Rebate Request Form 2009 Daviess-Martin County REMC Incentive Program

Daviess-Martin County REMC

812- 295-4200 or 1-800-762-7362 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
Daviess-Martin County REMC 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:
Installed by: _______________________________ Size (gallons): __________________________ Heat Pump 16 to 16.9 SEER NA $900 electric furnace
Date Installed:______________________________ Efficiency Rating: _______________________ electric ceiling cable heat
17 SEER or higher NA $1000
baseboard electric heat
Size (tons or Btus): __________________________ Type of home HVAC:_____________________
other type of wall electric heaters
ARI SEER Rating: ____________________________ Building Contractor’s Name: (Total heating needs of the home are being
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 eason for choosing electric water heater:
ETS Room Unit $30/kw $30/kw
Primary reason for choosing electric HVAC: Lower cost to install Installing a new one in a new home
ETS Whole House Unit $300 $300
Lower cost to install Safety $350 $350 Replacing a gas system
Safety Rebate or Incentive $400 $400
Rebate or Incentive Other:______________________________ To receive a rebate from Daviess-Martin County REMC, all homeowners must provide ARI (Air conditioning and
Refrigeration Institute) validation for all SEER ratings that can be obtained from the installing heating and cooling
Other:__________________________________ dealer. No rebate will be awarded based on HVAC dealer bid specifications, promotional material of dealer, For Daviess-Martin
manufacturer or any other source than ARI. A certificate of ARI-certified performance must be submitted. ALL
Age of replaced unit/system: Age of replaced unit/system: homeowners must complete a rebate request form and provide proof of purchase to receive any 2009 Daviess-Martin County REMC
1 to 5 years 1 to 5 years County REMC rebate. Deadline to apply for 2009 Rebate Program is Dec. 31, 2009. ALL homeowners and future Use Only:
homeowners receiving Daviess-Martin County REMC rebates agree to the future installation of load control devices on
6 to 10 years 6 to 10 years these rebated appliances to allow Daviess-Martin County REMC the opportunity to engage in future demand Total Rebate Amount:
11 to 15 years 11 to 15 years management load control procedures.
16 or more years 16 or more years Please sign here to indicate you understand these conditions:
$ _________________
_________________________________________Date:_____________