120 Adelaide Street West, Suite 1600
Toronto, Ontario M5H 1T1
T 416-967-7474
F 416-967-1947
www.ieso.ca
Prescribed Form – Screening and Setback Certificate
Page 1 of 2
(Section 2.4(d)(vi) of the FIT Contract)
December 2016
IESOCM-FIT-06
SUBMIT BY EMAIL (PDF WITH SIGNATURE) TO CONTRACT MANAGEMENT:
[email protected]
Capitalized terms not defined herein have the meaning ascribed thereto in the FIT Contract, and for the purposes of
FIT Contract versions 3.1 and 4.0.2, “IESO” refers to the Sponsor.
Date
<insert date>
Legal Name of Supplier
<insert legal name of Supplier>
FIT Contract Identification #
<insert FIT Contract ID #>
Contract Date
<insert Contract Date>
FIT Contract Version
Version 2.1.1
Version 3.0.1
Contract Capacity
<insert Contract Capacity>
Milestone Date for Commercial
Operation
<insert MCOD>
Version 3.1
Version 4.0.2
Municipal Address of Site
Property Identification Number(s)
(“PIN(s)”)
Legal Description of Site
(where there is no PIN(s))
The Supplier is submitting the attached Screening and Setback Certificate to satisfy the requirements of Section 2.4(d)(vi) of the FIT Contract.
The Supplier represents and warrants that all of the information in this Prescribed Form – Screening and Setback Certificate is complete, true
and accurate and that there is no material information omitted from this Prescribed Form – Screening and Setback Certificate that makes the
information contained herein misleading or inaccurate.
The Supplier acknowledges and agrees that this Prescribed Form – Screening and Setback Certificate is being delivered to the IESO solely for
the purposes of the FIT Contract. It does not constitute a notice for any other purpose, including, without limitation, to meet an obligation to
provide notice to the System Operator pursuant to the IESO Market Rules.
Supplier: <insert legal name of Supplier>
Signature:
Name:
Title:
I have the authority to bind the Supplier.
Dated this
day of
, 20
PRESCRIBED FORM – SCREENING AND SETBACK CERTIFICATE
120 Adelaide Street West, Suite 1600
Toronto, Ontario M5H 1T1
T 416-967-7474
F 416-967-1947
www.ieso.ca
Prescribed Form – Screening and Setback Certificate
Page 2 of 2
(Section 2.4(d)(vi) of the FIT Contract)
SOLEMN DECLARATION AND ATTESTATION
PROVINCE OF ONTARIO
December 2016
IESOCM-FIT-06
IN THE MATTER OF <insert FIT Contract Identification #>
(the “FIT Contract”)
Capitalized terms not defined herein have the meaning ascribed thereto in the FIT Contract, and for the purposes of FIT Contract version 3.1
and 4.0.2, “IESO” refers to the Sponsor.
This acknowledgement is provided to the IESO in connection with the FIT Contract, designated as FIT Contract Identification #<insert FIT
Contract Identification #>, where the Site is located, in whole or in part, on one or more Properties that are Rural-Residential Lands.
I, <insert name of declarant>, of the <insert City/Town/Region etc.> of <insert name of City/Town/Region etc.>, in <insert name of Province
or State> DO SOLEMNLY DECLARE, on behalf of the Supplier, without personal liability, that:
1.
The full legal name of the Supplier is <insert legal name of Supplier>.
2.
I am the/an <insert title of declarant, e.g. president, officer, director, etc.> of the Supplier and have knowledge of the matters
described herein.
3.
The Supplier and the IESO are parties to a Feed-In Tariff Contract dated as of <insert Contract Date> and designated FIT Contract
Identification #<insert FIT Contract Identification #> (as amended, supplemented, restated or replaced from time to time in
accordance with its terms and conditions) in respect of a Non-Rooftop Solar Facility
4.
The Property(ies) on which the Site of the Facility is located (check all that apply):
Abuts a Residential Cluster;
Abuts a Residential Property;
Abuts a Right of Way.
5.
I hereby confirm that the Supplier has complied and will comply with the Visual Screening Requirements and the Setback
Requirements.
AND I MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true, and knowing that it is of the same force and effect as if
made under oath and by virtue of the Canada Evidence Act.
Name of Declarant
<insert name of declarant>
Declared before me at <insert City, Town, Region, etc.> of <insert
name of City, Town, Region, etc.> in the Province of <insert name of
Province> this day of
, 20
Signature of Declarant
Name of Commissioner of Oaths, etc.
<insert name of Commissioner of Oaths, etc.>
Signature of Commissioner of Oaths, etc.
Note: Statutory declarations must be solemnly declared and signed
before commissioners of oaths or similar officials (e.g. notary public).
PRESCRIBED FORM – SCREENING AND SETBACK CERTIFICATE