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Business & Personal Information

STEP 1

Business and Personal Information

Business Information

Business Address

Business Contacts

Contact Information

Primary Contact

Alternate Contact

Authorized Contact

Please upload documentation verifying that the authorized representative can legally bind the organization into the program

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Login Information

Please create a password. Make sure it meets all of the following criteria:
Must be at least 8 characters
Must contain upper and lower case characters
Must contain at least one number
Must contain at least one special character
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Verify Email and Phone

STEP 2

Verify Email and Phone

Verify Email Address

Please verify your email below. Use the 5-digit code we have sent to

Provider Type & Experience

STEP 3

Provider Type and Experience

Provider Type

Please read carefully and select the option that best fits your case.

  • Energy Assessor: EXPLANATION.
  • Aggregator: An entity that engages with multiple single-family homes and/or multifamily buildings for the purpose of combining or streamlining projects as allowed by the State.
  • Contractor: An entity hired to perform assessments and install upgrades as allowed by the State.
  • Installer: A state-approved entity that performs installation of eligible home updates.

Type of Service

Experience

Please provide a detailed description of your experience, including any specific projects, years of experience, and areas of expertise relevant to the provider type selected above (Attach additional sheets if necessary):

255 Character Max

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Business Entity

STEP 4

Business Entity Detail

Entity Type

  • Individual/Sole Proprietor or Single-Member LLC
  • C Corporation
  • S Corporation
  • Partnership
  • Non-Profit Organization

Supporting Documentation

Select an entity type first to verify the required supporting documents.

Official Form

Please fill out the form below. Some fields will be automatically filled based on the information you have provided so far. Please make sure to carefully check each field before proceeding.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, page 4.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

Social security number
- -
or
Employer identification number
-
Part II Certification

Under penalties of perjury, I certify that:

  1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
  2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
  3. I am a U.S. citizen or other U.S. person (defined below); and
  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments

Sign Here
Signature of U.S. person ▶
Date ▶
Open W9 Form
Form W-9 (Rev. 10-2018)

Certification & Licensing

STEP 5

Certification and Licensing

State License

Upload a copy of the license

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Registration with SAM (System of Award Management)

Upload proof of Active Registration

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Upload a copy of the license

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Other Certifications for the Type of Work

No additional certifications added yet

Insurance & Bond Details

STEP 6

Insurance and Bond

General Liability

Does your company provide General Liability insurance to its workers?

Yes
No

Workers Compensation

Does your company provide Workers Compensation insurance to its workers?

Yes
No

Excess Liability

Does your company provide Excess Liability insurance to its workers?

Yes
No

Auto Liability

Does your company provide Auto Liability insurance to its workers?

Yes
No

Surety Bonds

Does your company provide Surety Bonds insurance to its workers?

Yes
No

Regulatory Compliance

STEP 7

Regulatory Compliance

Compliance with State and Federal Employment Laws

Company Policies and Procedures

Does your company possess documented company policies and procedures?

Yes
No

Employee Handbook

Does your company possess an employment handbook?

Yes
No

Employee Audit Results

Does your company perform periodic employment audits?

Yes
No

DEIA Committment

Is your company a minority or women owned business enterprise?

Yes
No

Payment Information

STEP 8

Payment Information

Payment Preference

What is your preferred method for receiving support from the program?

ACH
Check

Program Terms, Conditions, and Participation Agreement

STEP 9

Program Terms, Conditions, and Participation Agreement

Applicant Signature

Program Terms and Conditions: Please read the program terms and conditions [here](link to terms and conditions). By signing this form, you agree to adhere to these terms and conditions.

Program Participation Agreement: Please read and fill out the program participation agreement template [here](link to participation agreement template).

User Payment Agreement

I certify that I am authorized to act on behalf of the vendor and complete enrollment in the Energy Savings Rebate Program, and to the best of my knowledge and belief the information supplied is true, complete, and accurate for the purposes of this Request for Payment. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims, or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729 - 3730 and 3801 - 3812). I acknowledge that payments are issued in reliance of this certification, and false statements, misrepresentations, or material omissions may be the basis for immediate termination of the enrollment, termination of the Direct Pay Agreement, and repayment of all funds received.

Please sign below

Note: Please review and ensure all required documents are attached before submitting the form.
https://hudspeth.info/portal