of Contract.
Where to send this form?
Technical Assistance Administrator
Ms Orla Thornton
Sustainable Energy Authority of Ireland
Wilton Park House
Wilton Place, Dublin 2
Phone: 01 8082087
Fax:
01 8082013
Email: orla.thornton@seai.ie
Appendix 3 Application form for Technical Assistance
Sustainable Energy Authority of Ireland – National Energy Services Framework
5. Declaration of Lead Client Organisation
I/we hereby declare that the information provided in respect of this application is to the best of my/our
knowledge correct. I/we agree to allow SEAI or its delegated agent(s) to verify any of the information
contained herein. I am duly authorised to sign on behalf of the organisation(s) applying for funds.
Applicant Declaration

I confirm that funding approval, indicated through a funding offer, will be in place before any
product is ordered, purchased or work is commenced. I accept that, if any orders or purchases
have been made or works commenced prior to the funding approval date, this application will
be ineligible. I confirm that no such orders, purchases or works have occurred prior to the date
of this application.
 I note that inspection checks form part of the Technical Assistance. I acknowledge that I will
be required to grant full access within the specified period for an inspection.
 I understand that any false, fictitious or fraudulent statements or claims in any form knowingly
made by me to SEAI, its authorised officers or an SEAI Inspector may result in demand for
Technical Assistance repayment and full clawback of the funding and may result in current
and future applications being deemed ineligible by SEAI.
 I agree and consent to SEAI, as data controller, and its agents, storing on its database the
information which I provide to SEAI. I note that SEAI agrees that SEAI and its agents shall
only process my personal data in accordance with the Data Protection Acts 1988 and 2003. I
agree and consent to personal data which I provide being used by SEAI or its agents for the
purposes of the programme, including funding approval and payment purposes and to
facilitate the administration of the funding process and for the purposes of liaising with
appropriate inspectors and researchers. This may require my personal data being supplied to
and discussed with any other persons or organisations helping to assess and monitor this
application including, without limitation, SEAI’s professional advisers, outsourced service
providers and any inspectors and researchers which SEAI might engage. These persons will
be required to comply with the Data Protection Acts 1988 and 2003.
 I hereby consent to funding details being made available to the public and other authorities by
SEAI.
 I have read in full the National Energy Services Framework and Appendix 2 the Guide to
Technical Assistance
 I have read and accept the Terms and Conditions of the Technical Assistance as set out in the
National Energy Services Framework and Appendix 2 the Guide to Technical Assistance. I
certify that the information entered on this Application Form is true, accurate and complete in
all respects. I agree to allow SEAI or its agent(s) to verify any of the information contained
herein.
Signed on behalf of Lead Client Organisation by:
Full name
____________________________________
Position
____________________________________
Lead Client Organisation1 Signature: ____________________________________
Date:
____________________________________
1
Important: In the case of group applications, an authorised representative of the lead Client
Organisation should sign here and details of all other participating Client Organisation beneficiaries
should be completed in Appendix 3.1.
Appendix 3 Application form for Technical Assistance
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Sustainable Energy Authority of Ireland – National Energy Services Framework
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NOTE: A valid Tax Clearance Certificate must accompany this application form in respect of each
Client Organisation listed in 1a and Appendix A.
Faxed or scanned copies are acceptable in the case of electronic applications.
Appendix 3.1
In the case of grouped EPC/EPRP project applications, where the EPC project is proposed to be
implemented in more than one energy end-user organisation (‘Client Organisation’), all
participating Client Organisations must sign this declaration.
We hereby declare that we agree to allow the Lead Client Organisation, named in 1a above, to apply for
Technical Assistance and to disburse those funds on our behalf.
No.
Participant
Organisation
Address
Authorised
Signatory
[print name]
1
2
3
4
5
Appendix 3 Application form for Technical Assistance
Contact Email
Mobile
phone
number
Authorised
Signatory
(Signature)