Fillable Rebates For Your Home - Pse printable pdf download

Rebates for your home

Thank you for your commitment to energy efficiency

Confirm you’re qualified

You have the option to:

1) Contact an Energy Advisor at 1-800-562-1482 Monday through Friday 8 a.m. to 5 p.m.

2) Review rebates qualifications by category at

3) Review qualifications on the second page of this document

Fill out your account, name, address and home information

Account # (where equipment is installed)

Name (check payable to)

Address (where equipment is installed)

City

State

Zip

Mailing Address

City

State

Zip

Email Address

Phone #

Type of Home

Site-built

Manufactured

Year Home was Built

Home is a Rental

Heating Type Prior to Rebate

Natural Gas

Electric

Oil

Propane

Heat Pump

Baseboard/Ductless HP

Forced-Air Furnace

Boiler

Heating Equipment Prior to Rebate

Select the rebate product(s) you are applying for and enter product information

Electric Home Heating

Gas Home Heating

Water Heating

Electric Forced-Air Furnace to Heat Pump Conversion ($1,500)

Furnace ($250)

Electric Storage Water Heater ($50)

Air-Source Heat Pump Tier 2 [9.0 HSPF/14 SEER] ($350)

Fireplace ($200)

Heat Pump Water Heater Tier 1 ($500)

Air-Source Heat Pump Tier 3 [10.0 HSPF/16 SEER] ($800)

Boiler ($350)

Heat Pump Water Heater Tier 2 ($800)

HSPF Heat Pump Sizing & Lockout ($300)

Integrated Space &

Heat Pump Water Heater Install Location

Water Heat ($800)

Attic

Garage

Crawl Space

Ductless Heat Pump ($1,200)

Geothermal Heat Pump ($1,500)

Other _______________________________

Fuel Conversion

Windows ($75/window up $1,000)

Conversion Type

Previous Type

Square feet of windows/patio doors being replaced

Home & Water Heat (up to $3,550)

Baseboard

Single _______________ Double _______________

Home Heat Only (up to $2,600)

Forced-air

Number of windows/patio doors replaced

Water Heat Only (up to $950)

Single _______________ Double _______________

Total number of windows/patio doors installed _________________

Product Information and AHRI Certificate (AHRI for Heat Pump Products Only)

Brand/Model(s)

AHRI Number

Attach a copy of your final installation invoice or receipt

Your installation invoice or receipt must include an installation date, brand and model number(s) of all rebated equipment.

•

For Heat Pumps: Include the heat pump, air handler and/or coil model number on the invoice

•

For Heat Pump Sizing & Lockout: Include PSE sizing document with invoice

•

For Windows: *See back page

Sign the terms and conditions

I acknowledge that the product(s) described above have been purchased and installed at the location indicated. I understand that PSE provides rebate incentives

for measures that are designed to save energy but I acknowledge that estimated energy savings are not guaranteed and I understand that PSE has made

no express warranties or representations with regard to these products or their installation. I acknowledge that I am responsible for meeting applicable code

requirements, determining the adequacy of installation, and paying all amounts owed to contractors/suppliers. Further, I understand that this is a tariffed service

and is subject to change or termination without prior notice. PSE reserves the right to inspect any installation prior to rebate approval and/or after rebate payment

and I agree to provide PSE reasonable access for such purposes. I authorize PSE to release my customer account information, including my billing and energy

usage information, to an independent, third-party evaluator solely for the purposes of evaluating this rebate program, confirming energy savings and for other

quality assurance purposes. The disclosure of your private information will comply with PSE’s privacy policy and state regulation.

Signature (typed signature is accepted)

Date

CLEAR

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