Name First Last Account Number Meter Number HVAC Installation Date (MM/DD/YYYY) MM slash DD slash YYYY Installation Type: Equipment must be installed in primary residence Replacing existing A/C or Heat Pump; or New Construction Install (ASHP, MSHP, or GHP heat pump type) Replacing 100% Electric Resistance (HPRER or DMSHP heat pump type) HPRER must be primary heat source to home. Not qualified for 100% Electric Resistance Replacement: Heat pump with electric resistance, space heaters, gas furnace, wood stove, wood pellet, A/C, back-up heatReplacing or New Construction Install Existing home new Heat Pump install New construction install Replacing existing A/C Replacing existing heat pump What type of heat is being replaced?Required If you are replacing electric resistance. Add a description if "Other" is selected. Electric Coil Furnace Baseboard Ceiling Cable Other Heat Pump Type:Air Source/ Dual Fuel (ASHP) - Dual/ Variable/ Multi-speed compressor is required, Single speed compressor for mobile/manufactured homes only qualify Ductless Mini- Split Heat Pump (DMSHP) - Variable/multi-speed compressor is required for single room installation, Single room installation can include room additions or outbuildings. Must be located and serviced by member on account and must be occupied/used year-round (Seasonal occupancy does not qualify) Air Source/Dual Fuel (ASHP): $750 Geothermal Heat Pump (GHP): $1,500 Electric Resistance Replacement Air Source/Dual Fuel (HPRER) Ductless Mini-Split Heat Pump (DMSHP) Dual/Variable/Multi-Speed Compressor Single Speed Compressor Dual/Variable/Multi-Speed Compressor (GHP) Desuperheater installed? Yes No (GHP) Propane/gas back-up? Yes No Electric Resistance Replacement Air Source/Dual Fuel (HPRER) Single Speed Compressor: $800 Dual/Variable/Multi-Speed Compressor: $1,500 Electric Resistance Replacement Air Source/Dual Fuel (HPRER) Single Room Installation: $300 Dual/Variable/Multi-Speed Compressor: $1,500 Replacing existing A/C, HP or new construction - Whole-home, variable/multi-speed compressor: $750 Electric Resistance Replacement - Whole-home, variable/multi-speed compressor: $1,500 Does the heat pump have a gas furnace (Dual Fuel): Yes No Gas Furnace AFUE: Fossil Fuel Type: Quantity of Outdoor Units Installed:Quantity of Indoor Units Installed:Manufacturer Purchased from: Heat Pump Equipment Cost:Excluding labor costs.BTUs:Size:ASHRI SEER Rating: FileRequired: 1. AHRI Certificate 2. Invoice or Receipt Drop files here or Select files Max. file size: 100 MB. Outdoor Unit Model Number: Outdoor Unit Serial Number: Indoor Unit Model Number: Indoor Unit Serial Number: Installed by: Building Contractor's Name: First Last Note: HVAC contractor must indicate on the invoice, whether a single or dual/variable speed compressor was installed. The Residential Rebate Application form must also be completedConsent(Required)Submission of application expressly indicates member understanding and agreement to the following conditions: Limit of 2 rebates per household. Rebates for HVAC equipment are available for whole home installations only unless otherwise stated. To receive a rebate, all homeowners must provide AHRI (Air conditioning, Heating and Refrigeration Institute) validation for all SEER and EER ratings that can be obtained from the installing heating and cooling dealer. No rebate will be awarded based on HVAC dealer bid specifications, promotional material of dealer, manufacturer or any other source than AHRI. A certificate of AHRI-certified performance must be submitted. All homeowners must complete a rebate application form and provide proof of purchase to receive any 2023 rebate. Deadline to apply for 2023 Rebate Program is December 15, 2023. The cooperative reserves the right to approve, deny or select the appropriate rebate. The co-op also reserves the right to inspect and verify installation of equipment receiving a rebate. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required) NameThis field is for validation purposes and should be left unchanged.