Name First Last Account Number Meter Address Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email Home PhoneCell PhoneContractor's Name Contractor's Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Water Heater Installation Date (MM/DD/YYYY) Month Day Year Number of Units InstalledEquipment CostExcludes labor.File(Required)Attach invoice or receiptMax. file size: 100 MB.Manufacturer: Purchased from: Unit Model Number: Unit Serial Number: SizeGallonsEfficiency Rating: Type of Home HVAC: Building Contractor: Installed by: Note: Rebate available only for Heat Pump or Hybrid Water Heaters, minimum 40 gallon. There is no incentive for electric resistance tank or tankless water heaters. Limit of 2 water heater rebates per household. The Residential Rebate Application must also be completed. Consent(Required)Submission of application expressly indicates member understanding and agreement to the following conditions: Limit of 2 rebates per household. 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.
