+-----+----+-----+---+---+------------------+-----------------------+
| ![  |    |     |   |   |                  |                       |
| ](m |    |     |   |   |                  |                       |
| edi |    |     |   |   |                  |                       |
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| mag |    |     |   |   |                  |                       |
| e1. |    |     |   |   |                  |                       |
| png |    |     |   |   |                  |                       |
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| 666 |    |     |   |   |                  |                       |
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| hei |    |     |   |   |                  |                       |
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| .81 |    |     |   |   |                  |                       |
| 25i |    |     |   |   |                  |                       |
| n"} |    |     |   |   |                  |                       |
| **[ |    |     |   |   |                  |                       |
| ENE |    |     |   |   |                  |                       |
| RGY |    |     |   |   |                  |                       |
| ST  |    |     |   |   |                  |                       |
| AR] |    |     |   |   |                  |                       |
| {.s |    |     |   |   |                  |                       |
| mal |    |     |   |   |                  |                       |
| lca |    |     |   |   |                  |                       |
| ps} |    |     |   |   |                  |                       |
| ^®^ |    |     |   |   |                  |                       |
| QU  |    |     |   |   |                  |                       |
| ALI |    |     |   |   |                  |                       |
| FIE |    |     |   |   |                  |                       |
| D** |    |     |   |   |                  |                       |
|     |    |     |   |   |                  |                       |
| **P |    |     |   |   |                  |                       |
| ROD |    |     |   |   |                  |                       |
| UCT |    |     |   |   |                  |                       |
| IN  |    |     |   |   |                  |                       |
| FOR |    |     |   |   |                  |                       |
| MAT |    |     |   |   |                  |                       |
| ION |    |     |   |   |                  |                       |
| F   |    |     |   |   |                  |                       |
| ORM |    |     |   |   |                  |                       |
| FO  |    |     |   |   |                  |                       |
| R** |    |     |   |   |                  |                       |
|     |    |     |   |   |                  |                       |
| #   |    |     |   |   |                  |                       |
| IND |    |     |   |   |                  |                       |
| OOR |    |     |   |   |                  |                       |
|  RE |    |     |   |   |                  |                       |
| SID |    |     |   |   |                  |                       |
| ENT |    |     |   |   |                  |                       |
| IAL |    |     |   |   |                  |                       |
|  LI |    |     |   |   |                  |                       |
| GHT |    |     |   |   |                  |                       |
|  FI |    |     |   |   |                  |                       |
| XTU |    |     |   |   |                  |                       |
| RES |    |     |   |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+
| **  |    |     |   |   |                  |                       |
| ENE |    |     |   |   |                  |                       |
| RGY |    |     |   |   |                  |                       |
| S   |    |     |   |   |                  |                       |
| TAR |    |     |   |   |                  |                       |
| p   |    |     |   |   |                  |                       |
| rod |    |     |   |   |                  |                       |
| uct |    |     |   |   |                  |                       |
| in  |    |     |   |   |                  |                       |
| for |    |     |   |   |                  |                       |
| mat |    |     |   |   |                  |                       |
| ion |    |     |   |   |                  |                       |
| f   |    |     |   |   |                  |                       |
| orm |    |     |   |   |                  |                       |
| for |    |     |   |   |                  |                       |
| use |    |     |   |   |                  |                       |
| by  |    |     |   |   |                  |                       |
| [   |    |     |   |   |                  |                       |
| ENE |    |     |   |   |                  |                       |
| RGY |    |     |   |   |                  |                       |
| ST  |    |     |   |   |                  |                       |
| AR] |    |     |   |   |                  |                       |
| {.s |    |     |   |   |                  |                       |
| mal |    |     |   |   |                  |                       |
| lca |    |     |   |   |                  |                       |
| ps} |    |     |   |   |                  |                       |
| qua |    |     |   |   |                  |                       |
| lif |    |     |   |   |                  |                       |
| ied |    |     |   |   |                  |                       |
| re  |    |     |   |   |                  |                       |
| sid |    |     |   |   |                  |                       |
| ent |    |     |   |   |                  |                       |
| ial |    |     |   |   |                  |                       |
| li  |    |     |   |   |                  |                       |
| ght |    |     |   |   |                  |                       |
| f   |    |     |   |   |                  |                       |
| ixt |    |     |   |   |                  |                       |
| ure |    |     |   |   |                  |                       |
| p   |    |     |   |   |                  |                       |
| art |    |     |   |   |                  |                       |
| ner |    |     |   |   |                  |                       |
| s** |    |     |   |   |                  |                       |
|     |    |     |   |   |                  |                       |
| **( |    |     |   |   |                  |                       |
| Com |    |     |   |   |                  |                       |
| pan |    |     |   |   |                  |                       |
| ies |    |     |   |   |                  |                       |
| who |    |     |   |   |                  |                       |
| h   |    |     |   |   |                  |                       |
| ave |    |     |   |   |                  |                       |
| joi |    |     |   |   |                  |                       |
| ned |    |     |   |   |                  |                       |
| [   |    |     |   |   |                  |                       |
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| RGY |    |     |   |   |                  |                       |
| ST  |    |     |   |   |                  |                       |
| AR] |    |     |   |   |                  |                       |
| {.s |    |     |   |   |                  |                       |
| mal |    |     |   |   |                  |                       |
| lca |    |     |   |   |                  |                       |
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| for |    |     |   |   |                  |                       |
| re  |    |     |   |   |                  |                       |
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| ial |    |     |   |   |                  |                       |
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| ght |    |     |   |   |                  |                       |
| fi  |    |     |   |   |                  |                       |
| xtu |    |     |   |   |                  |                       |
| res |    |     |   |   |                  |                       |
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| ers |    |     |   |   |                  |                       |
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| Agr |    |     |   |   |                  |                       |
| eem |    |     |   |   |                  |                       |
| ent |    |     |   |   |                  |                       |
| )** |    |     |   |   |                  |                       |
|     |    |     |   |   |                  |                       |
| *   |    |     |   |   |                  |                       |
