$2REMC RESIDENTIAL HEAT PUMP REBATE APPLICATION ELIGIBLE CUSTOMERS South Cental Indiana REMC members are eligible for rebates when buying qualifying airsource or geothermal heat pumps REBATE DETAILS Equipment must be installed by a licensed, fulltime HVAC contractor, ‘SCI REMC issues rebates in the form of checks, not energy bill credits Rebates are valid orly for equipment installed between January 1 and December 31, 2010. Please submit one application per heat pump. ‘A copy of the sales invoice must be inchuded with the rebate application. Incomplete applications will not be processed and will be returned to the member. Please allow two to four weeks for rebate processing, Please keep a copy for your records. DISCLAIMER South Central Indiana RENC is not responsible if your HVAC contractor, builder or other party Drovides you with inaourae information about the amount or conditions ofthe actual scbate. SCL REMC will not rebate equipment that has been mislabeled or misrepresented. SCI REMC reserves the right to inspec the heat pump and its installation a the address indicated on the application form, SCI REMC is not responsible for any lst, lat, stolen, ineligible, misdirected or stage due mail. Rebate qualifications and amounts are subject to change at SCI REMC’s discretion and the program may end at any time. SEND COMPLETED APPLICATION TO: South Central Indiana REMC Heat Pump Rebate Program 300 Morton Avenue Martinsville, IN 461581 Fax: 765-382-4821 For Official Use Only Date Received ‘Account _ Approval:SQREMC RESIDENTIAL HEAT PUMP REBATE APPLICATION Tobe completed by homeowrer Dang ee Acoma ee Address where unit was installed lg sss Zap SS Dayle Phin ‘Mailing addres (if different then the installation adress): —__ City: ____State,__Zip:_ Phone: 1 installed in an existing home, vhat type of heating system did the home have previously? (check one) Jp Gas Furnace c1Eleetric Heat Pump oBlecric Furnace oil a Baseboard 0 Other (specify) ‘Age of equipment being replaced: 1-5 years 06-10years a 11-15 years a 16+ years What type of coling system willthe heat pump replace? (chee: one): ‘5 Cantal Air Conditioning © Window Ait Conditioners) Heat Pomp —oNone [Reason for replacing: © Rebate Cost oAge a Safety 0 What type of back-up (supplemental) heating system does your new heat pump use? (check one): Jawieciie Kesisance Gas None a Other (spect) certify that he heat pump listed elow was installed at headdress listed above. Lagree to allow a representative of South Central Indiana REMC to very the heat pup installation at the above addres. Signature Date [HEAT PUMP FQUIPMENT INFORMATION: Manvfactores____ Model “TirSearor Ga SSEER/HER Rating Capacity in Tons Installation Date CONTRACTOR INFORMATION VAC Contactor Name: ‘Contact Namne:__ Address cin: Zip: Phone: - certify that the equipment information is accurate, including clans of efficiency, sige and HVAC system information. I recognize that SCI REMC may verify the information that I provided Date: Contracter's Signa!