00 2009 Rebate Form - Ground Source Heat Pump (3)

LAKE COUNTRY POWER 2009 Residential Geothermal Ground Source Heat Pump Rebate Application Important: - Rebate amount is $400 per ton for qualifying GSHP's. Limit one rebate per member. - Rebates of under $1,000 are applied to power bill. - Rebates of $1,000 or more may be sent in check form if account is current. - PLEASE CHECK HERE FOR YOUR REQUEST (IF $1000 OR OVER) APPLY TO POWER BILL - GSHP must be installed within Lake Country Power service territory. - Fill out this form completely. Incomplete forms will not be processed. - Include a copy of the original dated sales receipt. - Include your account number and sign the form. - Submit completed rebate form and original sales receipt within 90 days of purchase date to: Lake Country Power OR: Lake Country Power OR: 2810 Elida Drive 8535 Park Ridge Drive Grand Rapids MN 55744 Mountain Iron MN 55768 - For questions, call Lake Country Power at: 800-421-9959

SEND CHECK

Lake Country Power PO Box 98 Kettle River MN 55757

Customer Information: Name:

Account #:

Address where GSHP is installed: City:

State:

Customer Type:

Homeowner

Zip:

Phone Number:

Landlord

Builder

Signature:

Other Today's date:

I certify that the GSHP for which I am claiming a rebate is a qualifying appliance, that it has been or will be installed at the address listed above and that this address represents a valid cooperative account.

Equipment Information: Manufacturer: (

) Tons

Model Number: Open Loop

Close Loop

Integrated Water Heater

Annual Energy Use (kWh/year) 1. Did this rebate influence your decision to buy this GSHP?

Yes

No

2. Is this a replacement appliance?

Yes

No

For statistical purposes only, please provide the following information. Lake Country Power will combine your response with others for analysis, as required by the Minnesota Dept. of Commerce. 1. Find your household size on the table to your right. 2. Determine your annual household income, before taxes, including pension, social security, etc. 3. Is your household income above or below the amount corresponding to your household size in this table?

Above

Below

Annual Household Size and Income (# of people) Annual Past 3 Mo. $21,184 $5,296 1 2 $27,702 $6,925 $34,220 $8,555 3 4 $40,738 $10,184 5 $47,256 $11,814 6 $53,774 $13,443 7 $54,996 $13,749 8 $56,219 $14,054

Contractor Information: Name:

City, State:

REBATES WILL BE APPLIED AS A CREDIT TO THE POWER BILL. Rebates are available only for the purchase of new GSHP's purchased on or after January 1, 2009. The GSHP must be installed where electricity is supplied by Lake Country Power. Rebate submittal must follow the guidelines as listed above. Lake Country Power is not responsible for inaccurate information supplied by appliance dealers. Call Lake Country Power to verify rebate program status.

2009 Ground Source Heat Pump Rebate Application