NIPSCO`s Participation Request Form

NIPSCO Feed-In Tariff
Participation Request Form
Completion of this form and acceptance by NIPSCO provides Requestor the opportunity to participate in the lottery to be
conducted on ________________. If this reservation form is selected in the lottery, you will be notified and required to
submit an interconnection application and meet all Feed-In Tariff (“FIT”) participation requirements. Selected participants
will be given 12 months from date of notification to complete all FIT requirements and place Facility as defined in Rider
665 into service. This form for participation in the lottery is not transferable or assignable. Results of the lottery shall be
final and made in the sole discretion of Northern Indiana Public Service Company. For additional information on the FIT or
the lottery process, please visit www.nipsco.com/our-services/selling-your-clean-energy
Please include a non-refundable processing fee of $25 plus $1 per kW with this form (i.e. the processing fee for a
100kW project would be $125). Checks should be made payable to NIPSCO. Application shall be deemed
received once payment of the processing fee is received. Please mail checks to:
NIPSCO Major Accounts Support
Attn: FIT Lottery
801 E. 86th Ave.
Merrillville, IN 46410
Email completed form to:
MAS@nisource.com
Customer Information
Customer Name: _________________________________________________________
NIPSCO Account Number:_________________________________________________
Customer Address: _______________________________________________________
Interconnection Address:___________________________________________________
(if different from above)
Project Contact Information
Project Contact Person: ____________________________________________________
Phone No.: ________________________Email Address:__________________________
System Owner Information (if different from above)
Name:____________________________________________________________
Contact Person:____________________________________________________
Contact Address:___________________________________________________
Phone No.: ________________________Email Address:__________________________
1|Page
Request Form #_______
Project Description
Total Name Plate Generating Capacity of Facility (AC):________(3 kW up to 200 kW for Wind; 5 kW up to 200 kW for
Solar; 100 kW up to 1 MW for Biomass)
Expected annual energy output:___________________
Anticipated commencement date:_________________________________________
Facility Technology (circle one):
Solar
Wind
Biomass
Description of
project:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________
Site Control (initial one)
________
Requestor holds title to the property.
________
Requestor has a duly executed contract for purchase of the property
________
Requestor has been granted a valid written option, unconditionally exercisable by Applicant, to
purchase the property included on this application at a pre-determined price upon execution of a
renewable purchase power agreement with NIPSCO. (The option is binding on the current owner of the
site and the current owner cannot unilaterally withdraw, revoke, or rescind the obligation to sell the
property to the Requestor.)
________
Requestor has a duly executed contract for the lease of the property. (The lease unconditionally binds
the owner, subject to payment of a named rent and compliance by the Requestor with standard
commercial terms.)
_________
Requestor has been granted a valid written option, unconditionally exercisable by applicant, to lease the
property for a pre-determined rent upon executing a renewable purchase power agreement with NIPSCO,
for a duration of no less than the term of the Agreement, including rights to install, own and operate a
project on the property. (The option is binding on the current owner of the site and the current owner
cannot unilaterally withdraw, revoke, or rescind the obligation to lease the property to the Requestor.)
By signing below, you indicate that you are a NIPSCO customer and that you have authority to submit this request and
that you understand that acceptance of this request does not guarantee a reservation of FIT capacity. You declare that:
1) the information provided in the form is true and correct; 2) that you have read and understand and agree to be bound
by NIPSCO’s Feed-in Tariff guidelines; 3) this request is genuine, and not a sham or collusive, nor made in the interest or
in behalf of any person not herein named; you have not directly or indirectly induced or solicited any other person to put in
a sham application, or any other person, firm or corporation to refrain from submitting a proposals; and have not, in any
manner, sought by collusion to secure for yourself an advantage over any other Requestor. Failure to abide by these
requirements will lead to exclusion of all requests submitted by the Requestor from the lottery process.
By:____________________________
Print
Title:___________________________
2|Page
__________________________
Signature
Request Form #_______