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Energy Efficiency Credit Application/Certification

HEAT PUMP
Today’s Date: . System Installation Date: .
REBATE MUST BE REQUESTED WITHIN 180 DAYS OF INSTALLATION.

Date Energy Audit Scheduled (required after installation) .

CONSUMER INFORMATION

Account Number: Phone Number: .

Consumer Name: .

Consumer Address: .

City: . State: . Zip: .

Applicant Is: Individual Partnership Corporation (circle one)

Application Is: Residential Non-Residential (circle one)

SS/Tax ID No: . (Required for non-residential or rebates greater than $600.00)

HEAT PUMP INFORMATION (please provide one form for each system installed. A receipt is required)

Brand: . Model #: .

SIZE (tons) .SEER: . EER: .Energy Star Rate: yes no (provide proof )

This Is: Replacing an existing Heat Pump, or a New System Replacing:


Natural Gas Propane Other None (explain) .

Heat Pump System Type


Ground Source - Closed Loop Open Loop DX (check all that apply)
COP: ____________ (required for Ground Source)
Air Source - Dual Fuel System Split System Single System (check all that apply)
HSPF:____________ (required for Air Source)

Backup (required only if Air Source selected above)


Electric Resistance Non-Electric Controlled ETS (circle one)

I certify that the system installed is as described above and that I have included:
A complete application form (required) .
Copies of receipts or Invoices (required) .
Proof of Energy- Star certification (optional) .

PVREA Customer Signature_____________________________________________


(the PVREA customer/member must sign this form)