City of Ukiah Solar Energy System Incentive Program Application Form

Pursuant to California Senate Bill 1

Please print clearly and complete the information below.

This application must be completed and submitted to the City of Ukiah in order to reserve an incentive for installation of a solar
photovoltaic system under the City of Ukiah Solar Energy System Incentive Program. A copy of your Solar Energy System
Proposal or contractor bid must accompany this application.
See City of Ukiah Solar Energy System Incentive Program Requirements Pursuant to California Senate Bill 1 for further details.
PURCHASER FEDERAL TAX ID NUMBER GENERATING SYSTEM

INSTALLATION ADDRESS PHOTOVOLTAIC MODULE MANUFACTURER

TELEPHONE NUMBER MODULE MODEL NUMBER

UKIAH ELECTRIC ACCOUNT NUMBER CEC MODULE POWER RATING

WATTS DC
RETAILER BUSINESS RESALE NUMBER TOTAL ARRAY OUTPUT (NO. OF MODULES X CEC MODULE POWER RATING)

WATTS DC
ADDRESS INVERTER MANUFACTURER

TELEPHONE NUMBER FAX NUMBER INVERTER MODEL NUMBER

CONTRACTOR CLASS & LICENSE NUMBER CEC INVERTER EFFICIENCY

%
INSTALLER (IF DIFFERENT FROM RETAILER) SYSTEM RATED OUTPUT (TOTAL ARRAY OUTPUT X CEC INVERTER EFF.)

WATTS AC
ADDRESS SYSTEM COST (COST OF SYSTEM BEFORE INCENTIVE)

$
TELEPHONE NUMBER FAX NUMBER REBATE ($ varies / WATTAC) X CEC SYSTEM RATED OUTPUT IN WATTSAC)
(Note: Not to excede rebate cap.)
$
CONTRACTOR CLASS & LICENSE NUMBER
PLEASE INDICATE WHO WILL
RECEIVE THE REBATE
PURCHASER RETAILER *

* I understand this rebate/payment to my retailer or contractor will be reported under

my Tax Identification Number on IRS Form 1099.
Terms and Conditions:
Each of the Undersigned declares under penalty of perjury that:
1) the purchaser has read and understood the program requirements set forth in this application with attachments and has agreed to abide by those requirements;
2) the information provided in this form is true and correct to the best of his or her knowledge;
3) the above described generating system is intended primarily to offset part or all of the purchaser's electrical needs at the site of installation;
4) the site of installation is located within the service territory of the City of Ukiah Electric Utility;
5) the purchaser understands this program may be discontinued at any time by the City of Ukiah, funds are limited and available on a first-come, first-served basis;
6) the purchaser understands that program funds are not guaranteed until the Project Approval Letter authorized by the City of Ukiah
is received by the purchaser;
7) the purchaser understands that they have one (1) year from the receipt of their Project Approval Letter to complete the project, or funds will be made
made available to other customers.
8) the purchaser agrees to hold the City of Ukiah harmless, that the selection, purchase, and ownership of the Equipment is his or her sole
responsibility. The City of Ukiah makes no representation as to the safety, reliability, and/or efficiency of the equipment selected or components
thereof. The City of Ukiah makes no warrantee, whether expressed or implied, including warrantee of merchantability or fitness for any particular
purpose, use or application of the equipment.

Important Tax Liability Information:

You are urged to consult your tax advisor concerning the taxability of rebates. The City of Ukiah is not responsible
for any taxes that may be imposed as a result of your receipt of this rebate/payment (directly or indirectly). Rebates
in excess of $600.00 may be reported on IRS Form 1099. A completed Form W-9 (Request for Taxpayer ID Number
and Certification) must accompany this application to help determine if Form 1099 will be issued by the City of Ukiah.

For Utility Use Only

PURCHASER SIGNATURE DATE DATE RECEIVED

REBATE AUTHORIZED SIGNATURE

PURCHASER SIGNATURE DATE

REBATE APPROVED REBATE DENIED

RETURN APPLICATION TO: City of Ukiah

DATE APPROVED/DENIED
Attn: Efficiency Services
PO Box 421
REBATE AMOUNT
Clackamas, OR 97015

WARRANTY, PD RECEIPT, INS DOCUMENTS RECEIVED

For questions regarding the City of Ukiah
Solar Energy System Incentive Program, contact YES NO
W-9 FORM RECEIVED (for non-dwelling units only)
Efficiency Services Group at 1-888-883-9879.
4/7/2008 YES NO