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2. 
4. DUCTLESS HEAT PUMP (DHP)

   Project Information Form for Residential Applicant

5. Date
   Date
7. SITE INFORMATION
8. Account Number*
10. Account Holder Name*
11. Phone Number*
13. Installation Street Address*
14. City/ State/ Zip Code*
16. Homeowner Name (if different)
17. Phone Number
19. Mailing/Homeowner Address (if different)
20. City/State/Zip Code
22. Email*
24. Qualifying Home Type

    * Contact Utility for Multifamily.  (Select One)

26. Option #1

    1. Existing Site Built
27. Option #2

    1. Existing Manufactured Home
28. Option #3

    1. New Manufactured Home
30. EXISTING HEAT INFORMATION

    Eligible Existing Heating System Being Displaced (Select One)

    * Includes electric, non-ducted: Ceiling cable, wall, baseboard, plug-in, and an electric boiler/water heater attached to a hydronic floor heating system.

32. Option #1

    1. Electric Forced Air
33. Option #2

    1. Electric Zonal
34. Option #3

    1. DHP
36. NEW EQUIPMENT INFORMATION
38. AHRI Reference Number*
39. Manufacturer*
40. Outdoor Unit Model #
41. Indoor Unit Model(s) #
43. ADDITIONAL INFORMATION

    Rebate offer(s) may be changed or discontinued at any time.  All warranties are offered through the manufacturer, not the utility, whether expressed or implied, regarding the product(s) listed above for any materials or labor associated with installation, maintenance, repair, or any energy savings associated with use.  Rebate offer(s) apply to new product(s) only.  Utility reserves the right to inspect installed product(s).  Product(s) must meet all program criteria to qualify for rebate(s).  

45. CHECKLIST
47. AHRI Certificate*

    1. AHRI Certificate
48. Invoice or purchase receipt*

    1. Invoice or Receipt

    Including Manufacturer & Model #, Date, and Cost

49. Upload Invoice or Receipt*
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature
54. Date
    Date
56. Internal Office Utility Use Only
58. ECC Reference #
59. Rebate
60. Savings @ Busbar
61. Payment $/Unit
63. Vendor #
64. Buget #
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field