Appendix A to Subpart F of Part 430 - Compliance Statement

COMPLIANCE STATEMENT Product: Manufacturer's or Private Labeler's Name and Address:

This compliance statement and all certification reports submitted are in accordance with 10 CFR Part 430 (Energy or Water Conservation Program for Consumer Products) and the Energy Policy and Conservation Act, as amended. The compliance statement is signed by a responsible official of the above named company. The basic model(s) listed in certification reports comply with the applicable energy conservation standard or water (in the case of faucets, showerheads, water closets, and urinals) conservation standard. All testing on which the certification reports are based was conducted in conformance with applicable test requirements prescribed in 10 CFR part 430 subpart B. All information reported in the certification report(s) is true, accurate, and complete. The company is aware of the penalties associated with violations of the Act, the regulations thereunder, and is also aware of the provisions contained in 18 U.S.C. 1001, which prohibits knowingly making false statements to the Federal Government.

Name of Company Official: Signature: Title: Firm or Organization: Address: Telephone Number: Facsimile Number: Date: Third Party Representation (if applicable)

For certification reports prepared and submitted by a third party organization under the provisions of § 430.62 of 10 CFR part 430, the company official who authorized said third party representation is:

Name: Title: Address: Telephone Number: Facsimile Number:

The third party organization submitting the certification report on behalf of the company is:

Third Party Organization: Address: Telephone Number: Facsimile Number: CERTIFICATION REPORT Date: Product Type: Product Class: Manufacturer: Private Labeler (if applicable): Name: Title: Address: Telephone Number: Facsimile Number:

For Existing, New, or Modified Models 1:

For Discontinued Models 2: