Form F4(S)
Part 1 Scheme Identification and Declaration
Q1. Site Name
Part 1 Scheme Identification and Declaration
Q2. Site ref.
Guidance: * The Programme Administrator will provide you with this Scheme ref. once Form F2(S) is processed.
Part 1 Scheme Identification and Declaration
Q3. Company Name
Part 1 Scheme Identification and Declaration
Q4. Scheme ref.*
Guidance: * The Programme Administrator will provide you with this Scheme ref. once Form F2(S) is processed.
Part 1 Scheme Identification and Declaration
Q5. I confirm that I am the nominated Responsible Person for the operation of the Scheme described in Form F2(S).
Part 1 Scheme Identification and Declaration
Q6. I confirm that I have supplied all necessary information, as required by the Administrator under the CHPQA programme, based on the CHP Scheme described in Form F2(S) and that all information provided in this form is correct and conforms to the requirements set out in the CHPQA Standard.
Part 1 Scheme Identification and Declaration
Q7. I undertake to inform the CHPQA programme should any of the above details change.
Part 1 Scheme Identification and Declaration
Q8. Signature _____________________________ Date ___________________
Part 1 Scheme Identification and Declaration
Q9. Name _____________________________ (block capitals)
Part 1 Scheme Identification and Declaration
Q10. Position ________________________________ (block capitals)
Part 2 Scheme Energy Inputs and Outputs
Q11. The energy inputs and outputs declared in Sections 4, 5 and 6 are based on _______ hours of operation of the CHP Scheme over a 12 month period.
Part 2 Scheme Energy Inputs and Outputs
Q12. Record below the total fuel inputs to the CHP Scheme.
Guidance: All fuel energy inputs should be based on gross calorific value (higher calorific value) i.e. as shown on gas bills.
For certain categories of Scheme the Total Fuel Input may be estimated by dividing the Total Power Output by the Power Efficiency obtained from the manufacturer. For further details of Schemes eligible to follow this process see Part 2 Section 4 of guidance note GN4(S).
Part 2 Scheme Energy Inputs and Outputs
Q13. Tag & Calc. No. M2(FcQ)
Fuel Type
Year of Self Assessment:
CHP Total Fuel Input (CHP ) (MWh)
TFI
Part 2 Scheme Energy Inputs and Outputs
Q14. Record the power generated by the CHP Scheme (power is gross generated i.e. measured at the generator terminals). See Part 2 Section 4 of guidance note GN4(S).
Each meter reading should be identified by meter tag number given on Form F2(S). See GN12.3
Part 2 Scheme Energy Inputs and Outputs
Q15. Tag or Calc. No. M3(EQ)
Year of Self Assessment:
CHP Total Power Output (CHP ) (MWh)
TPO
Part 2 Scheme Energy Inputs and Outputs
Q16. See Part 2 Section 4 of guidance note GN4(S).
 For CHP Schemes with CHP <2MW with no heat rejection facility complete Section 6a only.
TPC e
 For CHP Schemes with CHP TPC <2MW e with heat rejection facility complete Section 6b only.
Part 2 Scheme Energy Inputs and Outputs
Q17. Statement.
I declare that:
 All heat that is recovered from the CHP Scheme (down to exhaust gas discharge temperatures that are practically achievable and from engine cooling systems) is distributed to site.
 No exhaust gases by-pass the heat exchanger(s) in normal operation and no heat from the CHP Scheme is rejected (dumped to atmosphere) on site.
The total heat outputs supplied to the site from the CHP Scheme should be estimated for the 12 months Self-Assessment period by multiplying the design heat-to-power ratio from Form F2(S) by the Total Power Output. This equates to ………………. MWh* (this figure is known as CHP Qualifying Heat Output (CHP )).
QHO
* Use metered values if available.
Part 2 Scheme Energy Inputs and Outputs
Q18. For CHP <2MW with Heat Rejection Facility
 Record the useful heat generated by the CHP Scheme See Part 2 Section 4 of guidance note GN4(S).
 Each meter reading should be identified by meter tag number given on Form F2(S).
