LAKE COUNTRY POWER

2009 Residential Geothermal

Ground Source Heat Pump Rebate Application

Important:
- Rebate amount is $400 per ton for qualifying GSHP's. Limit one rebate per member.
- Rebates of under $1,000 are applied to power bill.
- Rebates of $1,000 or more may be sent in check form if account is current.
- PLEASE CHECK HERE FOR YOUR REQUEST (IF $1000 OR OVER) APPLY TO POWER BILL SEND CHECK
- GSHP must be installed within Lake Country Power service territory.
- Fill out this form completely. Incomplete forms will not be processed.
- Include a copy of the original dated sales receipt.
- Include your account number and sign the form.
- Submit completed rebate form and original sales receipt within 90 days of purchase date to:

Lake Country Power OR: Lake Country Power OR: Lake Country Power
2810 Elida Drive 8535 Park Ridge Drive PO Box 98
Grand Rapids MN 55744 Mountain Iron MN 55768 Kettle River MN 55757
- For questions, call Lake Country Power at: 800-421-9959
Customer Information:
Name: Account #:
Address where GSHP is installed:
City: State: Zip: Phone Number:
Customer Type: Homeowner Landlord Builder Other
Signature: Today's date:
I certify that the GSHP for which I am claiming a rebate is a qualifying appliance, that it has been or will be installed at the address listed above and that this
address represents a valid cooperative account.
Equipment Information:
Manufacturer: Model Number:
( ) Tons Open Loop Close Loop Integrated Water Heater
Annual Energy Use (kWh/year)
1. Did this rebate influence your decision to buy this GSHP? Yes No
2. Is this a replacement appliance? Yes No

For statistical purposes only, please provide the following information. Lake Country Power will combine your Annual Household Size and Income
response with others for analysis, as required by the Minnesota Dept. of Commerce. (# of people) Annual Past 3 Mo.
1 $21,184 $5,296
1. Find your household size on the table to your right. 2 $27,702 $6,925
3 $34,220 $8,555
2. Determine your annual household income, before taxes, 4 $40,738 $10,184
including pension, social security, etc. 5 $47,256 $11,814
6 $53,774 $13,443
3. Is your household income above or below the amount 7 $54,996 $13,749
corresponding to your household size in this table? Above Below 8 $56,219 $14,054

Contractor Information:
Name: City, State:
REBATES WILL BE APPLIED AS A CREDIT TO THE POWER BILL.
Rebates are available only for the purchase of new GSHP's purchased on or after January 1, 2009. The GSHP must be installed where electricity is supplied by
Lake Country Power. Rebate submittal must follow the guidelines as listed above. Lake Country Power is not responsible for inaccurate information supplied by
appliance dealers. Call Lake Country Power to verify rebate program status.

2009 Ground Source Heat Pump Rebate Application