Customer Rebate Form

GROUND SOURCE HEAT PUMP INSTALLATION

CUSTOMER INFORMATION
Name of Customer Minnesota Power Account Number

Mailing Address City State ZIP

Installation Address City State ZIP

Phone Number Email Address

INSTALLER INFORMATION
Company Name

Address City State ZIP

Phone Number Contact Person

SYSTEM SPECIFICATIONS
Manufacturer Model Number

Number of Tons–Size Installation Date (system operational)

Manufacturer Model Number

Loop Type  Open  Closed  Forced Air  Hot Water  New Home  Retrofit Desuperheater Installed  Yes  No

CUSTOMER REBATE

 $200/ton closed loop system  $100/ton open loop system TOTAL REBATE $

CUSTOMER AGREEMENT
The information in this application is accurate and complete. My signature also indicates that I have read and understood the Rules and Requirements of the GHP rebate
program, and I acknowledge and agree that Minnesota Power is not warranting any equipment nor will it be liable for any personal injury or property damage caused by
the equipment. All of the listed equipment will be purchased, installed, and operating at the facility listed above, and I will provide dated invoices and other requested
documentation verifying purchases. I understand that Minnesota Power may inspect and verify installation of the equipment before and after any rebate payment.

Customer Signature Date

REBATE PROCESS

 Complete all appropriate information in application  Sign application  Attach Invoice  Send rebate form to:
MAIL GHP Rebate, Attn. Andrea Prunuske, 431 Charmany Dr. Madison WI 53719
EMAIL andreap@weccusa.org (include scanned copy of the invoice)
RULES AND REQUIREMENTS
Qualifications
 GHP rebate incentives are available to Minnesota Power’s residential and commercial customers.
 The heat pump must be installed in homes of Minnesota Power residential customers on or before December 31, 2009.
 The heat pump must have a minimum Coefficient of Performance (COP) of 3.3 for closed loop and 3.6 for open loop systems.
 The heat pump must be installed by a certified GHP contractor.
Disclaimer
 Minnesota Power, by providing rebate incentives, does not warrant any of the equipment installed.
 Minnesota Power is not responsible or liable for any personal injury or property damage caused by this equipment.
 Rebate incentives are subject to the availability of GHP rebate funds.
Further Information
If you have any questions about the program or need assistance with the application, contact Andrea Prunuske at 608-249-9322 x303.

Please allow 6-8 weeks to receive your check. This form may be photocopied for further use.