| You |    |     |   |   |                  |                       |
| may |    |     |   |   |                  |                       |
| use |    |     |   |   |                  |                       |
| t   |    |     |   |   |                  |                       |
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| to  |    |     |   |   |                  |                       |
| rep |    |     |   |   |                  |                       |
| ort |    |     |   |   |                  |                       |
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| cts |    |     |   |   |                  |                       |
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| any |    |     |   |   |                  |                       |
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| me, |    |     |   |   |                  |                       |
| you |    |     |   |   |                  |                       |
| m   |    |     |   |   |                  |                       |
| ust |    |     |   |   |                  |                       |
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| on. |    |     |   |   |                  |                       |
| Ple |    |     |   |   |                  |                       |
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| c   |    |     |   |   |                  |                       |
| opy |    |     |   |   |                  |                       |
| t   |    |     |   |   |                  |                       |
| his |    |     |   |   |                  |                       |
| f   |    |     |   |   |                  |                       |
| orm |    |     |   |   |                  |                       |
| and |    |     |   |   |                  |                       |
| ret |    |     |   |   |                  |                       |
| urn |    |     |   |   |                  |                       |
| one |    |     |   |   |                  |                       |
| for |    |     |   |   |                  |                       |
| e   |    |     |   |   |                  |                       |
| ach |    |     |   |   |                  |                       |
| lam |    |     |   |   |                  |                       |
| p/b |    |     |   |   |                  |                       |
| all |    |     |   |   |                  |                       |
| ast |    |     |   |   |                  |                       |
| co  |    |     |   |   |                  |                       |
| mbi |    |     |   |   |                  |                       |
| nat |    |     |   |   |                  |                       |
| ion |    |     |   |   |                  |                       |
| to  |    |     |   |   |                  |                       |
| the |    |     |   |   |                  |                       |
| a   |    |     |   |   |                  |                       |
| ddr |    |     |   |   |                  |                       |
| ess |    |     |   |   |                  |                       |
| b   |    |     |   |   |                  |                       |
| elo |    |     |   |   |                  |                       |
| w.* |    |     |   |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+
| **  |    |     |   |   |                  |                       |
| MAN |    |     |   |   |                  |                       |
| UFA |    |     |   |   |                  |                       |
| CTU |    |     |   |   |                  |                       |
| RER |    |     |   |   |                  |                       |
| ([  |    |     |   |   |                  |                       |
| ENE |    |     |   |   |                  |                       |
| RGY |    |     |   |   |                  |                       |
| ST  |    |     |   |   |                  |                       |
| AR] |    |     |   |   |                  |                       |
| {.s |    |     |   |   |                  |                       |
| mal |    |     |   |   |                  |                       |
| lca |    |     |   |   |                  |                       |
| ps} |    |     |   |   |                  |                       |
| Par |    |     |   |   |                  |                       |
| tne |    |     |   |   |                  |                       |
| r): |    |     |   |   |                  |                       |
| \   |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| Sam |    |     |   |   |                  |                       |
| ple |    |     |   |   |                  |                       |
| Cor |    |     |   |   |                  |                       |
| por |    |     |   |   |                  |                       |
| ati |    |     |   |   |                  |                       |
| on\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| ­­­­­­\_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
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| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
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| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
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| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _\_ |    |     |   |   |                  |                       |
| \_\ |    |     |   |   |                  |                       |
| _** |    |     |   |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+
| **S |    |     |   |   |                  |                       |
| ECT |    |     |   |   |                  |                       |
| ION |    |     |   |   |                  |                       |
| I   |    |     |   |   |                  |                       |
| \-- |    |     |   |   |                  |                       |
| L   |    |     |   |   |                  |                       |
| AMP |    |     |   |   |                  |                       |
| &   |    |     |   |   |                  |                       |
| B   |    |     |   |   |                  |                       |
| ALL |    |     |   |   |                  |                       |
| AST |    |     |   |   |                  |                       |
| IN  |    |     |   |   |                  |                       |
| FOR |    |     |   |   |                  |                       |
| MAT |    |     |   |   |                  |                       |
| ION |    |     |   |   |                  |                       |
| :** |    |     |   |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+
| Num | Nu | I   | L | L | Lamp (e.g.,      | Ballast               |
| ber | mb | ndi | a | a | lightbulb)       |                       |
| of  | er | vid | m | m |                  | Manufacturer & Model  |
| Lam | of | ual | p | p | Manufacturer &   | Number                |
| ps/ | B  | Lis |   |   | Model Number     |                       |
| F   | al | ted | T | S |                  |                       |
| ixt | la | L   | y | i |                  |                       |
| ure | st | amp | p | z |                  |                       |
|     | s/ | W   | e | e |                  |                       |
|     | F  | att | ^ | ^ |                  |                       |
|     | ix | age | 1 | 2 |                  |                       |
|     | tu |     | ^ | ^ |                  |                       |
|     | re |     |   |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+
| 1   | 1  | 18  | C | T | LampCo 111       | BallastCo 2222        |
|     |    |     | F | 4 |                  |                       |
|     |    |     | L |   |                  |                       |
+-----+----+-----+---+---+------------------+-----------------------+

+---------------------+---------------+---+---+---+-------------------+
| ENERGY STAR should  |               |   |   |   |                   |
| review this         |               |   |   |   |                   |
| submittal as a      |               |   |   |   |                   |
| (circle one):       |               |   |   |   |                   |
| Complete Fixture    |               |   |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| 1\. Lamp Type: For  |               |   |   |   |                   |
| example, CFL =      |               |   |   |   |                   |
| Compact             |               |   |   |   |                   |
| Fluorescent, CR =   |               |   |   |   |                   |
| Circular, L =       |               |   |   |   |                   |
| Linear              |               |   |   |   |                   |
|                     |               |   |   |   |                   |
| 2\. Lamp Size: For  |               |   |   |   |                   |
| example, T4, T5, or |               |   |   |   |                   |
| T8.                 |               |   |   |   |                   |
