Form Form F3(S)
Part 1: Scheme Identification & Site Information
Q1. Site Name: Site ref.*
Guidance: * Provided by CHPQA Administrator following completion and submission of Form F1
Part 1: Scheme Identification & Site Information
Q2. Company Name: Scheme ref. [Office use only]
Guidance: [Office use only]
Part 1: Scheme Identification & Site Information
Q3. Sector (e.g. Public Administration - Health, see GN 12.1):
Part 1: Scheme Identification & Site Information
Q4a. Does this site have existing CHP Scheme(s) YES  NO 
Options: YES; NO
Part 1: Scheme Identification & Site Information
Q4b. If there is an existing CHP Scheme(s) on site, has that Scheme(s) been Registered with the CHPQA programme? YES  NO 
Options: YES; NO
Part 1: Scheme Identification & Site Information
Q4c. If YES What is the Scheme reference number(s)?
Part 1: Scheme Identification & Site Information
Q5. Is this Scheme a replacement (including upgrades) of an existing Scheme Upgrade  New  or completely new?
Options: Upgrade; New
Part 1: Scheme Identification & Site Information
Q6. Provide a general description of the proposed Scheme (see GN3(S))
Part 1: Scheme Identification & Site Information
Q7. What is the state of development of the proposed Scheme? (e.g. specification/tendering/procurement/installation/commissioning)
Part 1: Scheme Identification & Site Information
Q8a. When do you expect to: State month and year for each phase: (a) start installation
Part 1: Scheme Identification & Site Information
Q8b. (b) start commissioning
Part 1: Scheme Identification & Site Information
Q8c. (c) start Initial Operation (if known, see GN10.17)
Part 1: Scheme Identification & Site Information
Q9a. Heat/Steam Demand: Annual……………………….………… kWh/year
Part 1: Scheme Identification & Site Information
Q9b. Average: ………………….………….. kW *
Guidance: * In the space below (or on a separate, numbered attachment) show the calculation of heat demands in kW from the basic data (e.g. steam flow, pressure, temperature and specific enthalpy)
Part 1: Scheme Identification & Site Information
Q10a. Electricity Demand: Annual……………………….………. kWh/year
Part 1: Scheme Identification & Site Information
Q10b. Average……………………………… kW
Part 2: Description of Scheme
Q11. Use this table to provide details of the CHP unit upon which the CHP Scheme is based. The CHPQA CHP Unit List often contains this information, see: https://www.gov.uk/guidance/chpqa-guidance-notes Applicants must attach a Scheme Energy Flow Diagram to the application (see GN3(S))
Part 2: Description of Scheme
Q12a. Manufacturer Model/ Type Engine Type Total Power Capacity - Qualifying Heat equivalent to maximum instantaneous power (kW )
Part 2: Description of Scheme
Q12b. Total Power Capacity – equivalent instantaneous heat output (kW)
Part 2: Description of Scheme
Q13. Use this table to list all proposed metering stations (including the main gas meter) for your Scheme inputs and outputs. It is essential that you provide the Meter Point Reference (MPR) Number for the main Gas Networks meter. See GN3(S) for further guidance.
Part 2: Description of Scheme
Q14a. Tag MPR Serial Year Model/ Metered Metered Outputs Number Number Number Installed Type Service Range Units Gas (Main M1(FcQ) Gas Supply)
Part 2: Description of Scheme
Q14b. M2(FcQ) N/A Gas (CHP)
Part 2: Description of Scheme
Q14c. Electricity M3(EQ) N/A (CHP)
Part 2: Description of Scheme
Q14d. M4(H) N/A Heat
Part 2: Description of Scheme
Q15. Record below the estimated CHP Total Fuel Input to the CHP Scheme for the first year of operation (the period from the start of Initial Operation to the end of the first calendar year). All fuel energy inputs should be based on gross calorific value (higher calorific value) i.e. as shown on gas bills. For guidance on different fuel types see GN 14
Part 2: Description of Scheme
Q16. Fuel Type Estimated CHP Total Fuel Input (CHP ) (MWh) TFI
Part 2: Description of Scheme
Q17. Record below the estimated CHP Total Power Output from the CHP Scheme for the first year of operation (the period from the start of Initial Operation to the end of the first calendar year). Power is gross generated i.e. measured at the generator terminals (see GN 15 for further details)
Part 2: Description of Scheme
Q18. Estimated CHP Total Power Output (CHP ) (MWh) TPO
Part 2: Description of Scheme
Q19a. For CHP Schemes with no heat rejection facility completes Section 8a only.
