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2. 
3. Heat Pump Water Heater (HPWH)

   Project Information Form

4. Date
   Date
6. Account Number
7. Email
9. Name
10. Phone Number
12. Address, City, State, Zip
13. Mailing Address (if different)
15. Existing Equipment Information

    1. Yes
    2. No

    Does the water heater being replaced use resistance heat?

16. New Equipment Information

    1. Yes
    2. No

    Is the new equipment being installed on the QPL? 

18. Manufacturer
19. Model Number
21. Tier / Rebate

    1. 40 gal. all tiers ($1,400)
    2. Tier 3 - 50 gal or larger ($1,600)
    3. Tier 4 - 50 gal or larger ($1,800)
    4. Split System ($2,200)
22. Install Location

    1. Conditioned (ie., Garage or Crawlspace)
    2. Unconditioned (ie., Laundry Room, Basement)

    Is the location of install in a conditioned or unconditioned space. 

24. Upload Invoice or Receipt*
26. UTILITY USE ONLY
28. Reference Number
29. Rebate
30. Savings @ Busbar
31. Payment $/Unit
33. Vendor Number
34. Budget Number
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field