|                     |               |   |   |   |                   |
| 3\. A lamp and      |               |   |   |   |                   |
| ballast platform    |               |   |   |   |                   |
| does not receive    |               |   |   |   |                   |
| the [ENERGY         |               |   |   |   |                   |
| STAR]{.smallcaps}   |               |   |   |   |                   |
| mark and cannot be  |               |   |   |   |                   |
| promoted as an      |               |   |   |   |                   |
| [ENERGY             |               |   |   |   |                   |
| STAR]{.smallcaps}   |               |   |   |   |                   |
| qualified product.  |               |   |   |   |                   |
| Rather, you may     |               |   |   |   |                   |
| promote the         |               |   |   |   |                   |
| "qualified" lamp,   |               |   |   |   |                   |
| ballast, or         |               |   |   |   |                   |
| lamp/ballast        |               |   |   |   |                   |
| platform as a       |               |   |   |   |                   |
| component that      |               |   |   |   |                   |
| meets applicable    |               |   |   |   |                   |
| [ENERGY             |               |   |   |   |                   |
| STAR]{.smallcaps}   |               |   |   |   |                   |
| Program             |               |   |   |   |                   |
| Requirements when   |               |   |   |   |                   |
| used in [ENERGY     |               |   |   |   |                   |
| STAR]{.smallcaps}   |               |   |   |   |                   |
| qualified           |               |   |   |   |                   |
| residential light   |               |   |   |   |                   |
| fixtures.           |               |   |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| **SECTION II \--    |               |   |   |   |                   |
| TEST RESULTS:**     |               |   |   |   |                   |
| Enter results from  |               |   |   |   |                   |
| test report         |               |   |   |   |                   |
| (complete using     |               |   |   |   |                   |
| average of tested   |               |   |   |   |                   |
| samples) or         |               |   |   |   |                   |
| manufacturer data   |               |   |   |   |                   |
| as specified in the |               |   |   |   |                   |
| ENERGY STAR Program |               |   |   |   |                   |
| Requirements for    |               |   |   |   |                   |
| Residential Light   |               |   |   |   |                   |
| Fixtures Version    |               |   |   |   |                   |
| 4.0 and attach      |               |   |   |   |                   |
| required            |               |   |   |   |                   |
| documentation to    |               |   |   |   |                   |
| this form.          |               |   |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| **Performance       | ####          |   |   |   | **Required        |
| Characteristic**    | # Test Result |   |   |   | Documentation**   |
|                     |               |   |   |   |                   |
|                     |               |   |   |   | (please attach to |
|                     |               |   |   |   | this form)        |
+---------------------+---------------+---+---+---+-------------------+
| **Combined Lamp &   |               |   |   |   |                   |
| Ballast             |               |   |   |   |                   |
| Requirements**      |               |   |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| System Efficacy     | \_\_\_\_699.6 | T |   |   | Test report from  |
|                     | 7\_\_\_\_\_\_ | o |   |   | a lab accredited  |
|                     |               | t |   |   | by NVLAP or one   |
|                     |               | a |   |   | of its MRA        |
|                     |               | l |   |   | signatories, an   |
|                     |               | L |   |   | EPA approved      |
|                     |               | u |   |   | Platform Letter   |
|                     |               | m |   |   | of Qualification, |
|                     |               | e |   |   | or EPA-approved   |
|                     |               | n |   |   | documentation     |
|                     |               | O |   |   | from an industry  |
|                     |               | u |   |   | association.      |
|                     |               | t |   |   |                   |
|                     |               | p |   |   |                   |
|                     |               | u |   |   |                   |
|                     |               | t |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
|                     | \_\_\_\_\_1   | I |   |   |                   |
|                     | 2.3\_\_\_\_\_ | n |   |   |                   |
|                     |               | p |   |   |                   |
|                     |               | u |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | P |   |   |                   |
|                     |               | o |   |   |                   |
|                     |               | w |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               | r |   |   |                   |
|                     |               | ( |   |   |                   |
|                     |               | w |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | s |   |   |                   |
|                     |               | ) |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
|                     | \_\_\_\_56.7  | L |   |   |                   |
|                     | 3\_\_\_\_\_\_ | u |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               | n |   |   |                   |
|                     |               | s |   |   |                   |
|                     |               | P |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               | r |   |   |                   |
|                     |               | W |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | t |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| **Lamp              |               |   |   |   |                   |
| Requirements**      |               |   |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| Lamp Life           | \_\_\_10000\  | A |   |   | Test report from  |
|                     | _\_\_\_\_\_\_ | v |   |   | a lab accredited  |
|                     |               | e |   |   | by NVLAP or one   |
|                     |               | r |   |   | of its MRA        |
|                     |               | a |   |   | signatories, an   |
|                     |               | g |   |   | EPA approved      |
|                     |               | e |   |   | Platform Letter   |
|                     |               | R |   |   | of Qualification, |
|                     |               | a |   |   | EPA-approved      |
|                     |               | t |   |   | documentation     |
|                     |               | e |   |   | from an industry  |
|                     |               | d |   |   | association, or a |
|                     |               | H |   |   | test report from  |
|                     |               | o |   |   | an ISO 9000       |
|                     |               | u |   |   | registered        |
|                     |               | r |   |   | facility.         |
|                     |               | s |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| Lumen Maintenance   | \_\_\_\_87.   | \ |   |   |                   |
|                     | 7\_\_\_\_\_\_ | % |   |   |                   |
|                     |               | o |   |   |                   |
|                     |               | f |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | n |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | l |   |   |                   |
|                     |               | l |   |   |                   |
|                     |               | u |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               | n |   |   |                   |
|                     |               | s |   |   |                   |
|                     |               |   |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | 4 |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | % |   |   |                   |
|                     |               | r |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | t |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               | d |   |   |                   |
|                     |               | l |   |   |                   |
