Home Performance With Energy Star Rebate Application printable pdf download

Home Performance with

Qualifications:

ENERGY STAR® Rebate

•

PSE customer living in an existing single-family property or

attached housing with four units or less, permitted and built

Puget Sound Energy offers a $400 rebate for eligible

before 1990, where primary heat source is provided by

customers who meet the qualification standard for

PSE electric or PSE natural gas service

completing the Home Performance with ENERGY STAR

•

Customer must receive a comprehensive “test-in” home

Rebate Program

performance evaluation that includes documentation of

current conditions and recommendations using an

For more information, contractor referrals or for help

independent PSE-Qualified Specialist.

completing this form, call a PSE Energy Advisor at 1-800-

562-1482, Monday through Friday, 8 a.m. to 5 p.m.

•

Customer must implement at least three PSE-rebated

energy-efficiency upgrades using a PSE-referred

Directions:

contractor where required (see page 2).

Carefully fill out this application and submit to PSE,

•

Customer must receive a follow-up “test-out” assessment

securely attaching legible copies of all required

of the qualified home performance project, i.e. blower door,

documentation. Keep copies for your records.

combustion safety, ventilation. Your contractor will provide

the necessary documents.

Send Application and Required Documents to:

•

Customer must submit rebate application, test-in

Puget Sound Energy, Energy Efficiency Rebate Program

P.O. Box 97034, EST-10W, Bellevue, WA 98009-9734

evaluation, submission of PSE rebated upgrades, and test-

out documents.

•

Applies to PSE approved test-in evaluations completed

Required Documents

Attached

after January 1, 2016.

Home Performance Evaluation Test-In Report

•

All work must be completed, including test-out evaluation,

and rebate application must be received by PSE by

PSE Weatherization Rebate Form*

December 31, 2016, to be considered for a rebate

PSE Space Heat / Water Heat Rebate Form

Rebate application must be submitted within 30 days

•

Home Performance Test-Out Reports**

of completion of test-out evaluation

*PSE Uniform Bid Form

** PSE Air Sealing Form or WA Dept. of Commerce Exhibit 5.3.1

•

Limit of one rebate per qualifying customer

•

Installations must comply with all federal, state and local

code requirements

Provide your Account, Name, Address, and Home

Information:

Terms and Conditions:

I acknowledge that the product(s) described above have been

PSE Account Number (12 DIGITS)

purchased and installed at the location indicated. I understand that PSE

provides rebate incentives for measures that are designed to save

Name of Primary Account Holder:

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

Full Service Address

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

City, State, Zip

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

Mailing Address (if different)

customer account information, including my billing and energy usage

information, to an independent, third-party evaluator solely for the

City, State, Zip

purposes of evaluating this rebate program, confirming energy savings

and for other quality assurance purposes.

Daytime Phone

Signature

E-MAIL Address

Date (MM, DD, YY)

4665 04/16

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Home Performance With Energy Star Rebate Application

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