UNs gas, inc.

Efficient Home Heating Program

Rebate Application Form
Instructions for Completing Form:
1. Complete all sections of Rebate Application Form
2. Both the customer and contractor sign the Rebate Application Form
3. Contractor submits Rebate Application Form and copy of paid invoice to: UniSource Residential Energy Solutions – Rebate Processing Center Efficient Home Heating
2001 N. 3rd Street, Suite 106
Phoenix, AZ 85004

Customer Information

Customer Name: UNSG Account Number at Installation Address:

Installation Address:

City: State: Zip: Installation Date:

Mailing Address (if different):

City: State: Zip:

Daytime Phone: Alternate Phone:

Equipment Information - Unit #1

New Equipment: Old Equipment:

Manufacturer: Estimated Age of unit:

Model # ID# Rated BTUh Capacity:

Rated AFUE (90 minimum): Calculated Rebate Amount (see rebate schedule on reverse side):

Rated BTUh Capacity: Unit #1: $

Equipment Information - Unit #2

New Equipment: Old Equipment:

Manufacturer: Estimated Age of unit:

Model # ID# Rated BTUh Capacity:

Rated AFUE (90 minimum): Calculated Rebate Amount (see rebate schedule on reverse side):

Rated BTUh Capacity: Unit #2: $

I certify that I purchased the high-efficiency equipment described above, and on the enclosed invoice, and that it was installed at the location indicated.
I agree to the Terms and Conditions on this rebate application form, as they apply (see reverse side)

UNSG Customer Signature Date

I certify that the high-efficiency equipment described above, and on the enclosed invoice, was installed at the location indicated.
I agree to the Terms and Conditions on this rebate application form, as they apply (see reverse side)

HVAC Contractor Signature Date

Contractor ID#:

Paid for by UniSource Energy Services gas customers and approved by the Arizona Corporation Commission.
Participation in the UNSG Efficient Home Heating Program is subject to the Terms and Conditions
Terms and conditions
Customer Eligibility:
1. Rebates will be paid only to residential customers of UNS Gas (UNSG). Current UNSG account number for the address where the equipment will be installed must be
included on the application.

2. Equipment must be purchased and installed after February 27, 2008 to be eligible for a rebate. Rebate applications must be submitted within 90 days of installation. For
systems installed prior to June 16, 2008, rebate application must be received no later than September 14, 2008. Please allow 6-8 weeks for rebate processing.

3. Equipment must be installed by a heating or plumbing contractor holding a current license to install HVAC equipment in the state of Arizona.

4. Application must be filled out completely and signed by customer and contractor. Proof of purchase (copy of paid invoice) must accompany the application to qualify for
rebate incentive payment from UNSG. Invoice must include: manufacturer, model number, AFUE, installation date and contractor license number.

5. These incentives apply to total system replacements performed during the term of this rebate program.

6. Customer, in return for payment by the Company under the UNS Gas, Inc. Efficient Home Heating Program, assigns any energy efficiency credits and all resultant
associated environmental credits from the energy efficiency measures for which the rebate is paid, to the Company.

Installation Verification:
7. UNSG reserves the right to conduct an on-site inspection solely for the purpose of verifying that equipment meets efficiency standards and installation guidelines outlined
in the program requirements.

Warranties, Liabilities and Release:

8. Neither UNSG nor any third party administrator of the Program guarantee, warrant or recommend any particular contractor, manufacturer or installer of equipment.

9. Participant hereby releases and shall indemnify, hold harmless and defend UNSG and any Program administrator from all losses, harm, costs, liabilities, damages and
expenses (including attorney’s fees) of any nature whatsoever arising directly or indirectly out of or in connection with the installation of equipment at the address listed on
this application form.

Changes to Efficient Home Heating Program:

10. The Program is subject to change without prior notice and rebate amounts may increase or decrease at any time.

Tax Liability:
11. Participants in the Program may be subject to tax liability for the value of goods or services received through the Program pursuant to state or federal income tax codes.
Neither UNSG nor any Program administrators are liable for any tax liability which may be imposed on the participant as a result of receipt of rebate payments from UNSG.

Equipment Type Furnace Capacity Furnace Per Unit

ID# H260 (MBH) AFUE REBATE
Furnace Only 0 - 60 0.90 $200
Furnace Only 61 - 100 0.90 $225
Furnace Only 100+ 0.90 $250

Furnace Only 0 - 60 0.92 $250
Furnace Only 61 - 100 0.92 $275
Furnace Only 100+ 0.92 $300

Furnace Only 0 - 60 0.94 $275
Furnace Only 61 - 100 0.94 $300
Furnace Only 100+ 0.94 $325

For more information about the UNSG Efficient Home Heating Program, or for assistance completing your rebate application, please contact 1-866-322-4706
for general Program information please contact us at 1-877-UES-4YOU or 1-877-837-4968 or visit our website at uesaz.com .