Part 2 Scheme Energy Inputs and Outputs
Q19. Tag or Calc. No. M4(EQ)
Year of Self Assessment:
CHP Total Useful Heat Output (CHP )* (MWh)
QHO
*Based on actual heat monitoring figures.
Part 3 Criteria 1: Power Efficiency
Q20. Calculate the Heat and Power Efficiency for the CHP Scheme, using energies declared in Part 2. For those Schemes eligible to estimate their Total Fuel Input in Section 4, the Power Efficiency may simply be entered in the appropriate part of the box below.
[report efficiency % to 2 decimal places]
Power Efficiency,  = 100 x CHP / CHP
power TPO TFI
= 100 x _____________ / ________________ = * ________ %
Heat Efficiency,  = 100 x CHP /CHP
heat QHO TFI
= 100 x ______________/ ________________ = ________ %
* Efficiencies are commonly quoted in terms of % figures, as calculated above, but for all of the calculations that follow, efficiencies must be expressed as decimal fractions, e.g. 40.25% = 0.4025
Part 3 Criteria 1: Power Efficiency
Q21. A Scheme must meet or exceed the relevant Threshold Power Efficiency for all fuel input to qualify as inputs to Good Quality CHP.
The Power Efficiency Threshold for your Scheme is __20__ %
Did your Scheme achieve the Power Efficiency Threshold? (tick box) YES  NO 
Options: YES; NO
Part 3 Criteria 1: Power Efficiency
Q22. If YES then  Go To Section 9
If NO then  The Scheme does not meet the Threshold Power Efficiency. To achieve certification, the Full Form F4 must be completed.
Part 4 Quality Index
Q23. For Schemes that have been certified previously and prior to 1 January 2016 on the basis of an F3 submission or prior to 1 January 2017 on the basis of an F4 submission, the QI formulae in Table 1 of Issue 5 of the CHPQA Standard will continue to be used for certification in 2017.
For those Schemes that have not previously been certified under CHPQA or were certified for the first time between 1 January and 31 December 2016 on the basis of an F3 submission, the QI formulae in Table 1 of Issue 6 of the CHPQA Standard must be used for certification in 2017.
Please refer to CHPQA Standard (Issue 6) if further clarification is required.
Part 4 Quality Index
Q24. QI = ( X x  ) + ( Y x  ) =( ____x ____ )+ ( ____ x ____ )
Quality Index = ________
[Report QI to 2 decimal places]
Part 4 Quality Index
Q25. What is the QI Threshold for your Scheme?
(either 95 for Schemes in Initial Operation or 100 for Schemes in Long Term Annual Operation)
Did your Scheme achieve the QI Threshold? (tick box) YES  NO 
Options: YES; NO
Part 6 Secretary of State (CHP) Exemption Certificate Application
Q26. This section must be completed in order to obtain your Secretary of State (CHP) Exemption Certificate.
Please choose one of the options below (tick box).
1. Please maintain the validity of the Secretary of State (CHP) Exemption Certificate for this CHP Scheme.

2. Please send me the Secretary of State (CHP) Exemption Certificate for this CHP Scheme. 

3. Please vary the Secretary of State (CHP) Exemption Certificate for this CHP Scheme.
 It was previously certified as being partly exempt and now subsequently satisfies the conditions for full exemption, or
 Its efficiency percentage now falls below or rises above the prescribed threshold efficiency percentage.

4. A Secretary of State (CHP) Exemption Certificate is not required 

Options: 1; 2; 3; 4
ADDENDUM – PERMISSION TO PROVIDE DATA FOR PUBLICATION
Q27. Are you willing for the CHPQA programme to provide the following data from the F2 or F2(s) and F1 forms to BEIS to be placed on this database and thus freely available to the public?
Please tick this box if you agree for the data to be provided to BEIS YES 
Options: YES
ADDENDUM – PERMISSION TO PROVIDE DATA FOR PUBLICATION
Q28. I confirm that I am the nominated Responsible Person for the operation of the Scheme
Signature ______________________________ Date _______________________________
ADDENDUM – PERMISSION TO PROVIDE DATA FOR PUBLICATION
Q29. Name ______________________________ (block capitals)