|                     |               | a |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | p |   |   |                   |
|                     |               | l |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | f |   |   |                   |
|                     |               | e |   |   |                   |
|                     |               |   |   |   |                   |
|                     |               | ( |   |   |                   |
|                     |               | 4 |   |   |                   |
|                     |               | , |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | h |   |   |                   |
|                     |               | o |   |   |                   |
|                     |               | u |   |   |                   |
|                     |               | r |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | n |   |   |                   |
|                     |               | i |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | u |   |   |                   |
|                     |               | m |   |   |                   |
|                     |               | ) |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| Lamp Color          | \_\_\_\_\_81  | C |   |   | Test report from  |
| Rendering Index     | .57\_\_\_\_\_ | R |   |   | a lab accredited  |
|                     |               | I |   |   | by NVLAP or one   |
|                     |               |   |   |   | of its MRA        |
|                     |               |   |   |   | signatories, an   |
|                     |               |   |   |   | EPA approved      |
|                     |               |   |   |   | Platform Letter   |
|                     |               |   |   |   | of Qualification, |
|                     |               |   |   |   | or EPA-approved   |
|                     |               |   |   |   | documentation     |
|                     |               |   |   |   | from an industry  |
|                     |               |   |   |   | association.      |
+---------------------+---------------+---+---+---+-------------------+
| Lamp Correlated     | Target CCT    | * | 3 | 3 | Test report from  |
| Color Temperature   | (circle one)  | * | 0 | 5 | a lab accredited  |
| (CCT)               |               | * | 0 | 0 | by NVLAP or one   |
|                     |               | 2 | 0 | 0 | of its MRA        |
|                     |               | 7 | K | K | signatories, an   |
|                     |               | 0 |   |   | EPA approved      |
|                     |               | 0 |   |   | Platform Letter   |
|                     |               | K |   |   | of Qualification, |
|                     |               | * |   |   | EPA-approved      |
|                     |               | * |   |   | documentation     |
|                     |               | * |   |   | from an industry  |
|                     |               |   |   |   | association, or a |
|                     |               |   |   |   | test from an ISO  |
|                     |               |   |   |   | 9000 registered   |
|                     |               |   |   |   | facility.         |
+---------------------+---------------+---+---+---+-------------------+
|                     |               | 4 | 5 | 6 |                   |
|                     |               | 1 | 0 | 5 |                   |
|                     |               | 0 | 0 | 0 |                   |
|                     |               | 0 | 0 | 0 |                   |
|                     |               | K | K | K |                   |
+---------------------+---------------+---+---+---+-------------------+
|                     | Samples       | \ |   |   |                   |
|                     | falling       | _ |   |   |                   |
|                     | within 7-step | \ |   |   |                   |
|                     | Mac Adam      | _ |   |   |                   |
|                     | ellipse       | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | 1 |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | 0 |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | % |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| Lamp/Lampholder     | List ANSI-IEC | \ |   |   | No documentation  |
| Compatibility       | Designated    | _ |   |   | required at time  |
|                     |               | \ |   |   | of submittal.     |
|                     | **Lamp**      | _ |   |   |                   |
|                     | **Base Type** | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | G |   |   |                   |
|                     |               | 2 |   |   |                   |
|                     |               | 4 |   |   |                   |
|                     |               | Q |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
|                     | ANSI-IEC      | Y |   |   | For fixtures that |
|                     | Standardized  | e |   |   | do not use an     |
|                     | **Lamp**?     | s |   |   | ANSI-IEC          |
|                     |               | O |   |   | standardized lamp |
|                     |               | R |   |   | from ANSI C78.901 |
|                     |               | N |   |   | & C78.81 or IEC   |
|                     |               | o |   |   | 60901 & 60081,    |
|                     |               |   |   |   | supply a lamp     |
|                     |               |   |   |   | manufacturer      |
|                     |               |   |   |   | specification     |
|                     |               |   |   |   | sheet.            |
+---------------------+---------------+---+---+---+-------------------+
|                     | If "Yes",     | \ |   |   |                   |
|                     | list ANSI-IEC | _ |   |   |                   |
|                     | **Lamp**      | \ |   |   |                   |
|                     | Standard Data | _ |   |   |                   |
|                     | Sheet Number  | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | 2 |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | \ |   |   |                   |
|                     |               | _ |   |   |                   |
|                     |               | O |   |   |                   |
|                     |               | R |   |   |                   |
|                     |               | N |   |   |                   |
|                     |               | / |   |   |                   |
|                     |               | A |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+
| Lamp Labeling       | Check box if  |   |   |   | A copy of the     |
| Requirement         | lamp labeling |   |   |   | actual language   |
|                     | requirement   | - |   |   | that will be      |
|                     | has been met: | - |   |   | included on the   |
|                     |               | - |   |   | lamp base or      |
|                     |               |   |   |   | glass.            |
|                     |               |   |   |   |                   |
|                     |               | x |   |   |                   |
|                     |               |   |   |   |                   |
|                     |               |   |   |   |                   |
|                     |               |   |   |   |                   |
|                     |               | - |   |   |                   |
|                     |               | - |   |   |                   |
|                     |               | - |   |   |                   |
+---------------------+---------------+---+---+---+-------------------+

+-----------------+------------------+---+---+--------+-------------------+
| **SECTION II    |                  |   |   |        |                   |
| \-- TEST        |                  |   |   |        |                   |
| RESULTS         |                  |   |   |        |                   |
| (continued):**  |                  |   |   |        |                   |
| Enter results   |                  |   |   |        |                   |
| from test       |                  |   |   |        |                   |
| report          |                  |   |   |        |                   |
| (complete using |                  |   |   |        |                   |
| average of      |                  |   |   |        |                   |
| tested samples) |                  |   |   |        |                   |
| or manufacturer |                  |   |   |        |                   |
| data as         |                  |   |   |        |                   |
| specified in    |                  |   |   |        |                   |
| the ENERGY STAR |                  |   |   |        |                   |
| Program         |                  |   |   |        |                   |
| Requirements    |                  |   |   |        |                   |
| for Residential |                  |   |   |        |                   |
