OFFICIALUSEONLY

Indicate the payment receipt number

andthecorrespondingamount.
ReceiptNo.______________________
Amount:$______________________

RequestforCertification
ElectricPowerCompanies
NewRequest

AmendedRequest

RequesttoAmend

Instructions:
Whenfillingoutthisform,examinetheprovisionsofSection3.03ofRegulationNo.8618andbesuretoprovide
alltherequiredinformation.
IndicateN/Awheretheinformationisnotapplicable.
UseComplementarySheet(CEPRZ01)ifadditionalspaceisrequired.
IncludetherequireddocumentsaccordingtotheRegulationNo.8618,enumeratedintheAnnexessection.
PresentacopyofthepaymentevidencewhensubmittingthisForm.
A. ElectricPowerCompanyGeneralInformation
1. CompanyName:
2.

GenerationofEnergy

DistributedGenerationwith
cumulativecapacitygreaterthan
one(1)MW

EnergyStorage

ElectricPowerBilling

InstallationandMaintenanceof
DGs/BillingofElectricPower
producedbyDGs

ResaleofEnergy

TypeofElectricService:

B. InformationofElectricServiceFacilities
(Completethefollowinginformationforeachfacilitywherethecompanywillprovideservices.)
1. TypeofFacility:
New
Existing

EnergySourcesusedintheFacility:

PhysicalAddressof

Facility:

PostalAddressof
Facility:

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

ExistingunderRenovation

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

Municipality:
Sector:

2. TypeofFacility:
EnergySourcesusedintheFacility:

New

Neighborhood:
Other:

Existing

ExistingunderRenovation

CEPRB04(Rev.August2015)RequestforCertificationofElectricPowerCompanies
Reference:RegulationonCertification,AnnualFees,andOperationalPlansforElectricPowerCompaniesinPuertoRico,RegulationNo.8618.

Page1of4

PhysicalAddressof
Facility:

PostalAddressof
Facility:

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

Municipality:
Sector:

3. TypeofFacility:
EnergySourcesusedintheFacility:

PhysicalAddressof

Facility:

PostalAddressof
Facility:

New

Neighborhood:
Other:

Existing

ExistingunderRenovation

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

Municipality:
Sector:

5. TypeofFacility:
EnergySourcesusedintheFacility:

PhysicalAddressof

Facility:

PostalAddressof
Facility:

ExistingunderRenovation

Municipality:
Sector:

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

Existing

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

4. TypeofFacility:
EnergySourcesusedintheFacility:

PhysicalAddressof

Facility:

PostalAddressof
Facility:

Neighborhood:
Other:

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

New

New

Neighborhood:
Other:

Existing

ExistingunderRenovation

CEPRB04(Rev.August2015)RequestforCertificationofElectricPowerCompanies
Reference:RegulationonCertification,AnnualFees,andOperationalPlansforElectricPowerCompaniesinPuertoRico,RegulationNo.8618.

Page2of4

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

Municipality:
Sector:

6. TypeofFacility:
EnergySourcesusedintheFacility:

PhysicalAddressof

Facility:

PostalAddressof
Facility:

Neighborhood:
Other:

Existing

ExistingunderRenovation

Indicateifthecompanyisthe
ownerofthefacility:
TerritorialImpact:

New

Yes
No
Specifythetitleorlegalbusinesswherebyitisinpossession:

Municipality:
Sector:

Neighborhood:
Other:

C. OperationalInformationoftheElectricPowerCompany
1. IdentifyallthepermitsrequiredbylocalorfederallawsorregulationsfortheoperationoftheElectricPowerCompany.

2. IdentifythepermitsalreadyissuedbylocalorfederalpublicentitiesfortheoperationoftheElectricPowerCompany.

Annexes:(MarkthedocumentsincludedwiththeRequestforCertificationForm)
Acertificationstatingthatthecompanyhasobtainedallnecessarypermits,fromtheappropriatepublicentities,fortheconstructionofnew
facilities(Section3.03(A)(3)).
Acertificationthatatteststhatthecompanyhasthefinancialcapacityandsolvencytofinancetheconstructionandoperationofneworunder
renovationfacilities(Section3.03(A)(3)).
Descriptionoftechnicalspecificationsofunitsandequipment,amongothers,usedfortheprovisionoftheservice(Section3.03(A)(4)).
InformationaboutagreementsorlegaltransactionswithPREPAoranyotherelectricpowercompany(Section3.03(A)(7)).
Estimatesanditemizationofthecostofinvestments,madeorpending,toprovideservicesinPuertoRico(Section3.03(A)(8)).
StatementcertifiedbyaCertifiedPublicAccountantthatatteststheprovisionsofminimumfinancialresourcesofthecompany
(Section3.03(A)(9)).
Statementaffirmingthesufficiencyofthecompanyshumanresources(Section3.03(A)(10)).
CEPRB04(Rev.August2015)RequestforCertificationofElectricPowerCompanies
Reference:RegulationonCertification,AnnualFees,andOperationalPlansforElectricPowerCompaniesinPuertoRico,RegulationNo.8618.

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ComplementarySheet(CEPRZ01).
Other:
Formcompletedby:

Name

Position

Signature

Date

OATH
I, (Name) _____________________________, (Position) ________________________ of the electric company
_________________________________, certify, under oath and subject to the penalties provided for the crime of
perjury,thattheinformationprovidedinthisformandinalltheannexesiscompleteandcertain,andthatIhavelegal
capacitytobindthecompany.
In___________________________,PuertoRico,on______of__________________of________.

AFFIDAVITNo._________________________
Sworn and subscribed before me by ____________________________________________________ identified
accordingtothemeansprovidedbylaw,specificallyby__________________________.
In___________________________,PuertoRico,on______of__________________of________.

_______________________________
Notary

OFFICIALUSEONLY

CEPRCT_____________________
Determination:Therequest,withtheannexeshasbeenevaluatedandthedeterminationis:
Approved
RequiresAmendments

Conditionedto:
Denied

Observations:

CEPRB04(Rev.August2015)RequestforCertificationofElectricPowerCompanies
Reference:RegulationonCertification,AnnualFees,andOperationalPlansforElectricPowerCompaniesinPuertoRico,RegulationNo.8618.

Page4of4

Nombre

Puesto

Firma

CEPRB04(Rev.August2015)RequestforCertificationofElectricPowerCompanies
Reference:RegulationonCertification,AnnualFees,andOperationalPlansforElectricPowerCompaniesinPuertoRico,RegulationNo.8618.

Fecha

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