***[Tab 13:]{.underline}*** **Self-Evaluation Score Sheet**

§9006 Energy Efficiency Improvements Simple Grant Application

Name of Applicant:

Name of Project:

Type of Technology: [Energy Efficiency Improvement]{.underline}

Funding Request: [\$]{.underline}

Final Total Score -- sum of all categories below (1 through 9):

(This is your opportunity to "self-score" your proposal and to draw
attention to the particular strengths of your project that should be
taken into consideration by USDA's independent reviewers when they
complete the official score that will be used to rank your request for
funds. Be sure that your self-scoring claims are justified by
documentation that is included within your §9006 application. Your
Technical Report (tab 14) and your Energy Audit (tab 15) are the primary
supporting document for your assertions and the applicable sections
should be specifically referenced as appropriate. Additional sources may
be cited too when applicable, and if so, they should be attached or
referenced.)

**(1) Quantity of Energy Saved**

> (Award yourself 0, 5, 10, or 15 points based on your justification.)

+-------------------------------------------------------------+--------+
| \(1\) **The estimated energy expected to be saved** by the  | **Po   |
| installation of the energy efficiency improvements will be  | ints** |
| from:                                                       |        |
|                                                             |        |
| 20% up to but not including 30%, award 5 points.            |        |
+-------------------------------------------------------------+--------+
| 30% up to but not including 35%, award 10 points.           |        |
+-------------------------------------------------------------+--------+
| 35% or greater, award 15 points.                            |        |
+-------------------------------------------------------------+--------+

> [**Justification**: The energy efficiency savings expected for this
> §9006 project are expected to be]{.underline} [%. This is based
> on]{.underline} (e.g., a professional energy audit,
> professionally-developed vendor information, etc. as applicable)
> [prepared by]{.underline} [, whose credentials and expertise
> are]{.underline} [. Documentation substantiating this savings level is
> included in this application in tab 15.]{.underline}
>
> (Award yourself 0 or 5 points based on your justification.)

+-------------------------------------------------------------+--------+
| \(2\) **Additional points**                                 | **Po   |
|                                                             | ints** |
| The project has total eligible project costs of \$50,000 or |        |
| less AND opts to obtain a professional energy audit, award  |        |
| an additional 5 points.                                     |        |
+-------------------------------------------------------------+--------+

> **[Justification]{.underline}**: (Claim 5 points if your project costs
> ≤\$50,000 and you have obtained and included an energy audit at tab
> 15.)

**(2) Environmental benefits**

> (As explained below, it is always appropriate to claim 10 points in
> this category for Oregon projects.)

+-------------------------------------------------------------+--------+
| **Environmental benefits.** If the purpose of the proposed  | **Po   |
| system contributes to the environmental goals and           | ints** |
| objectives of other Federal, State, or local programs,      |        |
| award 10 points.                                            | **     |
|                                                             | [10]{. |
|                                                             | underl |
|                                                             | ine}** |
+-------------------------------------------------------------+--------+

> [**Justification**: This energy efficiency project will contribute to
> the State of Oregon's energy efficiency goals. The Oregon Department
> of Energy's "State of Oregon Energy Plan 2005-2007" sets forth the
> state's energy goals, which prominently support business energy
> efficiency improvements. This §9006 project is expressly in keeping
> with Goal #5 of "Energy's Action Plan" set forth on pages 36-37 of the
> Plan:]{.underline}
>
> ["5. **Encourage businesses to invest in cost-effective energy
> efficiency and renewable resources.** Tax credits are available to
> businesses for investments in energy efficiency and renewable
> resources to help them overcome the higher first-costs. ODOE evaluates
> the performance of the Business Energy Tax Credit program, identifies
> priority target markets and implements improvements. ODOE also will
> use the State Energy Loan Program AND WORK WITH OTHERS \[emphasis
> added\] to leverage tax credit benefits for Oregon businesses. The
> loan program is targeting at least \$5 million per year in efficiency
> investments in commercial buildings."]{.underline}
>
> [Reference:
> http://egov.oregon.gov/ENERGY/docs/EnergyPlan05.pdf]{.underline}
>
> [The support of the State of Oregon for this project is further
> demonstrated by]{.underline} (e.g., its award of Business Energy Tax
> Credit to this project, the award of a State Energy Loan Program loan
> to this project, an attached letter of support, etc. as applicable)

**(3) Commercial availability**

> (Award yourself 0, 5 or 10 points based on your justification.)

