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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Please verify that the following requirements are met before submitting your application.
Prescriptive Rebate Requirements
1.Applicant must be an IPL business customer and location of installed equipment Program applications and must have an active IPL electric service ID. required documents must be 2.Rebates are limited to a maximum cap of $20,000 in rebate dollars per service submitted by one of the ID and/or building behind a master meter for each calender year. Each energy folllowing methods: efcient program (Prescriptive and Custom) carry their own separate caps. US Mail: 3.This application covers products purchased and installed between IPL Business Energy January 1, 2013 and December 31, 2013. Incentive Program 4.Applications must be received within 60 calendar days of project installation 431 Charmany Drive or by December 31, 2013, whichever comes rst. Please keep a copy for your Madison, WI 53719 records. Incomplete or rejected applications will not be returned. Email: 6.This application must have complete information and be submitted with the IPLapplications@weccusa.org equipment manufacturer (OEM) specication sheets for each measure being Fax: applied for and an invoice itemizing the new equipment purchased. The invoice 608.249.0339 must indicate date of purchase, size, type, make, model, and part number of equipment being applied for. 7.Rebate funds are limited and available on a rst-come, rst-served basis. 8.Eligible customers may receive a rebate for each eligible piece of equipment installed. 9.Once completed paperwork is submitted, rebate payments are generally made within 68 weeks. 10.Incomplete applications will be processed but not released for payment until complete information has been received. A letter will be sent to the applicant stating the information that is missing. The applicant will have 30 days from letter date but no later than December 31, 2013 to submit missing information to be eligible for a rebate. 11.Rebates will not be paid until eligible equipment has been installed and operable. 12.IPL reserves the right to change or terminate rebate offers without notice at any time. 13.As state and local building codes and Federal Energy Policy Laws change, equipment efciency requirements are subject to change; therefore, qualifying efciency levels may change at any time. The most current rebate application forms can be downloaded from IPLs webpage. 14.Customers may elect to have their rebate issued directly to the Trade Ally who installed/supplied the equipment or to a Third Party Rebate Administrator. The customers signature is required in Section 4 to assign the rebate to either. This action constitutes an irrevocable assignment of the rebate and must be reected on the equipment invoice by an equivalent amount of the rebate. In addition, the customers, and vendors or Third Party Rebate Administrators signatures are required in Section 6 Terms and Conditions. 15.Equipment which, either separately or as part of a project, has or will receive a rebate/incentive from any other IPL program is ineligible. 16.The rebate recipient assumes all responsibilities for any tax consequences resulting from IPLs rebate payment. 17.For further information please call 877.399.1202 or visit IPLpower.com/Business/Business_Energy_Savings.

Revised December 2012

1.877.399.1202 www.IPLpower.com

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Is this application: NEW (original) or REVISED (changes made to original application)

Section 1:Customer Information


Customer Tax Status: Corporation Individual/Sole Proprietor
Customer/Business Name:

Partnership

LLC

Other_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Contact Name:

Phone:

IPL Customer Service ID Number (Where equipment is installed) (REQUIRED):

E-mail Address:

Mailing Address:

City:

State:

ZIP Code:

Installation Street Address:

City:

State:

ZIP Code:

How did you hear about this program? Contractor/Trade Ally Mail Bill Insert Utility Website Community Event Newspaper Other:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Section 2:Building Type Required (check one)


Education/K-12 College/University Dormitory Education Other Food Sales/Grocery Fast Food Restaurant Full-Service Restaurant Other: Data Centers Healthcare Elder Care/Nursing Home Public Assembly/Church Lodging Agricultural Industrial Warehouse Ofce Service Religious/Worship Public Order/Safety Retail (Non-mall) Retail (Mall)

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 3:Trade Ally Information
Business Name: Contact Name:

Phone:

Fax:

Street Address:

City:

State:

ZIP Code:

E-mail Address:

If IPL has questions about this application, who should we contact? Customer Trade Ally Third Party Rebate Administrator

Section 4:Rebate Payment Information


Make rebate check payable to: Customer Trade Ally (Customer signature required)
Customer Signature:

Third Party Rebate Administrator (Customer signature required)


Date:

I hereby authorize payment of incentive directly to the Trade Ally or Third Party Rebate Administrator:

Payee Legal Name (as shown on income tax return)

Payee Business Name (if different than payee legal name):

Payee Legal Address:

City:

State:

Zip Code:

Mail Check to: Payee Legal Address


Alternate Pay Address (optional):

Job Site Address

Alternate Address (complete below):


City: State: Zip Code:

Payee Federal Tax Classication (check ONE only): Corporation Partnership Sole Proprietor/Individual LLC Other tax exempt organization or govt agency Payee Taxpayer Identication Number (TIN) (Complete ONE only. Must match payee legal name above) FEIN #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ OR SSN: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Certication: the following certications are required in order for this form to substitute for the IRS form W-9. Under penalties of perjury, I certify that: 1. The payees TIN is correct 2. The payee is not subject to backup withholding due to failure to report interest and dividend income, and 3. The payee is a U.S. citizen The Internal Revenue Service does not require your consent to any provision of this document other than the certications required to avoid backup withholding. Payee Signature: Print Name:

Title:

Date:

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 5:Equipment Information
General Requirements:
The specications for the eligible equipment are listed within each technology on this form. If the technology you are installing is specied differently than how it is listed, please call 877.399.1202 to verify eligibility. Custom incentives are available for many technologies not listed. Equipment must be purchased new to qualify. Resale equipment or equipment that is leased, rebuilt, rented, received from insurance claim, or received from warranty is not eligible. Rebate not to exceed 50% of the project cost (equipment and external labor excluding sales tax) unless noted otherwise on form.

