This form must be filed with the Department of Small Business Services Energy Cost Savings Program, 110 William Street, 7th Floor, NY, NY 10038. Information from this form may be used to adjust ECSP credits, and a survey of energy use can be requested at any time by SBS to verify information. Failure to submit this form within 30 days may result in termination of benefits.

Please provide your contact information.
Company Name:*
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First Name:*	Last Name:*
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Business Address:*
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City:*	State:*	Zip Code:*
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Telephone #:* (Telephone # x Extension)	Email:*	Fax #:*
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Have there been any changes in your business activity? *		Yes   No
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Indicate current business activity: *		Select Manufacturing/Industrial Warehouse Service Retail Commerical Office Other
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Is any space used for retail activity? *		Yes   No
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If yes, what is the percentage of retail?*
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Are you a landlord or tenant?		Select Landlord Tenant
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For Property Owners/Landlords; Have there been or do you anticipate commercial tenants moving in or out of your building?*		Yes   No
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For Tenants; Have there been or do you anticipate any sub-tenants or retail activity moving in or out of your space?*		Yes   No
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If yes, please explain?*
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Does your utility bill indicate that you are still receiving ECSP benefits?*		Yes   No
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Is your business directly metered or sub-metered?*		Directly Metered Sub-metered
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Is electricity or natural gas used for space heating?*		Yes   No
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If yes, please indicate account #(s), whether electricity or gas, and percentage used for heating per account #:*
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Are you interested in additional programs and services?		Select Incentives Hiring Employees Training Recruitment Navigating Government
How many employees do you currently have?*
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Do you plan on hiring additional employees within the next 12 months?*		YesNo
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Is your Business IBZ or Empire Zone Certified?*		YesNo
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Additional Information:
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I confirm that the above information is accurate.
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