HomeMy WebLinkAboutPCE Eligibility Certification Dtrmntn Reqst Form 2019-PCEForm Revised 6/2014
POWER COST EQUALIZATION PROGRAM
COMMUNITY FACILITY CERTIFICATION AND ELIGIBILITY
DETERMINATION REQUEST
(Please complete a separate form for each facility)
Applicant Information
Applicant (Entity Name)
Applicant Mailing Address
Community
Utility Providing Power
Utility Account Name
Utility Account No. Account Balance
Facility Information
Type of Facility
[ ] Water and Sewer Facility [ ] Charitable Educational Facility
[ ] Public Outdoor Lighting [ ] Community Building
List all functions and/or services of this facility:
Is any portion of this facility used
for commercial, for-profit
purposes?
[ ] Yes [ ] No If yes, what portion or %?
If yes, is the commercial, for-profit portion separately metered?
[ ] Yes
[ ] No
Identify the Funding Sources used
to pay the Operating Expenses of
the Community Facility
Source of Funds Percentage Description
[ ] State of Alaska ____ % _____________________________________
[ ] Federal Government ____ % _____________________________________
[ ] Private Commercial Interests ____ % _____________________________________
[ ] Local Government or
Local Community Funds ____% _____________________________________
[ ] User Fees ____ % _____________________________________
[ ] Other ____ % _____________________________________
If the State of Alaska or the Federal Government is identified as a funding source for operation expenses of this facility, please
answer questions a and b below:
a. Does the state or federal government direct the facility, or its owner or operator to spend the
state or federal government funds on the operating costs of the community facility?
[ ] Yes
[ ] No
b. Will receipt of the power cost equalization payment reduce the amount of state or federal
government funding provided to the facility or to its owner or operator?
[ ] Yes
[ ] No
Certification of Truth, Accuracy, and Completeness (To be signed by the Responsible Official designated for the facility)
I certify the information provided herein is true, accurate, and complete.
Name Date
Title Phone
Email Fax
Completed forms should be submitted to the Alaska Energy Authority, 813 West Northern Lights Blvd, Anchorage, Alaska 99503
or emailed to pce@aidea.org