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Fuel conversion rebate application

If you currently heat your home with electricity fromPuget Sound Energy, you may be eligible for up to a$3,950 rebate to switch your home and water heatingsource to reliable and affordable natural gas.

For more information, contractor referrals or for helpcompleting this form, call a PSE Energy Advisor at1-800-562-1482, Monday through Friday, 8 a.m. to 5 p.m.

Directions:Carefully ll out this application and submit to PSE. Include a

copy of your sales receipt or invoice. Please keep copies foryour records.

Mail to: Puget Sound Energy, Fuel Conversion RebateProgram, P.O. BOX 97034, EST-10W, Bellevue, WA 98009-9734

Fax to: 425-456-2195

PSE fuel conversion rebate levels*

Type of heating Conversion rebate

Home and water $1,950 - $3,950

Home only $500 - $2,500Water only $950

* Rebate amount is dependent on current type of home and/or water heati

annual electricity usage and type of heating equipment installed. Rebate

amount is limited to 75 percent of total equipment and installation cost.

PSE equipment rebate levels**

Type of equipment Equipment rebate

Furnace $100

Storage water heater $50

Tankless water heater $150-$200

**Separate applications required for PSE equipment rebates. VisitPSE.com/ForYourHome to download. Other natural gas providers may offer

different equipment rebates.

PSE will review your rebate application and determine if your fuel conversion

project qualies for the rebate. Rebate amount is paid directly to the custom

Rebate is limited to one per customer dwelling. Please allow six to eight wee

to receive your rebate check. This is a tariffed service and is subject to chang

or termination without prior notice.

By signing below, I represent that I have read, understood and agreed to

the terms and conditions of this service and that all the information on this

form is true. I agree to random inspections for program compliance by a PSE

representative. I authorize my new natural gas provider, if other than PSE, to

conrm my customer status and release a copy of my service agreement to

for the purposes of conrming my eligibility to receive this rebate.

Further, I acknowledge that my existing primary heating system, either home

and/or water, was electric and was replaced with a natural gas system at

the location indicated. I know that PSE has made no implied or expressed

warranties or representation with regard to this conversion or energy savings

from its completion.

SIGNATURE _______________________________________________

DATE _______/_______/_______

Type of conversion:

Home and water heating Water heating onlyHome heating only

Current type of heating: Baseboard Forced air

Yes, I have also lled out PSE rebate applications for natural gasheating and/or watering heating equipment.

What other types of natural gas appliances do you planon purchasing?

Range Barbecue FireplaceClothes dryer Other_____________________________

(Please explain)

NAME OF PERSON REBATE CHECK SHOULD BE MADE PAYABLE TO

DAYTIME PHONE

FULL INSTALLATION ADDRESS

CITY STATE ZIP

MAILING ADDRESS (IF DIFFERENT)

CITY STATE ZIP

E-MAIL ADDRESS

NUMBER OF YEARS IN CURRENT HOME

Yes, sign me up for PSEs free RE-ENERGIZE Your Home e-newsletter.

Qualifcations Conversion must be completed within an existing single-fam

residence of four units or less. Manufactured and mobilehomes are not eligible. Modular homes may qualify if on apermanent foundation

Applicant must be a PSE electric customer currently usingelectricity as a primary source of home and/or water heating

Rebate is subject to the current minimum annual electric usrequirements, as determined by PSE

Applicant must install ENERGY STAR qualied natural gas

home and/or water heating equipment (replaces and boilerare not eligible)

Applicant is ineligible for home heating rebate if a hybrid systeand/or heat pump is installed in conjunction with natural gasequipment or if existing heat pump remains on the premises.

Applicant is responsible for complying with all applicable coand regulations

Rebate form must be submitted within 30 days of fuel andequipment conversion

Other requirements may apply

PSE ACCOUNT NUMBER (10 DIGITS)

REFERRAL NUMBER (7 DIGITS)

3405 06/10