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REBATE APPLICATION
INSTALLATION ADDRESS
CITY
STATE
ZIP
MI
MAILING ADDRESS (If different from installation address)
MAILING CITY
MAILING STATE
MAILING ZIP
PHONE NUMBER
EMAIL ADDRESS
121015
o Yes
o No
o Contractor
FIRST NAME
LAST NAME
MAILING ADDRESS
CITY
STATE
ZIP
PART 3: SIGNATURES
This rebate application cannot be processed unless all of the appropriate
fields on this application are complete. Please be sure you have read the
Terms and Conditions of this application.
I HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS. I CERTIFY
THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT AND THE
PRODUCT(S) AND/OR EQUIPMENT FOR WHICH I AM REQUESTING A REBATE
MEETS THE REQUIREMENTS IN THIS APPLICATION.
CUSTOMER SIGNATURE
DATE
Efficiency UNITED Home Performance Rebate Application n SEMCO ENERGY Gas Company n 1 of 4
PART 4: SPACE HEATING EQUIPMENT (Must be installed by a licensed contractor unless noted. Rebate applies to each qualifying product installed.)
HIGH EFFICIENCY NATURAL GAS BOILER: Must replace natural gas heating system. Not eligible if boiler is part of a system with an Air Source Heat Pump or
Ground Source (Geothermal) Heat Pump system.
MEASURE
REBATE
90+ AFUE
$1,000
INSTALLATION DATE
/
AFUE
Please complete the information below or attach the AHRI Product Rating Certificate and provide the corresponding AHRI Certified Reference number in the above field.
MANUFACTURER
MODEL #
SERIAL #
BOILER RESET CONTROL: Must be installed on a new or existing natural gas boiler.
MEASURE
REBATE
$100
INSTALLATION DATE
/
MANUFACTURER
MODEL #
HIGH EFFICIENCY NATURAL GAS FURNACE: Must replace natural gas heating system. Not eligible if furnace is part of a system with an Air Source Heat Pump or
Ground Source (Geothermal) Heat Pump system.
MEASURE
REBATE
INSTALLATION DATE
95 AFUE
$300
96+ AFUE
$440
AFUE
Please complete the information below or attach the AHRI Product Rating Certificate and provide the corresponding AHRI Certified Reference number in the above field.
MANUFACTURER
MODEL #
SERIAL #
THERMOSTAT: Must replace non-programmable thermostat and be installed with a new or existing natural gas furnace or boiler.
MEASURE
REBATE
WI-FI THERMOSTAT
$100
$30
$15
May be self-installed
Must be installed by a contractor
May be self-installed
INSTALLATION DATE
MANUFACTURER
MODEL #
SERIES
CONTRACTOR INFORMATION: Please ask the installing contractor to complete this section.
Install your programmable thermostat yourself? Write Self-Install under company name.
COMPANY NAME
EMAIL ADDRESS
PHONE NUMBER
CONTRACTOR LICENSE #
CITY
STATE
ZIP
PART 5: WATER HEATING EQUIPMENT (These items may be installed by a licensed contractor or self-installed. Rebate applies to each qualified product installed.)
WHAT IS YOUR EXISTING WATER HEATER FUEL TYPE?
o Electric
o Natural Gas
o Other
REBATE
INSTALLATION DATE
MANUFACTURER
MODEL #
EFFICIENCY (EF)
AHRI #
(if applicable)
$100
REBATE
INSTALLATION DATE
MANUFACTURER
MODEL #
EFFICIENCY (EF)
AHRI #
(if applicable)
0.82 EF or greater
$300
CONTRACTOR INFORMATION: Please ask the installing contractor to complete this section.
Install your water heater yourself? Write Self-Install under company name.
COMPANY NAME
COMPANYS MAILING ADDRESS
EMAIL ADDRESS
PHONE NUMBER
CONTRACTOR LICENSE #
CITY
STATE
ZIP
Efficiency UNITED Home Performance Rebate Application n SEMCO ENERGY Gas Company n 2 of 4
PART 6: INFILTRATION REDUCTION (These items may be installed by a licensed contractor or self-installed. Rebate applies to each qualified product installed.)
AIR SEALING: Primary heating system must be natural gas. Requires starting and ending leakage of total conditioned space area. Calculate percent change as
(Test-in - Test-out) / (Test-in)
MEASURE
REBATE
INSTALLATION DATE
$150
PERCENT CHANGE
DUCT SEALING: Primary heating system must be natural gas. Requires starting and ending leakage of total duct system. Calculate percent change as
(Test-in - Test-out) / (Test-in)
MEASURE
REBATE
INSTALLATION DATE
$100
PERCENT CHANGE
INSULATION: Maximum of one per home of each measure. Primary heating system must be natural gas. (May claim additional attic hatch rebates per home.)