| Light Fixtures  |                  |   |   |        |                   |
| Version 4.0 and |                  |   |   |        |                   |
| attach required |                  |   |   |        |                   |
| documentation   |                  |   |   |        |                   |
| to this form.   |                  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| **Ballast       |                  |   |   |        |                   |
| Requirements**  |                  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Lamp Start Time | \_\_\_\          |   | M |        | Test report from  |
|                 | _453\_\_\_\_\_\_ |   | i |        | a lab accredited  |
|                 |                  |   | l |        | by NVLAP or one   |
|                 |                  |   | l |        | of its MRA        |
|                 |                  |   | i |        | signatories, an   |
|                 |                  |   | s |        | EPA approved      |
|                 |                  |   | e |        | Platform Letter   |
|                 |                  |   | c |        | of Qualification, |
|                 |                  |   | o |        | EPA-approved      |
|                 |                  |   | n |        | documentation     |
|                 |                  |   | d |        | from an industry  |
|                 |                  |   | s |        | association, or a |
|                 |                  |   |   |        | test report from  |
|                 |                  |   |   |        | an OSHA NRTL      |
|                 |                  |   |   |        | laboratory.       |
+-----------------+------------------+---+---+--------+-------------------+
| Power Factor    | \_\_\_\_\        |   |   |        | Test report from  |
|                 | _0.654\_\_\_\_\_ |   |   |        | a lab accredited  |
|                 |                  |   |   |        | by NVLAP or one   |
|                 |                  |   |   |        | of its MRA        |
|                 |                  |   |   |        | signatories, an   |
|                 |                  |   |   |        | EPA approved      |
|                 |                  |   |   |        | Platform Letter   |
|                 |                  |   |   |        | of Qualification, |
|                 |                  |   |   |        | EPA-approved      |
|                 |                  |   |   |        | documentation     |
|                 |                  |   |   |        | from an industry  |
|                 |                  |   |   |        | association, or a |
|                 |                  |   |   |        | test report from  |
|                 |                  |   |   |        | the ballast or    |
|                 |                  |   |   |        | fixture           |
|                 |                  |   |   |        | manufacturer.     |
+-----------------+------------------+---+---+--------+-------------------+
| Lamp Current    | \_\_\_\_\        |   |   |        | Test report from  |
| Crest Factor    | _\_\_1.435\_\_\_ |   |   |        | a lab accredited  |
|                 |                  |   |   |        | by NVLAP or one   |
|                 |                  |   |   |        | of its MRA        |
|                 |                  |   |   |        | signatories, an   |
|                 |                  |   |   |        | EPA approved      |
|                 |                  |   |   |        | Platform Letter   |
|                 |                  |   |   |        | of Qualification, |
|                 |                  |   |   |        | EPA-approved      |
|                 |                  |   |   |        | documentation     |
|                 |                  |   |   |        | from an industry  |
|                 |                  |   |   |        | association, or a |
|                 |                  |   |   |        | test report from  |
|                 |                  |   |   |        | an OSHA NRTL      |
|                 |                  |   |   |        | laboratory.       |
+-----------------+------------------+---+---+--------+-------------------+
| Ballast Case    | Check box if     |   |   |        | Ballast           |
| Hot Spot        | hotspot diagram  |   |   |        | manufacturer      |
| Location        | has been         |   |   |        | documentation.    |
|                 | included with    |   |   |        |                   |
|                 | this submittal:  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Maximum         | \_\_\_\_         |   | d |        | Ballast           |
| Recommended     | \_85\_\_\_\_\_\_ |   | e |        | manufacturer      |
| Ballast Case    |                  |   | g |        | documentation.    |
| Temperature     |                  |   | r |        |                   |
| During Normal   |                  |   | e |        |                   |
| Operation       |                  |   | e |        |                   |
| Inside A        |                  |   | s |        |                   |
| Fixture         |                  |   | C |        |                   |
|                 |                  |   | e |        |                   |
|                 |                  |   | l |        |                   |
|                 |                  |   | s |        |                   |
|                 |                  |   | i |        |                   |
|                 |                  |   | u |        |                   |
|                 |                  |   | s |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Maximum         | \_\_\_\_\_       |   | d |        | Test report from  |
| Measured        | 63.3\_\_\_\_\_\_ |   | e |        | a lab accredited  |
| Ballast Case    |                  |   | g |        | by NVLAP or one   |
| Temperature     |                  |   | r |        | of its MRA        |
| During Normal   |                  |   | e |        | signatories, an   |
| Operation       |                  |   | e |        | OSHA NRTL         |
| Inside          |                  |   | s |        | laboratory, or    |
| Fixture(s)      |                  |   | C |        | the fixture or    |
|                 |                  |   | e |        | ballast           |
|                 |                  |   | l |        | manufacturer.     |
|                 |                  |   | s |        |                   |
|                 |                  |   | i |        |                   |
|                 |                  |   | u |        |                   |
|                 |                  |   | s |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Electromagnetic | Check box if the |   |   |        | No documentation  |
| and Radio       | ballast meets    |   |   |        | required at time  |
| Frequency       | FCC requirements |   | - |        | of submittal.     |
| Interference    | for consumer     |   | - |        |                   |
|                 | use:             |   | - |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   | x |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Ballast         | \_\_\_           |   | k |        | Test report from  |
| Frequency       | 47\_\_\_\_\_\_\_ |   | H |        | a lab accredited  |
|                 |                  |   | z |        | by NVLAP or one   |
|                 |                  |   |   |        | of its MRA        |
|                 |                  |   |   |        | signatories, an   |
|                 |                  |   |   |        | EPA approved      |
|                 |                  |   |   |        | Platform Letter   |
|                 |                  |   |   |        | of Qualification, |
|                 |                  |   |   |        | EPA-approved      |
|                 |                  |   |   |        | documentation     |
|                 |                  |   |   |        | from an industry  |
|                 |                  |   |   |        | association, or a |
|                 |                  |   |   |        | test report from  |
|                 |                  |   |   |        | the ballast or    |
|                 |                  |   |   |        | fixture           |
|                 |                  |   |   |        | manufacturer.     |
+-----------------+------------------+---+---+--------+-------------------+
| Transient       | Check box if     |   |   |        |                   |
| Protection      | ballast meets    |   |   |        |                   |
|                 | transient        |   |   |        |                   |
|                 | protection       |   |   |        |                   |
|                 | requirements:    |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| End of Life     | Testing          |   | Y |        | For T4 and T5     |
| Protection      | requirements     |   | e |        | lamps, test       |
| (Only required  | met?             |   | s |        | report from a lab |
