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Energy-efcient heating equipmentrebate application

For Puget Sound Energy use only

COMMENTS

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

DATE: ______/______/______

APPROVED Yes No TOTAL AMOUNT REBATED: $___________

Yor home s: Owner occe A renta home

Reacn exstn ement: Yes No

Home ha an exstn heat m ror to ths rchase:

Yes No

Home ha an exstn as boer or as frnace ror to ths rchase:

Yes No

Home has a natra as meter (even f ony se for cookn):

Yes No

Tye of home: Ste-bt Manfactre

Fonaton tye: Basement Craw sace

Sab-on-rae Other

EquipMENT MANuFACTuRER

MOdEl NO. (Heat ms: rove noor nt, otoor nt an frnace - f acab

dATE iNSTAllEd puRCHASE/iNSTAllATiON COST

iNSTAlliNg CONTRACTOR

pet Son Enery offers a varety of rebates for hh-

efciency heating systems for our natural gas and electricitycstomers to he them save money an the envronment.

Available rebates and qualications are listed on theback of this form

For more nformaton, contractor referras or for he

cometn ths form, ca a pSE Enery Avsor at

1-800-562-1482, Monay throh Fray, 8 a.m. to 5 .m.

Directions:Carefully ll out this application and submit to PSE, securely

attachn ebe coes of recets or nvoces that ceary show

the ement bran name, f moe nmber(s), rchase rcean where rchase. Keep copies for your records.

Mail to: Puget Sound Energy, Energy Efciency Rebateproram, p.O. Box 97034, EST-10W, Beeve, WA 98009-9734

PSE will review your rebate application and determine if your new equipmentqualies for a rebate. Applications with missing or incomplete information wil

be processed. Please allow six to eight weeks for processing.

By signing below you acknowledge that: your qualifying natural gas equipmeis installed at a residence in PSEs natural gas service area and/or your qualif

electric equipment is installed at a residence in PSEs electric service area;PSE may inspect these products upon request; PSE has made no implied or

express warranties or representations with regard to these products or energ

savings from their installation; this is a tariffed service and is subject to chang

termination without prior notice.

I have read, understood and agreed to the terms and conditions of this

service and certify that the equipment described above has been purchas

and installed at the location indicated. I authorize PSE to release my

customer account information, including my billing and energy usage

information, to an independent, third-party evaluator solely for the purpos

of evaluating this rebate program, conrming energy savings and other

quality assurance purposes.

SIGNATURE _______________________________________________

DATE _______/_______/_______

DUCTLESS HEAT PUMPELECTRIC FORCED-AIR FURNACE TOHEAT PUMP CONVERSION

AHRI reference number Heat pump AHRI reference number

Did you receive pre-approval from PSE?

Yes (REQUIRED) No

AIR-SOURCE HEAT PUMP GEOTHERMAL HEAT PUMP

AHRI reference number

BOILER FORCED-AIR FURNACE

AFUE rating AFUE rating

Which rebate are you applying for?

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

Sq. FOOTAgE OF HOME NuMBER OF OCCupANTS YEAR BuilT

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

pSE ACCOuNT NuMBER (10 digiTS)

REFERRAl NuMBER (OpTiONAl)

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General qualications

Rebate acaton mst be sbmtte wthn 30 ays

ement nstaaton

qafyn natra as ement mst be nstae n

pSEs natra as servce area an afyn eectrc

ement mst be nstae n pSEs eectrc servce ar

Ement mst be nstae n 2010

Aes to exstn sne-famy roertes (ncnmanfactre) or nvay-metere attache hos

wth for nts or ess

Super Good Cents/ENERGY STAR qualied

manfactre homes are not ebe for heat

m rebates

One rebate er afyn cstomer. For ar-sorce

heat m an natra as boer an frnace rebat

one rebate er afyn ece of ement (not to

excee two)

Cannot be combne wth any other sace heatn

rebate excet cte, ar-sorce heat m rebates c

be combne wth pSEs ar-sorce heat m szn

ock-ot contro rebate Cstomers who receve an ENERgY STAR natra a

frnace rebate wthn the ast two years o not afy

any heat m rebate

Ement that s reace ner warranty w not be

ebe for a secon rebate

Mst nsta to comy wth a feera, state an oca

coe rerements

pSE may nsect nstaaton for comance

with qualications

Natural gas heating systems

Boiler $350 rebate Must install ENERGY STAR qualied equipment with

a 95 percent Annual Fuel Utilization Efciency (AFUE)

ratn or better

Forced-air furnace $100 rebate Must install ENERGY STAR qualied equipment with a

90 ercent AFuE ratn or better Cannot have an exstn frnace wth 90 ercent AFu

ratn or better

Cannot be nstae wth a new or exstn heat m

Electric heating systems

Ductless heat pump $800 rebate Equipment must be certied by the Air-Conditioning,

Heatn an Refreraton insttte (AHRi), se nverter

technooy an be a mnmm of 1.0 ton

Mst se eectrc resstance heat as rmary heatn

sorce whch nces eectrc zona (baseboar,

cabe, wa heater), eectrc hyronc or eectrc force-

ar frnace

Mst nsta at east one nt n the man vn area ofthe home. Ement ony nstae n a beroom s

not ebe

Cannot have an exstn heat m or natra as

servce, even f ony se for cookn

Geothermal heat pump $1,500 rebate Must install ENERGY STAR qualied equipment

Cannot have an exstn eotherma heat m nstae

Axary heatn sorces o not afy for

atona rebates

Electric forced-air furnace (FAF) to air-source heatpump conversion

$1,000 rebate pre-arova rere. Mst sbmt atona form to

pSE an receve re-arova ror to nstaaton

Mst have an exstn eectrc FAF an rae to an

AHRI performance certied heat pump with a 8.5 HSPF

an 14 SEER or hher

Cannot have an exstn heat m, ncn a ctess

heat m, or a as frnace or as boer

Eectrc zona cstomers are not ebe

Axary heatn sorces o not afy for an

atona rebate

Air-source heat pump Tier 1 - $200 rebate

- 8.5 HSpF or hher

- 14 SEER or hher

Tier 2 - $350 rebate- 9.0 HSpF or hher

- 14 SEER or hher

Heat pump system must be AHRI performance certied

Cstomers who o not afy for the ctess heat

m or eectrc FAF to heat m converson

rebates can afy for ths rebate f ement meets

efciency requirements

Axary heatn sorces o not afy for

atona rebates

4402 06/10

Converting to natural gas

When avaabe, pSE recommens sn natra as recty for

sace an water heatn. Yo may be ebe for converson

rebates. Vst pSE.com/Rebates for more nformaton.

Keep saving:

Save even more energy with these PSE energy-efciency

ncentve rorams an servces:

insaton an ct sean rebates

Heat m ar haner or frnace motor rae reba

Homeprnt home enery-se evaaton

Heat m szn an ock-ot contro rebate

High-efciency natural gas replace rebate

Contractor referrals: nd a pre-screened, independent

contractor for neary any roct reacement or hom

mrovement roject

For more information about PSE energy-efciency program

vst PSE.com/ForYourHome or ca a pSE Enery Avsor

1-800-562-1482, Monay throh Fray, 8 a.m. to 5 .m.