Rebate Request Form 2010 Dubois REC Rebate Program

Dubois REC
482-5454 Existing Home
(Including
Type of System New Mobile or
Please provide the necessary information pertaining to your particular request. Rebates cannot be (check all that apply) Specs Homes Modular) Check the conditions that apply
processed without complete information and proof of purchase (invoice or receipt.)
Electric 40, 50 or 75 gal. $50 $50 Replacing old electric water heater
Name: __________________________________________________________________ Water Heater
Replacing a gas/propane water heater
Dubios REC Account #: _____________________________________________________ Energy Factor must 80 gal. $150 $150
be .90 or higher Installing in a new home.
Address: ________________________________________________________________
Home Phone: ____________________________________________________________
Central Air 14 to 15.9 SEER $200 $200 Replacing an old air conditioner
Work Phone: _____________________________________________________________
Please indicate the type of home you have: Conditioner 16 to 16.9 SEER $250 $250 Installing in a new AC in a new home.
New Construction 17 SEER or higher $300 $300
Existing Home
Replacing an old heat pump
Mobile or Modular Home All Electric 14 to 15.9 SEER $300 $300
Installing a new one in a new home
Heat Pump 16 to 16.9 SEER $350 $350 Replacing a natural gas, propane, oil
HVAC Water Heater or wood furnace
17 SEER or higher $400 $400
Brand: ____________________________________ Brand: ________________________________
Heat Pump 14 to15.9 SEER $300 $300 Installing as a dual fuel system either
Purchased from: ____________________________ Purchased from: ________________________ replacing an existing air conditioner or
Dual Fuel 16 to 16.9 SEER $350 $350 an existing heat pump
Outdoor Unit Model #: _______________________ Unit Model #: __________________________
Application Installing as a dual fuel system in a
Outdoor Unit Serial#: ________________________ Unit Serial#:____________________________ 17 SEER or higher $400 $400
new home
Indoor Unit Model #: ________________________ Installed by: ___________________________ To replace an old air conditioner in a
Indoor Unit Serial#:__________________________ Date Installed:__________________________ All Electric 14 to 15.9 SEER NA $800 home that has:
electric furnace
Installed by: _______________________________ Size (gallons): __________________________ Heat Pump 16 to 16.9 SEER NA $900
electric ceiling cable heat
Date Installed:______________________________ 17 SEER or higher NA $1000 baseboard electric heat
Size (tons or Btus): __________________________ Type of home HVAC:_____________________ other type of wall electric heaters
(Total heating needs of the home are being
ARI SEER Rating: ____________________________ Building Contractor’s Name:
met by electric resistance heating units.)
Building Contractor’s Name: __________________ ________________________________
Geothermal $1000 $1000 Installing a new one in a new home
Back-up electric heat Kw: _____________________ Heat Pump Installing in an existing home
Primary reason for choosing electric water heater:
Primary reason for choosing electric HVAC: Lower cost to install ETS Room Unit $30/kw $30/kw Installing a new one in a new home
ETS Whole House Unit $300 $300 Replacing a gas system
Lower cost to install Safety
$350 $350
Safety Rebate or Incentive $400 $400
Rebate or Incentive Other:______________________________
To receive a rebate from Dubois REC, all homeowners must provide ARI (Air conditioning and Refrigeration
Other:__________________________________ Institute) validation for all SEER ratings that can be obtained from the installing heating and cooling dealer. No For Dubois REC
Age of replaced unit/system: Age of replaced unit/system: Use Only:
1 to 5 years 1 to 5 years complete a rebate request form and provide proof of purchase to receive any 2010 Dubois REC rebate. Deadline
to apply for 2010 Rebate Program is Dec. 31, 2010. ALL homeowners and future homeowners receiving Dubois Total Rebate Amount:
6 to 10 years 6 to 10 years REC rebates agree to the future installation of load control devices on these rebated appliances to allow Dubois
11 to 15 years 11 to 15 years REC the opportunity to engage in future demand management load control procedures.
16 or more years 16 or more years Please sign here to indicate you understand these conditions:
$ ________________
_________________________________________Date:_____________