MEASURE
REBATE
INSTALLATION DATE
EXISTING R-VALUE
NEW R-VALUE
$250
square feet
$300
square feet
$20
square feet
$20
square feet
$250
square feet
$200
square feet
$100
square feet
$200
lineal feet
CONTRACTOR INFORMATION: Please ask the installing contractor to complete this section.
Installed this product yourself? Write Self-Install under company name.
COMPANY NAME
EMAIL ADDRESS
PHONE NUMBER
CONTRACTOR LICENSE #
CITY
STATE
ZIP
PART 7:
WINDOW REPLACEMENT: Primary heating system must be natural gas. Windows may be self-installed.
MEASURE
REBATE
INSTALLATION DATE
$70 each
($350 maximum)
# OF WINDOWS
SHGC OR U-FACTOR
CONTRACTOR INFORMATION: Please ask the installing contractor to complete this section.
Installed this product yourself? Write Self-Install under company name.
COMPANY NAME
EMAIL ADDRESS
PHONE NUMBER
CONTRACTOR LICENSE #
CITY
STATE
ZIP
Efficiency UNITED Home Performance Rebate Application n SEMCO ENERGY Gas Company n 3 of 4
LIMITED FUNDS: Funds for rebates are limited and available on a first-come, firstserved basis. Rebate amounts are valid while funds last. Efficiency UNITED and their
contractors reserve the right to not pay this rebate if funds are not available at the time
of application approval, or if the form and all required additional information are not
filled out completely and accurately.
ELIGIBILITY: This offer is valid for residential customers applying through the
Efficiency UNITED Home Performance Program only. Customers applying for a rebate
must receive service from SEMCO ENERGY Gas Company. This offer is not valid
for new construction homes or commercial properties. Equipment must be installed in
SEMCO ENERGY Gas Company service territory. Each customer is
eligible to receive rebates up to the stated maximums, irrespective of which Efficiency
UNITED program(s) participation occurs in. Efficiency UNITED will process
claims for rebates and/or requests for measures up to this maximum limit across all
programs. Rebate requests that exceed the per-customer annual maximum will not be
granted. The application must be received within 45 days of service or before December
31, 2016.
INFORMATION RELEASE: Customer requests and authorizes SEMCO ENERGY
Gas Company to release natural gas usage for the preceding twelve months to
Efficiency UNITED in order to participate in the program. The authorization to release
information expires automatically two (2) years after signature date. Customer agrees
that Efficiency UNITED and their contractors may include customers name, address,
utility account number, SEMCO ENERGY Gas Company services and resulting energy
savings (Information) in a database hosted by a contractor of Efficiency UNITED
and such information may be included in reports or other documentation submitted
to SEMCO ENERGY Gas Company, and their contractors and/or the Michigan
Public Service Commission (Reports). Such parties will treat such Information as
confidential and the Information in the Reports shall only be in the aggregate.
APPROVAL, VERIFICATION AND INSPECTION: Prior to any payment of rebates,
Efficiency UNITED and their contractors reserve the right to verify sales transactions.
Customers contractor will verify that the installed energy saving measures meet all
applicable building codes, zoning laws, local, state, and federal requirements, and other
relevant requirements. Contractor is responsible for any applicable permits
as required by aforementioned code/law. Outdoor temperatures may affect this
verification process. Customers home may also be selected for a quality control postinstallation inspection by Efficiency UNITED and their contractors. No warranty is
implied by this inspection.
PROOF OF PURCHASE: A contractors invoice itemizing the purchased equipment
must accompany each Efficiency UNITED Home Performance Rebate Application.
Refer to requirements outlined on page 1 of application for specific submission
guidelines.
PAYMENT: Please allow up to 6-8 weeks for payment. Payment processing may
take longer or be denied if information is missing on the application. Please visit
efficiencyunited.com if you have any questions about your rebate.
TAX LIABILITY: Efficiency UNITED and their contractors will not be responsible for
any tax liability that may be imposed on the customer as a result of the payment of
rebates. Please contact your tax advisor for more information.
FACSIMILE/SCANNED: Facsimile transmission of any signed original document, and
the retransmission of any signed facsimile transmission, shall be the same as delivery
of the original signed document. Scanned original documents transmitted to Efficiency
UNITED and their contractors as an attachment via electronic mail shall be the same
Efficiency UNITED Home Performance Rebate Application n SEMCO ENERGY Gas Company n 4 of 4