Heat Pump Rebate Form

P.O. Box 272550, Ft. Collins, CO 80527-2550

Energy Efficiency Credit Application/Certification HEAT PUMP CONSUMER INFORMATION Consumer Name: Account Number: Consumer Address: City: State: Zip: Phone Number: Applicant Is: Application Is: *SS/Tax ID No:

_____________________________________ Individual

Partnership

Residential

Corporation

Non-Residential

_____________________________________

HEAT PUMP INFORMATION Total Number of Units: Brand: Model #:

_____________________________________

SEER

____________________________________

Size (tons)

____________________________________

Energy Star Rated

yes

no

(circle one) Page 1

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( cirlce one) *required for non-residential or rebates greater than $600.00

Date Installed: _____________________________________ This Is: _______Replacing existing Heat Pump _______New System

Replacing: Natural Gas

Propane

Other

None

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System Type Ground Source - Closed Loop Ground Source - Water Source COP:____________

(required for Ground Source)

Air Source HSPF:____________

(required for Air Source)

Backup (required only if Air Source selected above) Electric Resistance

Non-Electric

Controlled ETS

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Signature_____________________________________________

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