Part 2: Description of Scheme
Q19b. For CHP Schemes with heat rejection facility completes Section 8b only.
Part 2: Description of Scheme
Q20a. 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 used on site. No exhaust gases by-pass the heat exchanger(s) in normal operation and no heat from the CHP Scheme is rejected (dumped) on site.
Part 2: Description of Scheme
Q20b. The total heat outputs supplied to the site from the CHP Scheme should be estimated for the first year of operation (the period from Initial Operation to the end of the first calendar year) by multiplying the design heat-to-power ratio by the CHP Total Power Output. This equates to ………………. MWh (this figure is known as CHP ). QHO
Part 2: Description of Scheme
Q21a. Statement. The heat demands of the site based on design/ estimates/measurements are approximately, …………… kW applicable for …..……... h/year in the Winter (Heating Season) months
Part 2: Description of Scheme
Q21b. …………….. kW applicable for …..……... h/year in the Summer months.
Part 2: Description of Scheme
Q21c. The heat output of the CHP Scheme at full load will be …………… kW in the form of hot water …………… kW in the form of steam
Part 2: Description of Scheme
Q21d. Heat that is recovered from the CHP Scheme (down to exhaust gas discharge temperatures that are practically achievable and from engine cooling systems) will be, whenever possible, used on site.
Part 2: Description of Scheme
Q21e. When the CHP heat available exceeds the site demand: (delete as necessary) Hot exhaust gases by-pass the heat exchanger(s) Excess heat recovered from the CHP Scheme is rejected (dumped)
Part 2: Description of Scheme
Q21f. It is estimated that the maximum heat output from the CHP Scheme will be utilised on site for ……… % of the CHP operating hours.
Part 2: Description of Scheme
Q21g. It is estimated that the total heat output likely to be supplied to the site from the CHP Scheme in the first year of operation (the period from Initial Operation to the end of the first calendar year) will be …………………… MWh (this figure is known as CHP ). QHO
Part 3: Heat and Power Efficiencies
Q22a. Calculate the Heat and Power Efficiencies for the CHP Scheme, using energies declared in sections 5, 6 and 7.
Part 3: Heat and Power Efficiencies
Q22b. Power Efficiency,  = 100 x CHP / CHP POWER TPO TFI = 100 x _____________ / ________________ = ________ % *
Guidance: * 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: Heat and Power Efficiencies
Q22c. Heat Efficiency,  = 100 x CHP / CHP heat QHO TFI = 100 x ______________ / ________________ = ________ % *
Guidance: * 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: Heat and Power Efficiencies
Q23. The Threshold Power Efficiency for the Scheme is __20__ % Did the Scheme achieve the Threshold Power Efficiency? (tick box) YES  NO 
Options: YES; NO
Part 3: Heat and Power Efficiencies
Q24a. If YES then  Go To Section 11
Part 3: Heat and Power Efficiencies
Q24b. If NO then  The Scheme does not meet the Threshold Power Efficiency Criterion. The Full Form F3 must be used to complete the Self-Assessment.
Part 4: Quality Index
Q25a. For Schemes that have been certified previously and prior to 1 January 2016 on the basis of an F3 submission, the QI formulae in Table 1 of Issue 5 of the CHPQA Standard will continue to be used for certification in 2017.
Part 4: Quality Index
Q25b. 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.
Part 4: Quality Index
Q25c. Please refer to CHPQA Standard (Issue 6) if further clarification is required.
