
 Instructions
 To qualify for ENERGY STAR, a home must meet the National Program Requirements and the measures listed in these checklists:

    ::	Design Requirements Checklist (either Prescriptive Path or Performance Path)
    ::	Thermal Enclosure System Checklist
    ::	HVAC System Quality Installation Checklist
    ::	HVAC System Quality Verification Checklist
    ::	Water Management System Checklist (or Indoor airPLUS Verification Checklist)1
 Checklist items flagged for field verification are verified by a Rater.2 Raters are expected to use their experience and discretion to verify that the overall intent of each inspection checklist item has been met (i.e., identifying major defects that undermine the intent of the checklist item versus identifying minor defects that the Rater may deem acceptable). The column titled "N/A," which denotes items that are "not applicable," should be used when the checklist item is not present in the home or conflicts with local requirements.

 In the event that a Rater finds an item that is inconsistent with the intent of the inspection checklists, the home cannot earn the ENERGY STAR until the item is corrected. If correction of the item is not possible, the home cannot earn the ENERGY STAR.

 The Rater is required to keep electronic or hard copies of the completed and signed checklists. The signature of the HVAC technician is required if any of the HVAC equipment specified on the HVAC System Quality Installation Checklist is installed in the home.

 To receive the home label(s) and certificate, the Rater must send this Modular Home Completion Report,
 a copy of all completed and signed Inspection Checklists and a check for $50 per home* (builder's report processing fee for home certificate and site label) to:

       Systems Building Research Alliance
       1776 Broadway, Suite 2205
       New York, NY 10019

 Please allow up to 5 days for delivery. For 2-Day delivery, enclose an additional $20 S&H fee.

 * If this is a plant certification home, the following processing fees apply (select one):

     $150 plant certification home ($100 for plant QA label + $50 builder's fee)
                                                         - OR -
     $100 "temporarily installed" plant certification home3 (for plant QA label only)

 Send labels to (check one):

     Certifier / Rater Primary Contact	Contact:  	

     Field Inspector / Tester	Company:  	

     Modular Plant	Address:  	

     Modular Builder	City:  	

     Homeowner	State:  	 Zip:  	

     Other (specify in space at right)	Phone or Email:  	



 1   A completed and signed Indoor airPLUS Verification Checklist may be completed by the Rater and submitted in lieu of the
   Water Management System checklist. For more information, see the EPA website: www.epa.gov/indoorairplus.
   2   The term "Rater" refers to the person completing the third-party inspections required for qualification. This party may be a certified Home Energy Rater, Rating Field Inspector or BOP Inspector.
 3   Temporarily installed homes must be re-inspected by a Rater when installed on the final home site and a new Completion
   Report must be submitted along with the $50 report processing fee for the home certificate and site label.



  Home Address:  	  HOME ID:  	

  City:  	  State:  	  Zip:  	

  Homeowner Name:  	  Phone:  	

  1.  CONTACT INFORMATION
    Certifier / Rater Primary Contact	Field Inspector / Tester (if different from Primary Contact)


    Company	Contact Name	Company	Contact Name

    Address	Address

City
       State
Zip

City
                                                                          State
 Zip
Phone
   Fax


Phone
                                          Fax

Plant and QC Staff



Builder


Corporate Parent (if applicable)



Company
        Contact Name

Plant Name
   QC Contact Name


Address


Plant City
       State
Zip

City
                                                                          State
 Zip
Phone
   Fax


Phone
                                          Fax

    HVAC Contractor / Technician	HVAC System Designer (if different from Cont. / Tech.)


    Company	Contact Name	Company	Contact Name

    Address	Address

    City	State	Zip	City	State	Zip

    Phone	Fax	Phone	Fax

  2.  WAS THIS HOME TESTED?	 Yes	 No  If No, skip to question 5.

  3.  HOUSE TIGHTNESS
    a) Infiltration rate ( <= 6.0 in CZs 1, 2 | <= 5.0 in CZs 3, 4 | <= 4.0 in CZs 5, 6, 7 | <= 3.0 in CZ 8).	Measured:  	ACH50 ....................

  4.  DUCT TIGHTNESS (fill in and check ONE)
    a) Duct leakage to outdoors ( <= 6 CFM25 Performance Path; <= 4 CFM25 Prescriptive Path).	Measured:  	CFM25 / 100 sq ft ...
      *Homes with < 1,200 sq ft CFA: <= 5 CFM25 / 100 sq ft
                                                        - OR -
    b) All ducts and air handling equipment are located within the home's air and thermal barriers and envelope leakage has been tested to be
      <= 3.0 ACH50 in CZs 1, 2 | <= 2.5 ACH50 in CZs 3, 4 | <= 2.0 ACH50 in CZs 5, 6, 7 | <= 1.5 ACH50 in CZ 8. .....................................................

  5.  QUALITY ASSURANCE (QA) LABEL (must check ONE to pass)
    a) An SBRA quality assurance (QA) modular home label is affixed to home interior and signed and dated by a factory representative ...........
                                                        - OR -
   b) This is one of the factory's initial three certification homes. The plant QA label will be signed and affixed with the blue ENERGY STAR(R)
      Qualified New Home site label (see instructions) ................................................................................................................................................

  6.  CERTIFIER / RATER EVALUATION (check ONE)
    a) PASSES: No discrepancies were identified......................................................................................................................................................... b) PASSES: Minor discrepancies were identified and repaired, and the home was re-inspected ........................................................................ c) FAILS: Discrepancies are described below .........................................................................................................................................................

 Signature of Certifier / Rater:  		Date:  	


 Modular Home Completion Report
 PROBLEMS / DISCREPANCIES & REMEDIATION ACTIONS	HOME ID:  	

 Item No.	Discrepancy	 	





           Remediation	 	






 Item No.	Discrepancy	 	





           Remediation	 	






 Item No.	Discrepancy	 	





           Remediation	 	






 Item No.	Discrepancy	 	





           Remediation	 	






 Item No.	Discrepancy	 	





           EPA Form 5900-189
The government estimates the average time needed to fill out this form is 0.25 hours 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.

Remediation	 	