  --------------------------------------------------------------- ------------
  **Commercial availability.** If the proposed system or          **Points**
  improvement is currently commercially available and replicable, 
  award 5 points.                                                 

  If the proposed system or improvement is commercially available 
  and replicable and is also provided with a 5-year or longer     
  warranty providing the purchaser protection against system      
  degradation or breakdown or component breakdown, award 10       
  points.                                                         
  --------------------------------------------------------------- ------------

> [**Justification**: As indicated in the Project Summary (tab 11,
> section iii.2.), this §9006 project will use commercially-available
> technology. The proposed §9006 energy efficiency
> improvements]{.underline} (will/will not) [be covered by a 5-year or
> longer warranty. A copy of the warranty information, reflecting the
> term of the warranty is appended to the end of this Self-Evaluation
> Score Sheet.]{.underline}

**(4) Technical Merit**

> (Award yourself 0 to 3.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(A\) **Qualifications of the project team.** The applicant    Points
  has described the project team service providers, their        
  professional credentials, and relevant experience. The         
  description supports that the project team service, equipment, 
  and installation providers have the necessary professional     
  credentials, licenses, certifications, or relevant experience  
  to develop the proposed project. Maximum possible score 3.5    
  points.                                                        

  [**Justification:** The qualifications of the project team are 
  contained in Section "a" of the Technical Report (tab 14) and  
  the appendix to the Energy Audit (tab 15). In this regard, the 
  following strengths of the team should be noted:]{.underline}  
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(B\) **Agreements and Permits**. The applicant has described  Points
  the necessary agreements and permits required for the project  
  and the schedule for securing those agreements and permits.    
  Maximum possible score 1.75 points.                            

  [**Justification:** The agreements and permits required for    
  this project are discussed in Section "b" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 3.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(C\) **Energy or Resource Assessment.** The applicant has     Points
  described the quality and availability of a suitable renewable 
  resource or an assessment of expected energy savings for the   
  proposed system. Maximum possible score 3.5 points.            

  [**Justification:** The energy assessment for this project's   
  expected energy savings are discussed in Section "c" of the    
  Technical Report (tab 14) and the Energy Audit (tab 15). In    
  this regard, the following strengths of this project should be 
  noted:]{.underline}                                            
  -------------------------------------------------------------- --------

> (Award yourself 0 to 10.5 points based on your justification.)

  -------------------------------------------------------------- --------
  \(D\) **Design and Engineering**. The applicant has described  Points
  the design, engineering, and testing needed for the proposed   
  project. The description supports that the system will be      
  designed, engineered, and tested so as to meet its intended    
  purpose, ensure public safety, and comply with applicable      
  laws, regulations, agreements, permits, codes, and standards.  
  Maximum possible score 10.5 points.                            

  [**Justification:** The design and engineering requirements    
  for this project are discussed in Section "d" of the Technical 
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(E\) **Project Development Schedule.** The applicant has      Points
  described the development method, including the key project    
  development activities and the proposed schedule for each      
  activity. The description identifies each significant task,    
  its beginning and end, and its relationship to the time needed 
  to initiate and carry the project through to successful        
  completion. The description addresses grantee or borrower      
  project development cashflow requirements. Maximum possible    
  score 1.75 points.                                             

  [**Justification:** The project development schedule aspects   
  of this project are discussed in Section "e" of the Technical  
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 7 points based on your justification.)

  -------------------------------------------------------------- --------
  \(F\) **Project Economic Assessment.** The applicant has       Points
  described the financial performance of the proposed project,   
  including the calculation of simple payback. The description   
  addresses project costs and revenues, such as applicable       
  investment and production incentives, and other information to 
  allow the assessment of the project's cost effectiveness.      
  Maximum possible score 7.0 points.                             

  [**Justification:** An economic assessment of this project is  
  contained in Section "f" of the Technical Report (tab 14) and  
  the Energy Audit (tab 15). In this regard, the following       
  strengths of this project should be noted:]{.underline}        
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(G\) **Equipment Procurement.** The applicant has described   Points
  the availability of the equipment required by the system. The  
  description supports that the required equipment is available, 
  and can be procured and delivered within the proposed project  
  development schedule. Maximum possible score 1.75 points.      

  [**Justification:** The equipment procurement requirements of  
  this project are contained in Section "g" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(H\) **Equipment Installation.** The applicant has described  Points
  the plan for site development and system installation. Maximum 
  possible score 1.75 points.                                    

  [**Justification:** The equipment installation requirements of 
  this project are contained in Section "h" of the Technical     
  Report (tab 14). In this regard, the following strengths of    
  this project should be noted:]{.underline}                     
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(I\) **Operations and Maintenance.** The applicant has        Points
  described the operations and maintenance requirements of the   
  system necessary for the system to operate as designed over    
  the design life. Maximum possible score 1.75 points.           

  [**Justification:** The O&M requirements of this project are   
  contained in Section "i" of the Technical Report (tab 14). In  
  this regard, the following strengths of this project should be 
  noted:]{.underline}                                            
  -------------------------------------------------------------- --------

> (Award yourself 0 to 1.75 points based on your justification.)

  -------------------------------------------------------------- --------
  \(J\) **Dismantling and disposal of project components.** The  Points
  applicant has described the requirements for dismantling and   
  disposing of project components at the end of their useful     
  lives and associated wastes. Maximum possible score 1.75       
  points.                                                        

  [**Justification:** The decommissioning requirements of this   
  project are contained in Section "j" of the Technical Report   
  (tab 14). In this regard, the following strengths of this      
  project should be noted:]{.underline}                          
  -------------------------------------------------------------- --------

> (Total all of the recommended scores in "A" through "J" above.)