| for ballasts    |                  |   |   |        | accredited by     |
| with lamps      |                  |   |   |        | NVLAP or one of   |
| sized T5 &      |                  |   |   |        | its MRA           |
| smaller)        |                  |   |   |        | signatories, an   |
|                 |                  |   |   |        | EPA approved      |
|                 |                  |   |   |        | Platform Letter   |
|                 |                  |   |   |        | of Qualification, |
|                 |                  |   |   |        | EPA-approved      |
|                 |                  |   |   |        | documentation     |
|                 |                  |   |   |        | from an industry  |
|                 |                  |   |   |        | association, or a |
|                 |                  |   |   |        | test report from  |
|                 |                  |   |   |        | the ballast or    |
|                 |                  |   |   |        | fixture           |
|                 |                  |   |   |        | manufacturer. For |
|                 |                  |   |   |        | T3 lamps and      |
|                 |                  |   |   |        | smaller, a        |
|                 |                  |   |   |        | circuit diagram   |
|                 |                  |   |   |        | and engineering   |
|                 |                  |   |   |        | description.      |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Maximum number   |   | \ |        |                   |
|                 | of lamps shut    |   | _ |        |                   |
|                 | down when lamp   |   | \ |        |                   |
|                 | end of life      |   | _ |        |                   |
|                 | event occurs:    |   | 1 |        |                   |
|                 |                  |   | \ |        |                   |
|                 |                  |   | _ |        |                   |
|                 |                  |   | \ |        |                   |
|                 |                  |   | _ |        |                   |
|                 |                  |   | \ |        |                   |
|                 |                  |   | _ |        |                   |
|                 |                  |   | O |        |                   |
|                 |                  |   | R |        |                   |
|                 |                  |   | N |        |                   |
|                 |                  |   | / |        |                   |
|                 |                  |   | A |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Dimming         | Dimming-Capable  |   | N |        | No documentation  |
|                 | Ballast?         |   | o |        | required at time  |
|                 |                  |   |   |        | of submittal,     |
|                 |                  |   |   |        | except when       |
|                 |                  |   |   |        | torchiere         |
|                 |                  |   |   |        | fixtures are      |
|                 |                  |   |   |        | submitted.        |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Check one box if |   |   | 3-Way  |                   |
|                 | ballast is       |   |   | Swi    |                   |
|                 | dimming-capable: |   | - | tching |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 |                  |   |   | Cont   |                   |
|                 |                  |   |   | inuous |                   |
|                 |                  |   | - | D      |                   |
|                 |                  |   | - | imming |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Safety --       | Listed for       |   | Y |        | Cover page of a   |
| Ballasts and    | Safety?          |   | e |        | safety test       |
| "Non Edison     |                  |   | s |        | report or a       |
| base            |                  |   | O |        | general coverage  |
| Fluorescent     |                  |   | R |        | statement.        |
| Adapters"       |                  |   | N |        |                   |
|                 |                  |   | / |        |                   |
|                 |                  |   | A |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Line Voltage    | Do any of the    | > |   |        | No documentation  |
| Socket (LVS)    | submitted        |   |   |        | required at time  |
|                 | fixtures use the | Y |   |        | of submittal.     |
| Standard Design | twist-and-lock   | e |   |        |                   |
|                 | LVS standard     | s |   |        |                   |
|                 | design?          |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Line Voltage    | Do any of the    | Y |   |        | No documentation  |
| Socket (LVS)    | submitted        | e |   |        | required at time  |
|                 | fixtures ship    | s |   |        | of submittal.     |
| Standard Design | with             |   |   |        |                   |
| with            | self-ballasted   |   |   |        |                   |
| Self-Ballasted  | pin-based lamps  |   |   |        |                   |
| Pin-Based Lamp  | (i.e.,           |   |   |        |                   |
|                 | integrated lamp  |   |   |        |                   |
|                 | and ballast)     |   |   |        |                   |
|                 | that use the     |   |   |        |                   |
|                 | twist-and-lock   |   |   |        |                   |
|                 | LVS standard     |   |   |        |                   |
|                 | design?          |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| **Fixture       |                  |   |   |        |                   |
| Requirements**  |                  |   |   |        |                   |
| (Only required  |                  |   |   |        |                   |
| for fixture     |                  |   |   |        |                   |
| submittals.     |                  |   |   |        |                   |
| Leave blank for |                  |   |   |        |                   |
| lamp/ballast    |                  |   |   |        |                   |
| platform        |                  |   |   |        |                   |
| submittals.)    |                  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Fixture         | Check box if     |   |   |        | Provide two-year  |
| Warranty        | fixture warranty |   |   |        | fixture           |
|                 | is included with |   | - |        | manufacturer      |
|                 | fixture          |   | - |        | written warranty  |
|                 | packaging:       |   | - |        | language that is  |
|                 |                  |   |   |        | included with     |
|                 |                  |   |   |        | product           |
|                 |                  |   | x |        | packaging.        |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
|                 |                  |   | - |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Noise           | \_\_\_           |   | d |        | No documentation  |
|                 | 24\_\_\_\_\_\_\_ |   | B |        | required at time  |
|                 |                  |   | A |        | of submittal.     |
+-----------------+------------------+---+---+--------+-------------------+
| **SECTION II    |                  |   |   |        |                   |
| \-- TEST        |                  |   |   |        |                   |
| RESULTS         |                  |   |   |        |                   |
| (continued):**  |                  |   |   |        |                   |
| Enter results   |                  |   |   |        |                   |
| from test       |                  |   |   |        |                   |
| report          |                  |   |   |        |                   |
| (complete using |                  |   |   |        |                   |
| average of      |                  |   |   |        |                   |
| tested samples) |                  |   |   |        |                   |
| or manufacturer |                  |   |   |        |                   |
| data as         |                  |   |   |        |                   |
| specified in    |                  |   |   |        |                   |
| the ENERGY STAR |                  |   |   |        |                   |
| Program         |                  |   |   |        |                   |
| Requirements    |                  |   |   |        |                   |
| for Residential |                  |   |   |        |                   |
| Light Fixtures  |                  |   |   |        |                   |