A. High Efciency Pumps


Pump load must be served by IPL and installed in customers facility. Pump(s) must operate a minimum of 2,000 hours annually to be eligible. Pump efciency is based on the design point on the pump curve. Documentation of the pump curve is required to receive a rebate. The pump efciency at the design point on the pump curve must meet nominal efciencies as stated in table below. The Equipment below is (check one):

New Equipment

Retrot Equipment Installed Nominal Efciency*

Replace Failed Equipment Annual Operating Hours


(minimum of 2,000)

Pump 1.5 HP 2 HP 3 HP 5 HP 7.5 HP 10 HP 15 HP 20 HP

Make/ Model or Catalog #

Quantity

Rebate $22.50/ pump $30.00/ pump $45.00/ pump $75.00/ pump $112.50/ pump $150.00/ pump $225.00/ pump $300.00/ pump

(pump curve)

Equipment Cost $ $ $ $ $ $ $ $

Date Installed and Operable


(mm/yy)

Total Rebate
(Qty x Rebate)

% % % % % % % %

Hrs Hrs Hrs Hrs Hrs Hrs Hrs Hrs

$ $ $ $ $ $ $ $ TOTAL FOR SECTION A: $

* Must meet efciency requirements as listed in table below to be eligible Efciencies for Premium Pump Measures Nominal Efciencies for Pumps Pump HP 1.5 2 3 5 7.5 10 15 20 Efciency Requirement efciency of 65% or more for system (pump and motor) efciency of 65% or more for system (pump and motor) efciency of 67% or more for system (pump and motor) efciency of 70% or more for system (pump and motor) efciency of 73% or more for system (pump and motor) efciency of 75% or more for system (pump and motor) efciency of 77% or more for system (pump and motor) efciency of 77% or more for system (pump and motor)

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 5:Equipment Information, continued
B. Central Air Unit (Rooftop and Unitary AC or Heat Pump)
Must provide an AHRI reference number or documentation from the AHRI Manual to verify the required efciency level for all central air systems. If the equipment or matched set is not in the AHRI manuals, the manufacturers technical fact sheets must be provided showing the efciency level tested under AHRI conditions. Equipment capacity (size) and efciency must be based on AHRI design conditions. For split systems, the indoor coil and condenser must be a matched set to be eligible for rebate. Cooling system(s) must operate > 1,500 hours annually to be eligible. Write-in the annual hours of equipment operation next to or below the respective equipment make/model or catalog number on invoice. Rebates are only available for Air-to-Air Heat Pump units. Ground source and water source heat pumps are not eligible for rebates but may qualify for custom incentives. The Equipment below is (check one):

New Equipment

Retrot Equipment

Replace Failed Equipment Annual Operating Hours


(minimum of 1,500)

Description
(see below)

Make/Model #*

Number of Units

Tons per Unit

AHRI Reference Number


(required)

Date Installed and Operable


(mm/yy)

Total Rebate**
(# of Units x # of Tons x $35/Ton)

$ $ $ $ $ TOTAL FOR SECTION B: * For Split System, supply both the indoor and outdoor coil number ** Rebate capped at 50% of the equipment cost (excluding sales tax) Cooling Rebate Table and AHRI Rated Efciency Requirements Description A B C Size Range 136,000-240,000 BTUH 241,000-760,000 BTUH >760,000 BTUH Minimum AHRI Efciency 11.5 EER 10.5 EER 9.7 EER Rebate $35/ton $35/ton $35/ton $

Unitary and Rooftop Heat Pump (only Air-to-Air Heat Pump units qualify) Description D E Size Range 136,000-240,000 BTUH >241,000 BTUH Minimum AHRI Efciency 11.5 EER 10.5 EER Rebate $35/ton $35/ton

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 5:Equipment Information, continued
C. High Efciency Residential Electric Water Heater for Commercial Businesses
Energy Factor (EF) must be a minimum of 0.93 to qualify. Must provide an equipment data sheet stating the Energy Factor (EF). Water heater must operate > 1,500 hours annually to be eligible. Write-in the annual hours of equipment operation next to or below the respective equipment make/model or catalog # on invoice.

