Read Heat Pump Rebate form - HENDRICKS text version

Electric to Electric

(For upgrading existing electric system with new electric system ONLY.)


Please verify that the following requirements have been met before submitting this form Rebate Requirements 1. Applicant must be a current member of an electric co-op participating in Wabash Valley Power's heat pump rebate program. 2. Qualified equipment must be installed and operable in applicant's single-family, owner-occupied residence located on co-op lines. 3. Rebates are for replacement equipment only (equipment to be installed must be new). Rebates cannot be paid for installations in new construction. 4. Member is eligible for as many rebates as qualifying electric HVAC systems located within their primary residence. For example, if a member has two electric heating systems they are eligible for two heat pump rebates. Multiple baseboard units in a home count only as one system. 5. All applicable fields must be completed on the form to receive a rebate (installation address is required). 6. A copy of the invoice(s) for the new equipment must be stapled to the back of this form. Invoice must be marked "paid" or show a zero balance. Invoice must show the manufacturer and model number of the unit(s) installed. If you are installing your own unit, you must provide a copy of the receipt for the purchase of the equipment showing the manufacturer and model number of the unit installed. If the manufacturer and model number are not located on the invoice or receipt, provide separate documentation that shows the manufacturer and model number of the unit installed. 7. A copy of the Air-Conditioning, Heating and Refrigeration Institute (AHRI) certificate and a copy of the heat loss/heat gain calucation must accompany the application. Both should be obtained from the installing contractor. 8. Equipment must be purchased on or after March 15, 2010. The rebate form and invoices must be postmarked within 30 days of the product purchase or installation. Rebate is for equipment purchase only and does not include labor costs. 9. Total heat pump or geothermal rebates are limited to a maximum of 10 tons. 10. Please allow 6 to 8 weeks to receive your rebate. Incomplete rebate forms will not be processed. Rebate may be a check or bill credit at the sole discretion of your local electric cooperative. 11. Wabash Valley Power Association and it's member electric cooperatives reserve the right to change or terminate this program at any time without notice. 12. Completed and signed rebate forms with a copy of the paid invoice for equipment and proof of installation can be mailed or dropped off at your electric cooperative. ATTN: Gregg Wright/Steven Hite, Energy Advisors Hendricks Power Cooperative P.O. Box 309 (317) 745-5473 Danville, IN 46122


First Name Mailing Address Daytime Phone Address of installation (if different from above) Name of electric cooperative City

Allow 6 to 8 weeks for the processing of this rebate application

Last Name State ZIP

E-mail (optional) City Eletric cooperative account number State ZIP

v. 8/31/10

- see page 2 -


Name of new equipment installer Name of business from which new equipment was purchased

City City

State State

ZIP ZIP Date Installed

Install date:

Installed New Equipment Air Source Heat Pump SPLIT SYSTEM

(at least 8.5 HSFP, 15 SEER & 12.5 EER)


Brand and Model Number Indoor:

Serial Number Indoor: Outdoor: Indoor: Outdoor:

$125/ton (10 ton/$1250 limit) Air Source Heat Pump PACKAGED SYSTEM

(at least 8 HSFP, 14 SEER & 12 EER)

Tons:___ $_______ Outdoor:


Efficiency Rating HSPF:_______ SEER: _______

AHRI Cert #________________ Recommended size __________ HSPF:_______ SEER: _______

Install date:

$125/ton (10 ton/$1250 limit) Ground Source Heat Pump CLOSED LOOP

(at least 3.3 COP & 14.1 EER)

Tons:___ $_______ Outdoor:

AHRI Cert #________________ Recommended size __________ COP: __________ EER: __________

Install date:

$150/ton (10 ton/$1500 limit) Ground Source Heat Pump OPEN LOOP

(at least 3.6 COP & 16.2 EER)

Tons:___ $_______

AHRI Cert #________________ Recommended size __________ COP: __________ EER: __________

Install date:

$150/ton (10 ton/$1500 limit)

Tons:___ $_______

AHRI Cert #________________ Recommended size __________ &

NOTE: Attach copy of AHRI certificate, copy of heat lost/heat gain calculation showing size recommendation copy of paid invoice to this application Age of home: Square footage of home: Number of people living in this home:

Not at all 1 2 3 Very Much 4 5

Did this rebate influence your decision to buy this new HVAC equipment? Brand and Model Number Serial Number Replaced Existing Equipment (if known) (if known) Electric furnace Electric baseboard Electric ceiling cable Electric Air Source Heat Pump Geothermal (Open Loop) Geothermal (Closed Loop)

Efficiency Rating and Size

(estimate if not known)

Year Installed

(estimate if not known)

I certify that I have purchased equipment meeting the minimum efficiency indicated on this form and that the unit was installed at my primary residence, the address indicated on this form. I agree to allow access at the address listed on this form so that equipment efficiency and installation may be verified. I have read and understand the rebate requirements, eligibility and conditions associated with this program. I understand that personal information provided will be treated as confidential to the maximum extent possible. Wabash Valley Power and its associated cooperatives are not warranting any equipment or its performance, nor will either be liable for any personal injury or property damage caused by the equipment. I certify that the information contained herein is accurate and complete.

Customer Signature

Customer Printed Name



Heat Pump Rebate form - HENDRICKS

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