| Version 4.0 and |                  |   |   |        |                   |
| attach required |                  |   |   |        |                   |
| documentation   |                  |   |   |        |                   |
| to this form.   |                  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Replaceable     | Check box if the |   |   |        | A copy of the     |
| Ballast         | submitted        |   |   |        | language that     |
|                 | fixtures meet    | - |   |        | includes guidance |
|                 | the replaceable  | - |   |        | on ballast        |
|                 | ballast          | - |   |        | replacement and   |
|                 | requirement:     |   |   |        | states that the   |
|                 |                  |   |   |        | ballast is        |
|                 |                  | x |   |        | replaceable with  |
|                 |                  |   |   |        | the use of a      |
|                 |                  |   |   |        | "qualified        |
|                 |                  |   |   |        | electrician"      |
|                 |                  | - |   |        | without the       |
|                 |                  | - |   |        | cutting of wires. |
|                 |                  | - |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Safety --       | Listed for       | N |   |        | Cover page of a   |
| Portable        | Safety?          | / |   |        | safety test       |
| Fixtures        |                  | A |   |        | report or a       |
|                 |                  |   |   |        | general coverage  |
|                 |                  |   |   |        | statement.        |
+-----------------+------------------+---+---+--------+-------------------+
| Safety --       | Listed for       | Y |   |        | Cover page of a   |
| Hardwired       | Safety?          | e |   |        | safety test       |
| Fixtures        |                  | s |   |        | report or a       |
|                 |                  |   |   |        | general coverage  |
|                 |                  |   |   |        | statement.        |
+-----------------+------------------+---+---+--------+-------------------+
| Decorative LEDs | Do any of the    | N |   |        | Manufacturer      |
|                 | submitted        | o |   |        | documentation     |
|                 | fixtures use     |   |   |        | including total   |
|                 | decorative LEDs? |   |   |        | wattage consumed  |
|                 |                  |   |   |        | by all LEDs,      |
|                 |                  |   |   |        | manufacturer      |
|                 |                  |   |   |        | warranty, and     |
|                 |                  |   |   |        | spec. sheet       |
|                 |                  |   |   |        | showing wattage,  |
|                 |                  |   |   |        | efficacy, LED     |
|                 |                  |   |   |        | life, color, and  |
|                 |                  |   |   |        | lumen             |
|                 |                  |   |   |        | depreciation.     |
+-----------------+------------------+---+---+--------+-------------------+
| Permanent       | Do any of the    | N |   |        | No documentation  |
| Conversions     | submitted        | o |   |        | required at time  |
|                 | fixtures use a   |   |   |        | of submittal.     |
|                 | f                |   |   |        |                   |
|                 | actory-installed |   |   |        |                   |
|                 | device to        |   |   |        |                   |
|                 | permanently      |   |   |        |                   |
|                 | convert an       |   |   |        |                   |
|                 | Edison lamp base |   |   |        |                   |
|                 | to a pin-base    |   |   |        |                   |
|                 | for              |   |   |        |                   |
|                 | fluorescents?    |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Product         | *For fixtures    |   |   |        | Written copy or   |
| Packaging for   | that are not     |   |   |        | PDF graphic of    |
| Consumer        | shipped with     |   |   |        | the language that |
| Awareness       | lamps:*          |   |   |        | will be displayed |
| Requirements    |                  |   |   |        | on product        |
|                 |                  |   |   |        | packaging and     |
|                 |                  |   |   |        | within the        |
|                 |                  |   |   |        | packaging, as     |
|                 |                  |   |   |        | required.         |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Does the         | N |   |        |                   |
|                 | packaging        | / |   |        |                   |
|                 | include a NEMA   | A |   |        |                   |
|                 | or ANSI generic  |   |   |        |                   |
|                 | lamp             |   |   |        |                   |
|                 | description,     |   |   |        |                   |
|                 | including a      |   |   |        |                   |
|                 | color            |   |   |        |                   |
|                 | designation?     |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Does the         | N |   |        |                   |
|                 | packaging        | / |   |        |                   |
|                 | suggest that the | A |   |        |                   |
|                 | consumer select  |   |   |        |                   |
|                 | a lamp with a    |   |   |        |                   |
|                 | rated lamp life  |   |   |        |                   |
|                 | of 10,000 hours  |   |   |        |                   |
|                 | or more?         |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | *For fixtures    |   |   |        |                   |
|                 | that are shipped |   |   |        |                   |
|                 | with lamps:*     |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Does the         | Y |   |        |                   |
|                 | packaging        | e |   |        |                   |
|                 | clearly describe | s |   |        |                   |
|                 | the target CCT   |   |   |        |                   |
|                 | designation in   |   |   |        |                   |
|                 | Kelvin?          |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | *For recessed    |   |   |        |                   |
|                 | downlight        |   |   |        |                   |
|                 | fixtures that    |   |   |        |                   |
|                 | are IC-Rated:*   |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Does the         | N |   |        |                   |
|                 | packaging        | / |   |        |                   |
|                 | clearly state    | A |   |        |                   |
|                 | this rating?     |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | *For recessed    |   |   |        |                   |
|                 | downlight        |   |   |        |                   |
|                 | fixtures that    |   |   |        |                   |
|                 | are Air-Tight    |   |   |        |                   |
|                 | (AT) rated:*     |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Does the         | N |   |        |                   |
|                 | packaging        | / |   |        |                   |
|                 | include an       | A |   |        |                   |
|                 | "air-tight" or   |   |   |        |                   |
|                 | similar          |   |   |        |                   |
|                 | designation to   |   |   |        |                   |
|                 | clearly show     |   |   |        |                   |
|                 | that the fixture |   |   |        |                   |
|                 | produces less    |   |   |        |                   |
|                 | air leakage than |   |   |        |                   |
|                 | 2.0 CFM at 75    |   |   |        |                   |
|                 | Pascals when     |   |   |        |                   |
|                 | tested in        |   |   |        |                   |
|                 | accordance with  |   |   |        |                   |
|                 | ASTM E283?       |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Is the fixture   | N |   |        |                   |
|                 | itself labeled   | / |   |        |                   |