+--------------------------------------------------------------+--------+
| **Technical Merit Subtotal**                                 | **Po   |
|                                                              | ints** |
| **(**Maximum possible Technical Merit subtotal score 35      |        |
| points)                                                      |        |
+--------------------------------------------------------------+--------+
| [The sum of the above recommend technical merit scores       |        |
| is:]{.underline}                                             |        |
+--------------------------------------------------------------+--------+

**(5) Readiness**

> (Award yourself 0, 5, 10, or 15 points based on your justification.)

+-------------------------------------------------------------+--------+
| **Readiness** Applicant has written commitments from the    | **Po   |
| source(s) confirming commitment of:                         | ints** |
|                                                             |        |
| 50% up to, but not including, 75% of the matching funds,    |        |
| award 5 points.                                             |        |
+-------------------------------------------------------------+--------+
| 75% up to, but not including, 100% of the matching funds,   |        |
| award 10 points.                                            |        |
+-------------------------------------------------------------+--------+
| 100% of the matching funds, award 15 points.                |        |
+-------------------------------------------------------------+--------+

> [**Justification:** The funding sources for this §9006 project are set
> forth in the funding spreadsheet (tab 12). As indicated on the
> spreadsheet,]{.underline} [% of the financing sources have provided
> written commitments.]{.underline}

**(6) Small Agricultural Producer/Very Small Rural Business**

> (Award yourself 0, 5, or 10 points based on your justification.)

  -------------------------------------------------------------- ------------
  **Applicant size.** The applicant is an agricultural producer  **Points**
  producing agricultural products with a gross market value of   
  less than \$600,000 in the preceding year, award 5 points.     

  The applicant is an agricultural producer producing            
  agricultural products with a gross market value of less than   
  \$200,000 in the preceding year, award 10 points.              

  The applicant a Very Small Rural Business as defined in        
  4280.103 (a business with less than 15 employees and less than 
  \$1 million in annual receipts), award 10 points.              
  -------------------------------------------------------------- ------------

> **[Justification:]{.underline}**
>
> Pick the one that is applicable. EITHER
>
> [As indicated in the Project Summary (tab 11), **the applicant is an
> agricultural producer**. As further certified there in section (v),
> the gross market value of the agricultural products produced by the
> applicant was \$]{.underline} [.]{.underline}
>
> OR
>
> [As indicated in the Project Summary (tab 11), **the applicant is a
> small business**. As further certified there, the applicant's total
> annual gross receipts in the previous year was \$]{.underline} [and
> the applicant's number of employees is]{.underline} [.]{.underline}

**(7) Simplified application**

> (If you are using this template and your project's total cost is
> ≤\$200,000, you can claim the 5 "simplified application" points.)

+--------------------------------------------------------------+-------+
| **Simplified application.** If an applicant is eligible for  | **Poi |
| and uses the simplified application process or if the        | nts** |
| project has total eligible project costs of \$200,000 or     |       |
| less, award 5 points.                                        | **[0  |
|                                                              | ]{.un |
|                                                              | derli |
|                                                              | ne}** |
+--------------------------------------------------------------+-------+

> [**Justification:** This project does not qualify to use the
> simplified application process.]{.underline}

**(8) Previous grantees and borrowers**

> (Assuming you have not received a previous §9006 award, you can claim
> 5 points.)

+--------------------------------------------------------------+-------+
| **Previous award.** If the applicant has not been awarded a  | **Poi |
| grant or loan under this program within the 2 previous       | nts** |
| Federal fiscal years, award 5 points.                        |       |
|                                                              | >     |
|                                                              |  **[5 |
|                                                              | ]{.un |
|                                                              | derli |
|                                                              | ne}** |
+--------------------------------------------------------------+-------+

> [**Justification:** The applicant hereby affirms that the applicant
> has not been awarded a grant or loan under the §9006 program within
> the two previous federal fiscal years.]{.underline}

**(9) Return on investment**

> (Award yourself 0, 2, 4, or 10 points based on your justification.)

+--------------------------------------------------------------+-------+
| **Payback.** The proposed project will return the cost of    | **Poi |
| investment in                                                | nts** |
|                                                              |       |
| Less than 4 years, award 10 points.                          |       |
+--------------------------------------------------------------+-------+
| 4 years up to but not including 8 years, award 4 points.     |       |
+--------------------------------------------------------------+-------+
| 8 years up to 11 years, award 2 point.                       |       |
+--------------------------------------------------------------+-------+

> [**Justification:** The energy audit (tab 15), indicates a simple
> payback of the cost of the energy efficiency improvements proposed
> in]{.underline} [months.]{.underline} (It is advisable to further
> explain the basis for this calculation.)

**TOTAL SELF-EVALUATION SCORE**

> (Add up all of the priority score categories and enter the sum.)

+--------------------------------------------------------------+-------+
| **Total Score**                                              | **Poi |
|                                                              | nts** |
| **(**Maximum possible score 120 points)                      |       |
+--------------------------------------------------------------+-------+
| [The sum of the above recommended scores is:]{.underline}    |       |
+--------------------------------------------------------------+-------+