Early Boiler Replacement Rebate Form printable pdf download

Early BOilEr rEplaCEmEnt rEBatE FOrm

Please review the comPlete terms and conditions on the back of this form Prior to comPleting.

: ________________________

______________________

__________________________

Request #

Site Visit Date:

Energy Specialist:

Utility Account Holder Name: _________________________________________________ Account #:__________________________________

Address: __________________________________________________ City: ______________________________ State: _______ Zip: ___________

(Where equipment is to be installed)

Phone #: ____________________________________ Email: _____________________________________________________________________

Landlord/Owner Name (if Applicable): ______________________________________________________________________________________

Address: __________________________________________________ City: ______________________________ State: _______ Zip: ____________

Phone #: ____________________________________ Email: ______________________________________________________________________

Customer/Owner Signature: __________________________________________________________________ Date: _________________________

ExiSting EquipmEnt

(Note: You must have an existing Natural Gas boiler in order to qualify. Fuel switching/conversion is not eligible for this offer)

Heating Equipment

year

manufacturer

model #

Serial #

(FHW/Steam)

COntraCtOr inFOrmatiOn

(to be filled out by Licensed Contractor)

Company Name: _________________________________________________________________________________________________________

Address: __________________________________________________ City: ______________________________ State: _______ Zip: ___________

Contractor’s Name: _____________________________________________________________ License # (Required): _______________________

Business Phone: ___________________________ Fax: _______________________ Email: ______________________________________________

nEW EquipmEnt

(New equipment must meet the minimum eligibility requirements as stated on the reverse of this form.)

new Heating

Date

aFuE

installed

Equipment

manufacturer

model #

installed

rating

Cost

(FHW/Steam)

I certify that the described equipment has been installed in accordance with all program guidelines and applicable codes.

Contractor’s Signature: _________________________________________________________________ Date: _____________________________

DEaDlinE anD nExt StEpS tO partiCipatE

• Install a qualifying new boiler and submit the required documentation below by October 1, 2013

• the customer must complete and submit the following required documentation:

o Early Boiler Replacement Rebate Form — completed and signed by all parties.

o Dated contractor receipt/invoice/work order noting the completion of installation.

• Documents must be postmarked no later than October 1, 2013.

Mail completed documents to: Early Boiler Replacement, c/o Honeywell, 65 Shawmut Rd #5, Canton, MA 02021

• Please allow approximately 6-8 weeks to process qualified incentives.

FOr aDDitiOnal inFOrmatiOn, plEaSE COntaCt rEBatE VEnDOr at 800-247-4112.

Office Copy — White

Customer (mail-in) — Yellow

Customer Copy — Pink

4/13

Early Boiler Replacement Rebate Form

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