|                 | "air tight," or  | A |   |        |                   |
|                 | similar          |   |   |        |                   |
|                 | designation?     |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Are installation | N |   |        |                   |
|                 | instructions     | / |   |        |                   |
|                 | included?        | A |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| **ADDITIONAL    |                  |   |   |        |                   |
| TEST RESULTS    |                  |   |   |        |                   |
| FOR INDOOR      |                  |   |   |        |                   |
| RECESSED        |                  |   |   |        |                   |
| DOWNLIGHT       |                  |   |   |        |                   |
| RETROFIT KITS   |                  |   |   |        |                   |
| ONLY:** When    |                  |   |   |        |                   |
| qualifying a    |                  |   |   |        |                   |
| recessed        |                  |   |   |        |                   |
| downlight       |                  |   |   |        |                   |
| retrofit kit    |                  |   |   |        |                   |
| for ENERGY      |                  |   |   |        |                   |
| STAR, the       |                  |   |   |        |                   |
| following       |                  |   |   |        |                   |
| documentation   |                  |   |   |        |                   |
| must be         |                  |   |   |        |                   |
| provided **in   |                  |   |   |        |                   |
| addition** to   |                  |   |   |        |                   |
| the information |                  |   |   |        |                   |
| required above. |                  |   |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Reflector Type  | \_\_             |   |   |        | No supplemental   |
|                 | \_\_\_\_\_\_\_\_ |   |   |        | documentation     |
|                 |                  |   |   |        | required          |
+-----------------+------------------+---+---+--------+-------------------+
| Aperture Size   | \_\_             | I |   |        | No supplemental   |
|                 | \_\_\_\_\_\_\_\_ | n |   |        | documentation     |
|                 |                  | c |   |        | required          |
|                 |                  | h |   |        |                   |
|                 |                  | e |   |        |                   |
|                 |                  | s |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Air Tight For   | Check box if     |   |   |        | Manufacturer or   |
| Restricted Air  | submitted        |   |   |        | laboratory data   |
| Movement        | fixtures meet    | - |   |        |                   |
|                 | air tight        | - |   |        |                   |
|                 | requirement:     |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  |   |   |        |                   |
|                 |                  | - |   |        |                   |
|                 |                  | - |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Electrical      | Check box if     |   |   |        | Manufacturer      |
| Connections     | submitted        |   |   |        | engineering       |
|                 | fixtures have an | - |   |        | description       |
|                 | Edison lamp      | - |   |        | and/or diagram    |
|                 | socket with wire |   |   |        | describing        |
|                 | "pigtail" to the |   |   |        | electrical        |
|                 | ballast:         |   |   |        | connection        |
|                 |                  | - |   |        |                   |
|                 |                  | - |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Safety --       | Check box if     |   |   |        | Cover page of a   |
| Fixture         | submitted        |   |   |        | safety test       |
| Conversions,    | fixtures meet    | - |   |        | report or a       |
| Retrofits       | safety           | - |   |        | general coverage  |
|                 | requirements for |   |   |        | statement         |
|                 | conversions &    |   |   |        | included          |
|                 | retrofits:       |   |   |        |                   |
|                 |                  | - |   |        |                   |
|                 |                  | - |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
| Product         | Fixture          | Y |   |        | Written copy or   |
| Packaging for   | Compatibility    | e |   |        | PDF graphic of    |
| Consumer        | List?            | s |   |        | the language that |
| Awareness       |                  | N |   |        | will be displayed |
| Requirements    |                  | / |   |        | on product        |
|                 |                  | A |   |        | packaging as well |
|                 |                  |   |   |        | as installation   |
|                 |                  |   |   |        | instructions      |
+-----------------+------------------+---+---+--------+-------------------+
|                 | ASTM E283        | Y |   |        |                   |
|                 | Compliance       | e |   |        |                   |
|                 | Language?        | s |   |        |                   |
|                 |                  | N |   |        |                   |
|                 |                  | / |   |        |                   |
|                 |                  | A |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+
|                 | Installation     | Y |   |        |                   |
|                 | Instructions?    | e |   |        |                   |
|                 |                  | s |   |        |                   |
|                 |                  | N |   |        |                   |
|                 |                  | / |   |        |                   |
|                 |                  | A |   |        |                   |
+-----------------+------------------+---+---+--------+-------------------+

+---+---+----------------------------------+---+--------------------------+---+
|   | * |                                  |   |                          |   |
|   | * |                                  |   |                          |   |
|   | S |                                  |   |                          |   |
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+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+
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| : |   |                                  |   |                          |   |
+---+---+----------------------------------+---+--------------------------+---+
| \ |   |                                  |   |                          |   |
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+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+
| 1 |   | Complete all required data       | 3 | Fill out one form for    |   |
| \ |   | fields in one RLF Supplemental   | \ | each lamp/ballast        |   |
| . |   | Information                      | . | combination              |   |
+---+---+----------------------------------+---+--------------------------+---+
|   |   | Reporting (SIR) form to be       |   | (note: multiple fixtures |   |
|   |   | associated with one Qualified    |   | can be associated with   |   |
|   |   | Product Information              |   | one platform)            |   |
+---+---+----------------------------------+---+--------------------------+---+
|   |   | Reporting Form (QPI - this       | 4 | Attach and email the     |   |
|   |   | document). Refer to SIR          | \ | compiled submittal:      |   |
|   |   | "Instructions" Section for       | . |                          |   |
+---+---+----------------------------------+---+--------------------------+---+
|   |   | further guidance                 |   | • one (1) QPI form, and  |   |
+---+---+----------------------------------+---+--------------------------+---+
| 2 |   | Fill out entire RLF QPI form     |   | • one (1) RLF SIR form   |   |
| \ |   | based on requirements for        |   |                          |   |
| . |   | submittal type ("Lamp            |   |                          |   |
+---+---+----------------------------------+---+--------------------------+---+
|   |   | &/or Ballast Platform,"          | 5 | Email to:                |   |
|   |   | "Complete Fixture," or "Both")   | \ | ESRLF_                   |   |
|   |   |                                  | . | Submit@icfconsulting.com |   |
+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+
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+---+---+----------------------------------+---+--------------------------+---+