Description
(see below)

Make/ Model #

Annual Hours of Operation Quantity Size Range MBH MBH MBH


(minimum of 1,500)

Installed Energy Factor (EF)

Equipment Cost $ $ $

Date Installed and Operable


(mm/yy)

Total Rebate*
(Quantity x $20/Tank)

$ $ $ TOTAL FOR SECTION C: $

* Rebate capped at 50% of the equipment cost (excluding sales tax) High Efciency Residential Electric Water Heater Rebate for Commercial Businesses Table Description A Size Range ALL Minimum Energy Factor (EF) 0.93 Rebate $20.00/unit

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 5:Equipment Information, continued
D. Window Film
Window lm must be installed in accordance to the manufacturers instructions on south, east or west facing windows and cover the entire window aperture. The combined effect of the window and lm must result in a solar heat gain coefcient (SHGC) of 0.40 or less or a shading coefcient of 0.45 or less. Provide manufacturers specications and/or product data listing SHGC or shading coefcient.

Item Number
(Model #)

SHGC or Shading Coefcient

Total Square Feet Installed sf sf sf

Direction Window Faces Rebate per Square Foot $1/sf $1/sf $1/sf
(East, West or South)

Number of Windows

Date Installed and Operable


(mm/yy)

Total Rebate* Project Cost $ $ $ $ $ $ $


(Square Feet Installed x Rebate/SF)

East West South

TOTAL FOR SECTION D: * Rebate capped at 50% of the equipment cost (excluding sales tax)

E. Guestroom Energy Management Controls (Retrot only)


Rebates are available for sensors that control HVAC units for individual hotel rooms. Sensors controlled by a front desk system are not eligible. During unoccupied periods, the default setting for controlled units should differ by at least 8 degrees from the operating set point. The rebate is per guest room controlled, not per sensor; for multi-room suites the rebate is available per room controlled, if a sensor is installed in each room. Replacement or upgrades of existing occupancy-based controls are not eligible for this rebate.

Description
(see below)

Make/Model #

Quantity

Rebate per Room $ $ $

Equipment Cost $ $ $

Date Installed and Operable


(mm/yy)

Total Rebate* $ $ $

TOTAL FOR SECTION E: * Rebate capped at 50% of the equipment cost (excluding sales tax) Guestroom Energy Management Controls Rebate Table Description A B Guestroom Energy Management Controls for rooms heated by electric Guestroom Energy Management Controls for rooms heated by gas

Rebate $80/room $30/room

Revised December 2012

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2013 IPL Business Energy Incentive Program

Prescriptive Non-Lighting Measures Application


Section 6:Terms and Conditions
Applicants who provide their Social Security Number as their Federal Tax Identication Number for tax purposes must consent to release this information to IPLs third-party administrator. The third-party administrator is responsible for mailing the 1099 form at the end of the calendar year for tax ling. Authorized agents for IPL and the third-party administrator have signed a condentiality agreement to protect your personal information. I do hereby consent to IPL disclosing my personal information including my Social Security Number to IPLs third-party administrator for the purposes of administering this program. The following certications are required in order for this form to substitute for the IRS form W-9 Under penalties of perjury, I certify that: 1.The number shown on this form is the correct Federal Taxpayer Identication Number. 2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, (b) I have not been notied by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notied me that I am no longer subject to backup withholding. The signatory agrees that the stated energy efcient measure(s) was (were) completed or installed at the location listed in Section 1 as part of the IPL Business Energy Incentives Program. I have read and agree to the Terms and Conditions within this application. To the best of my knowledge, the statements made on this application are correct, and I have submitted the appropriate supporting documentation to receive a rebate payment. I certify that this premise is served by IPL, that the information provided herein is accurate and complete, and that I have purchased and installed the high-efciency equipment (indicated herein) for the business facility listed herein and not for resale. Attached is an itemized invoice for the indicated installed equipment. I understand that the proposed rebate payment from IPL is subject to change based on verication and IPLs approval. I agree to IPLs verication of both the sales transaction and equipment installation, which may include a site inspection from an IPL representative or an IPL authorized agent. I understand that I am not allowed to receive more than one rebate/incentive from IPL on any piece of equipment. I also understand that my participation in the program may be taxable and that my company is solely responsible for paying all such taxes. I hereby agree to indemnify, hold harmless, and release IPL and its afliates from any and all actions or claims in regard to the installation, operation and disposal of equipment (and related materials) covered herein including liability from incidental or consequential damages. IPL does not endorse any particular manufacturer, product or system design within these programs; does not expressly or implicitly warrant the performance of installed equipment (contact your contractor for details regarding equipment warranties) and is not liable for any damage caused by the installation of the equipment nor for any damage caused by the malfunction of the installed equipment. Rebates are subject to change and may be discontinued at the sole discretion of IPL. Equipment must be installed and in operation to be eligible for rebate. I have read and hereby agree to the IPL Business Energy Incentive Program Requirements, Terms and Conditions, and Certication(s) as stated in this application form.

Customer Signature

Print Name

Date

Signature
(if Payee is Trade Ally or Third Party Rebate Administrator)

Print Name

Date

Revised December 2012

1.877.399.1202 www.IPLpower.com

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