Name(Required) First Last Account #(Required)Phone(Required)Type of Phone(Required) Cellphone Home Email(Required) Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Type(Required) Stick-built/Modular Mobile/Manufactured Occupancy Status(Required) Owner Renter/Tenant Landlord Vacation rental Equipment InformationHow many heat pumps did you install?(Required)Date of Installation(Required) MM slash DD slash YYYY New Equipment Installed(Required)Air Source/Dual Fuel Heat PumpMini-split heat pumpSingle-room mini-split heat pumpGeothermal heat pumpSpeed(Required) Single speed Dual speed Variable speed Manufacturer/BrandOutdoor Unit Model #(Required)Outdoor Unit Serial #(Required)Inside Unit Model #(Required)BTUs (1 ton = 12,000 BTUs)(Required)AHRI SEER2 Rating(Required)AHRI HSPFS2 Rating(Required)Gas Furnace AFUR(Required)Fossil Fuel Type Natural Gas Propane Does it have a desuperheater?(Required) Yes No Type of equipment being replaced(Required) Gas furnace with A/C Electric resistant/coil furnace with A/C Air source heat pump Mini-split heat pump Geothermal heat pump ETs unit baseboard heating Ceiling cable heating New construction Other Upload a copy of your installation invoice(Required)Max. file size: 500 MB. Upload a copy of your equipment's AHRI certificate(Required)Max. file size: 500 MB. Contractor InformationContractor Name(Required)Company(Required)Company Phone #(Required)Contractor Email(Required) How did you hear about the incentive?(Required) Newsletter Social media Bartholomew County REMC website WhyElectrify website Word of mouth Other Contractor Confirmation(Required) I certify that this installation was performed by the professional listed in this form.Terms and Conditions Confirmation(Required) I understand and agree to the programs rules and conditions.Eligibility Requirement: • Must be a current Bartholomew County REMC residential member-consumer. • Equipment installations or upgrades must be in a home served by Bartholomew County REMC. • Applicant must be a year-round occupant of the home where the equipment is installed. • Program eligibility includes prior participation in rebate programs, with incentive and measure caps specific for each program. Applications in excess of program caps will not be processed. HVAC Rebate Program Requirements: • The HVAC rebate is designed for installation or upgrades of air source heat pumps, geothermal heat pumps, ductless mini-split heat pumps or dual fuel heat pumps. • Rebates for HVAC equipment are for whole-home installations only unless otherwise stated. • All homeowners must provide an AHRI (Air conditioning, Heating and Refrigeration Institute) Certificate. This information is obtained from the installing heating and cooling contractor. • Submission for HVAC rebate must include application, AHRI Certificate and itemized receipt or invoice. Applicant understands no rebate will be given if applicant and/or applicant’s contractor fails to provide required documentation. • No rebate will be awarded based on HVAC dealer bid specifications, promotional materials of dealer, manufacturer or any source other than AHRI Certificate. • Limit of two rebates per household, per useful life of rebated equipment. Program Parameters: • All rebated equipment must be new. Used or rebuilt equipment is not eligible for an incentive. • Rebated equipment must meet all requirements from the manufacturer’s warranty. • Rebated equipment must meet the technical specifications listed in the application form. • Applicant agrees to purchase power from Bartholomew County REMC for a period not less than the deemed measured useful life of rebated equipment. Should the applicant receive 100% of their power from any source other than Bartholomew County REMC, including generation owned by the customer before the end of the equipment’s deemed useful life, the applicant agrees to refund the full amount of the rebate to Bartholomew County REMC. • Hoosier Energy maintains full discretion over the rebate and reserves the right to modify the program at any time. Application Procedures and Deadlines: • Applications are processed on a first-come, first-served basis while funds are available. • Submission for rebates must be within 90 days of installation in the same calendar year. • Applications become the property of Bartholomew County REMC and will not be returned. Please keep a copy for your records. Right to Confirm Installation Pre-install inspection: Bartholomew County REMC reserves the right to inspect the program participant’s premises to verify that equipment meeting program qualifications exists prior to providing an incentive. The program participant agrees to provide reasonable access to the premises for such purposes. • Post-install inspection: Bartholomew County REMC reserves the right to inspect the program participant’s premises to verify that equipment matching the information provided on the program application has been placed in service at that location. The program participant agrees to provide reasonable access to the premises for such purposes. • Post-inspection: The program participant will have 30 days from the request date to submit any additional information requested by Bartholomew County REMC. Failure to submit requested information may result in application rejection. • If any requested inspection finds the program participant or the program participant’s contractor did not comply with program rules and standards, any incentive received must be returned to Bartholomew County REMC within 60 days of notice of such inspection. • Bartholomew County REMC reserves the right to conduct an additional post-install inspection for program portfolio evaluation, measurement and verification (EM&V) purposes. Incentives received will not be affected by the results of this inspection. Incentive Payments: • Bartholomew County REMC reserves the right to approve or deny incentive. • The incentive payment cannot exceed 50% of the total equipment cost. Installation, taxes and fees cannot be included in the equipment cost. • Rebates may take up to six weeks from receipt of the application by Bartholomew County REMC to process. • Approved rebates will be returned to the applicant in the form of a bill credit or a check by mail, via the U.S. Postal Service. Application approval is not a guarantee of incentive payment. • Bartholomew County REMC reserves the right to withhold payment for products that do not meet the program requirements as determined within its sole discretion. • Bartholomew County REMC is not liable for incentives promised to members as a result of a contractor misrepresenting or not verifying the rules of the program. Only Bartholomew County REMC has the right to approve an application and the incentives. • Incentives are paid as a one-time, one-program offer and cannot be combined with incentive payments, rebates or discount programs from other utility providers. Logo Usage: • Program applicants and program participants may not use any member cooperative or Hoosier Energy logo or name without prior express written permission. Program Disclaimers: • Your electric cooperative and Hoosier Energy REC, Inc. • Does not endorse any particular contractor, manufacturer, product or system design by offering these incentives; • Will not be responsible for any tax liability imposed on any program participant as a result of the payment of incentives; • Does not expressly or impliedly warrant the performance of any purchased equipment or service and hereby disclaim any and all warranties, express or implied, including the warranties of merchantability or fitness for a particular purpose. • Is not responsible for the handling, storage, treatment, transportation or disposal of any waste generated as a result of any measures for which incentives have been applied for and/or received under this program nor any resultant environmental contamination related to the same; • Is not liable for any damage caused by the operation or malfunction of the installed equipment or service by contractor; and • Does not guarantee that a specific level of energy or cost savings will result from the implementation of energy conservation measures or the use of products funded under this program.Electronic Signature Consent(Required) I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Applicant Electronic Signature (Full Name)(Required)
