HOME MANUFACTURER 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 quality assurance (QA) label are affixed to the home (near the 

HUD data plate or the main electrical panel).

4. When all ENERGY STAR construction 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.

RETAILER*

Company Contact Email address

Address City State Zip Telephone

HOMEOWNER*

Name Telephone

Address City State Zip County

ENERGY STAR 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 ceiling, 

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. (Foam 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. Identify 

that the following items are completed:

 All exterior ducts have been installed and wrapped with insulation.

 Crossover collar is secured to the trunk with at least three screws and cannot rotate or move.

 All exterior duct insulation is a minimum of R-_______.

 Nylon or metal straps and saddles are used to support the exterior duct; duct does not touch the ground.

 Three or more screws are placed below the straps through the flexible duct and into the crossover collar.

 Exterior duct insulation is pushed into the floor cavity and sealed with tape or foam sealant at all bottom board penetrations.

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 UNHEATED BASEMENT. All interior stairwells 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 HEATED BASEMENT. 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 STAR

® 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.