Residential Water Heating Systems
Valid July 1, 2016 - December 31, 2016
Heat Pump Water Heaters • Solar Hot Water • Electric Water Heater Fuel Switch
Steps to Getting Your Rebate
„„ Purchase and install new eligible equipment.
Mail:
Efficiency Vermont
c/o Rebate Coordinator
128 Lakeside Ave., Suite 401
Burlington, VT 05401
„„ Complete and sign rebate form.
Fax: 802-658-1643
„„ Submit rebate form with contractor invoice.
E-mail: info@efficiencyvermont.com
„„ Confirm that equipment and installer are eligible.
Customer Information & Agreement
Customer Name
Electric Utility Account Holder Name (if different than customer)
Address (of installation location)
City/Town State Zip
Mailing Address (if different)
City/Town
State Zip
Telephone #
E-mail Address
n Check to receive energy-saving offers and updates via email
Electric Utility Company
Electric Utility Account # (of installation location)
Vermont Gas Systems Account #
(if applicable)
Installer Company Name
Installer Technician Name
Installer Telephone #
Installer Company Address
City/Town State Zip
I certify that all equipment for which I am requesting a rebate has been installed, that I meet the eligibility requirements of this rebate program, and that all information submitted
as part of this application, including proof of purchase, is correct to the best of my knowledge. I agree to the terms and conditions listed on the bottom of this form.
Customer Signature (required even if rebate is going to installer)
Rebate Payee Information
Date
(Required if rebate is not going to homeowner)
Rebate check payable to (must match EIN/TIN or SSN below):
Payee’s Federal Tax ID Number (TIN) — check one and provide EIN/TIN or SSN:
n Corporation or Tax-Exempt Organization (provide TIN)
n City, County, or State Dept., Govt. or Agency (provide TIN)
n Other (provide EIN/TIN or SSN)
Employer Identification Number
Social Security Number
or
n Contact information same as above
Contact Name
Mailing Address
City/Town State Zip
I certify that the “Payee Information” above, including Federal Tax ID Number (if applicable), is correct to the best of my knowledge.
I acknowledge that as Payee I am responsible for any tax liability associated with my receipt of the rebate payment.
For Internal Use
Payee Signature (if different from customer)
Date
Project #
Rebates are brought to you in partnership with:
Burlington Electric Department administers efficiency programs for
the City of Burlington. For more information, call 802-865-7362.
Vermont Gas Systems administers efficiency programs for residents
with natural gas service. For more information, call 802-863-4511.
For more information about Efficiency Vermont services and incentives visit www.efficiencyvermont.com or call 888-921-5990.
Heat Pump Water Heaters
Rebate Amount
$400
Discount is applied upon equipment purchase from participating distributors for homeowners who do not have an existing
natural gas unit. For more information visit: www.efficiencyvermont.com/hpwhpartners.
Solar Hot Water
Eligibility Requirements:
• Must use a Renewable Energy Vermont installer (see www.efficiencyvermont.com/solarHW).
• View a list of qualified systems at www.efficiencyvermont.com/solarHW.
• Must install monitoring device that is accessible remotely via the internet.
• Monitoring device must measure solar production, provide alerts when performance is compromised, and come with a two-year minimum warranty.
Rebate
Amount
$950
Installation Date
Invoice Date
Packaged System Model Number
(SRCC OG-300 Number if applicable)
Number of Occupants in Building
Monitoring Device Manufacturer
Monitoring Device Model Number
Size of Backup Water Tank (Gallons)
Tank System
Existing Water Heater Type
Back Up/Replacement Water Heater Fuel Type
n DIRECT FIRED n INDIRECT TANK n TANKLESS COIL n ON-DEMAND
n PROPANE n OIL n NATURAL GAS n ELECTRIC
Electric Water Heater Fuel Switch
Eligibility Requirements:
n ONE TANK n TWO TANK
Rebate Amount
Outside Burlington
Rebate Amount
Burlington
Eligible Natural
Gas Systems
Minimum Efficiency
(Energy Factor)
$200
$500
Rental
70%
$400
$700
Stand-alone
(direct-fired storage tank)
70%
$800
$800
On-demand (tankless)
82%-89%
$1,000
$1,000
On-demand (tankless)
90%
$600
$600
Indirect (storage tank
heated off boiler)
92%
APUE of boiler
• Home must be served by Vermont Gas Systems (VGS).
• A functional electric water heater must be removed and
disposed of properly and replaced with a natural gas unit
meeting minimum efficiency requirements.
• A copy of a dated installation invoice must be included
and must indicate:
° Proper removal and disposal of old electric water heater.
° Fuel source, make and model of new water heating system.
ost of new system including installation labor and materials.
°C
Rebate
Amount
Make
Model #
Number of
Bedrooms
in House
Equipment
Rental?
Yes
No
n
n
Equipment Type
n Direct-fired n Indirect-fired n On-demand
Only required if installing indirect water heater:
Boiler Make:
Boiler Model #:
Efficiency:
Terms & Conditions
REBATE is for new equipment installed between July 1, 2016 and December 31, 2016 by customers of Vermont electric utilities, except that rebates are not available to the
following customers: IBM, Omya, and electric utility companies. Equipment must be installed within the state of Vermont. Rebate forms must be postmarked or received
by January 31, 2017. Rebate offer is subject to change without notice and may not be combined with any other Efficiency Vermont offer. Solar Hot Water and monitoring
system must be verified to operate as designed. LIMITATIONS: This form also cannot be used for any non-residential project involving new construction within the City of
Burlington, or for any project outside the City of Burlington involving new construction of greater than 10,000 sq. ft.; please call Burlington Electric Department or Efficiency
Vermont, respectively, for information on such projects. PROOF OF PURCHASE: Invoice(s) must include the quantity, size, type, manufacturer, model or part number,
purchase date, and vendor of the efficient equipment. All sales transactions and installations are subject to verification and inspection. By signing this form, the customer
consents to allow Efficiency Vermont (or, the city of Burlington, Burlington Electric Department) 1.) to access the equipment for purposes of verification and inspection, and
2.) to disclose the customer’s information )including but not limited to the customer’s information included on this form and information on the invoice(s)) to the vendor and/
or contractor who sold or installed the equipment to verify equipment puchase/installation and to collect additional information about the equipment and its installation.
LIMITATION OF LIABILITY: Performance of installed equipment is not guaranteed expressly or implicitly. ENDORSEMENT: No particular manufacturers, products, or system
designs are endorsed through this program. PAYMENT: Allow 60 calendar days for delivery of payment. Incomplete or missing information will delay processing of rebate form
and payment. MAXIMUM PAYMENT will not exceed 100% of the equipment purchase price. Customer is responsible for all costs associated with sales tax, installation, and
disposal/recycling. Customer is responsible for any tax liability associated with rebate payment. CAPACITY CREDITS/ENVIRONMENTAL CREDITS: In accepting these financial
incentives, the customer agrees that Efficiency Vermont (or, for customers within its service territory, Burlington Electric Department) holds the sole rights to any electric
system capacity credits and environmental credits associated with the energy efficiency measures for which incentives have been received. These credits will be used for the
benefit of Vermont ratepayers.
EV-3715-0716-RNBX