Part 4: Quality Index
Q25d. QI = ( X x  ) + ( Y x  ) = ( ____ x ____ ) + ( ____ x ____ ) power heat Quality Index = ________
Part 4: Quality Index
Q26a.  If the Quality Index is above 105 then sign the declaration.
Part 4: Quality Index
Q26b.  If the Quality Index is less than 105 then complete the Full Version of F3.
Part 5: Exports of Electricity
Q27a. Does/will your Scheme export Electricity (See GN15.10 to15.14) YES  NO 
Options: YES; NO
Part 5: Exports of Electricity
Q27b. If YES then  Complete your customers’ details in the tables below.
Part 5: Exports of Electricity
Q27c. If NO then  Go to Declaration.
Part 5: Exports of Electricity
Q28a. Providing details of electricity customers, including the amount of electricity to be supplied to these customers is necessary for Energy Efficiency Certification. See GN15.12.
Part 5: Exports of Electricity
Q28b. Organisation Name Sector (See GN12.1)
Part 5: Exports of Electricity
Q28c. Contact Name Position held:
Part 5: Exports of Electricity
Q28d. Address Town County Postcode:
Part 5: Exports of Electricity
Q28e. Telephone No. Email:
Part 5: Exports of Electricity
Q28f. Annual Electricity supplied ________________ MWh
Part 5: Exports of Electricity
Q28g. For electricity sales, is this company (tick where appropriate)  Part of the same qualifying group?   A licensed electricity supplier? 
Options: Part of the same qualifying group?; A licensed electricity supplier?
Part 5: Exports of Electricity
Q29a. Organisation Name Sector (See GN12.1)
Part 5: Exports of Electricity
Q29b. Contact Name Position held:
Part 5: Exports of Electricity
Q29c. Address Town County Postcode:
Part 5: Exports of Electricity
Q29d. Telephone No. Email:
Part 5: Exports of Electricity
Q29e. Annual Electricity supplied ________________ MWh
Part 5: Exports of Electricity
Q29f. For electricity sales, is this company (tick where appropriate)  Part of the same qualifying group?   A licensed electricity supplier? 
Options: Part of the same qualifying group?; A licensed electricity supplier?
Part 5: Exports of Electricity
Q30. What proportion of the electricity generated is likely to be exported to unknown users (via the grid) ........% of total output
Part 6: Secretary of State (CHP) Exemption Certificate Application
Q31a. 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.
Options: Please maintain the validity of the Secretary of State (CHP) Exemption Certificate for this CHP Scheme.
Part 6: Secretary of State (CHP) Exemption Certificate Application
Q31b. 2. Please send me the Secretary of State (CHP) Exemption Certificate for this CHP Scheme.
Options: Please send me the Secretary of State (CHP) Exemption Certificate for this CHP Scheme.
Part 6: Secretary of State (CHP) Exemption Certificate Application
Q31c. 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.
Options: 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.
Part 6: Secretary of State (CHP) Exemption Certificate Application
Q31d. 4. A Secretary of State (CHP) Exemption Certificate is not required
Options: A Secretary of State (CHP) Exemption Certificate is not required
Declaration
Q32. I confirm that I am the Responsible Person registered with CHPQA for the operation of the Scheme described in Part 2 of this form.
Declaration
Q33. I confirm that I have supplied all necessary information as required by the CHPQA Administrator, based on the CHP Scheme described in this form and that all information provided in this form is correct and conforms to the requirements set out in the CHPQA Standard.
Declaration
Q34. I undertake to inform the CHPQA Administrator should any of the above details change.
Declaration
Q35. I require a Certificate of Energy Efficiency* in accordance with Section 45B of the Capital Allowances Act 2001. (tick box)  * If a Certificate of Energy Efficiency is required, you must provide a list of identified potential electricity customers and complete Part 5.
Options: I require a Certificate of Energy Efficiency* in accordance with Section 45B of the Capital Allowances Act 2001.
Guidance: * If a Certificate of Energy Efficiency is required, you must provide a list of identified potential electricity customers and complete Part 5.
Declaration
Q36. Signature _____________________________ Date ___________________ Name ______________________________________ (block capitals) Position ______________________________________ (block capitals)