2015 Early Ac Hp Replacement Rebate Form
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22015 EARLY AC/HP REPLACEMENT – REBATE FORM
Attention Customer
Attention Verifier
• Rebate is only valid for installations between
• For your Customer to qualify and receive this form, you
April 1, 2015 and October 30, 2015.
must verify that the existing system is functional and at
least 12 years old.
• Cannot be combined with COOL SMART® Rebates.
• Verifier issuing this form (Home Energy Specialist OR
• Municipal and National Grid electric customers
QIV Trained Contractor) must complete the Customer
are not eligible.
and Existing Equipment sections, sign and date.
PLEASE REVIEW THE COMPLETE TERMS AND CONDITIONS ON THE BACK OF THIS FORM PRIOR TO COMPLETING.
NEW EQUIPMENT REQUIREMENTS
SEER
EER
CustomerRebate
SEER
HSPF
Customer Rebate
≥ 16
≥ 13
≥ 16
≥ 8.5
Early Central AC
$750
Early Air Source Heat Pump
$750
≥ 18
≥ 13
≥ 18
≥ 9.6
Early Central AC
$1,000
Early Air Source Heat Pump
$1,000
CUSTOMER INFORMATION
(To be completed by Home Energy Specialist or QIV Trained Contractor)
Electric Account Holder Name: _______________________________________________ Electric Account #: __________________________
Cape Light Compact
Eversource
Unitil
Address: _________________________________________________ City: ___________________________ State: _______ Zip: ___________
(Where equipment is to be installed)
Phone #: ________________________________________ Email: _____________________________________________________________
Landlord/Owner Name: _______________________________________________________________________________________________
(If payee information is different from account holder information)
Address: ________________________________________________ City: ____________________________ State: _______ Zip: ___________
By signing this form, you signify that you agree to the terms and conditions outlined on the back of this form.
Customer/Owner Signature: ________________________________________________________________________ Date: _____________
EXISTING EQUIPMENT
(To be completed and signed by Home Energy Specialist or QIV Trained Contractor)
Existing Unit Tons
Manufacturer
Condenser Model #
Coil Model #
Existing Unit Age
Please select existing system verification method:
QIV Test
Nameplate
Other (specify): ________________________________
If verification is performed by Home Energy Specialist, provide Customer Site ID: ________________________________________________
Select whichever applies, sign and date below:
Age of equipment AND functionality verified by:
Home Energy Specialist
OR
QIV Trained Contractor
By signing below, verifier attests to existing equipment meeting program requirements:
Name: ____________________________________________ Signature: _________________________________ Date:_________________
CONTRACTOR INFORMATION
(To be filled out by HVAC Contractor)
Company Name: ________________________________________ Technician Name: ____________________ EPA License #: _______________
Address: ________________________________________________ City: ______________________________ State: _______ Zip: ___________
Business Phone: ___________________________ Fax: ___________________________ Email: ________________________________________
NEW EQUIPMENT
QIV Testing must be completed only if using
Install
AHRI
Customer
Ducted Equipment Type
a COOL SMART QIV Trained Contractor.
Date
Ref. #
Rebate
Customer will receive $150 QIV Test Rebate per new system
$
QIV Pre Test #:
QIV Post T est #:
Central AC
Air Source Heat Pump
$
QIV Pre Test #:
QIV Post T est #:
Central AC
Air Source Heat Pump
I certify that the described equipment has been installed in accordance with all program guidelines and applicable codes.
Contractor’s Signature: _________________________________________________________________ Date: _____________________________
FOR ADDITIONAL INFORMATION, PLEASE CALL 508-365-3260
2002-CS-ECAC-2 R4.15
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