**H OME MA** **NUFA CTURER**  OMB Control No. 2060 - 0586

Company Contact Home serial number Address City State Zip Telephone 

### Instructions for manufacturer's field representative: 1. Fill in retailer and homeowner contact information. 2. Verify that all **ENERGY STAR CONSTRUCTION REQUIREMENTS**  listed below have been successfully completed. 3. Confirm that the blue EPA ENERGY STAR label and gray q uality a ssurance (QA) label are affixed to the home (near the HUD data plate or the main electrical panel). 4. Wh en all ENERGY STAR constru ction requirements have been successfully completed: • Sign and date this form. • Sign and date the QA label. • Promptly return this completed form to the manufacturer. **If there are any**

**discrepancies, contact the manufacturer immediately .**  **RETA ILER** * Com pany Contact Email address Address City State Zip Telephone **HOMEOWNER*** Name Telephone Address City State Zip County **ENERGY STA R CONSTRUCTION REQUIREMENTS**  **A. Marriage Line Seal**  The marriage line areas must be filled with a continuous non - porous insulating gasket creating a permanent air barrier at joints in the ce iling, walls and floor. Acceptable gaskets can be one or two - part systems, including proprietary gaskets, foams, insulation wrapped in poly, and insulation covered by butyl or other long - life tape on one side. In addition, there must be no visible signs of gaps or tears. **B. Tears in Bottom Board Material Repaired** All tears in the bottom board material must be covered and sealed with a durable, permanent patch to prevent air leakage. (Fo am sealant can be used on lag bolt and other small holes.) **C. Exterior ( Including Crossover) Duct Installation**  For multi - section homes, the exterior ducts must be sealed with a permanent connection per the Manufacturer's Installation Manual. Iden tify that the following items are completed:  **Al l exterior ducts have been installe**  **d and wrapped with insulation.**  **Crossover collar is secured to the trunk with at least three screws and cannot rotate or move.**  **Al l exterior duct insulation is a minimum of R**  **- _______.**   **Ny lon or metal straps and saddles are used to support the exterior duct; d**  **uct does not touch the ground.**  **Three or more screws are placed below the straps through the flexible duct and into the crossover collar.**  **Exterior d**  **uct insulation is pushed into the floor cavity and sealed with tape or foam sealant at all bottom board penet**  **rations. D. Field Installed Heat Pump**   **Heating equipment efficiency meets or exceeds the following specification: HSPF**  **-**
**___ _**  **___ .**  **E. For Homes Installed Over Basements (One of the following must be checked)**  **This home has an UNHEA TED BA** **SEMENT. A ll interior sta**  **irwells from the heated space into the basement are constructed in the same**  **manner as an exterior wall with full insulation and a weather -** **stripped, insulated exterior door.**  **This home has a HEA TED BA**  **SEMENT. The basement wall insulation level is a minimum of**  **: R -** 
**___ _**  **___ .**  

### Signature (Manufacturer's Representative) Print Name Date 

### Fax this completed form to **or mail to the home manufacturer at the address above.** Fax Number 

# Site Installation Checklist **for ENERGY STA R** **®** 

## Qualified Manufactured Homes

### * The retailer and/or homeowner may be contacted as part of the ENERGY STAR for Homes quality assurance program.

EPA Form 5900 - 172 The government estimates the average time needed to fill out this form is 15 minutes and welcomes suggestions for reducing this effort. Send comments (referencing OMB Control Number) to the Director, Collection Strategies Division, U.S. EPA (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460

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