Rebate Form

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Incentive Program Rebate Form Completion Checklist ‰ ‰ ‰ ‰

Information is complete and accurate. Copy of receipt has been attached. Back of form has been signed. Seperate form completed for each rebate.

the fine print... Submit completed form and copy of receipt to: Douglas Electric Cooperative 1981 NE Stephens Roseburg, OR 97470. This program applies to measures and/or appliances purchased after 02/01/06 and installed in Douglas Electric Cooperative service territory. Any application containing incomplete information will be returned for completion. All rebate amounts will be credited to the member’s account. Rebate amounts and measures are subject to change.

Member Information Please print name.

Name ___________________________ Account # ______________________ Mailing Address ___________________________ City __________________ Installed Address ___________________________ City __________________ Phone ______________(h) ______________(w)

Appliances Appliances must meet Oregon Department of Energy residential tax-credit standards and hot water source must be electric.

Water Heater 50 gallon tanks and smaller must have a minimum Energy Factor (EF) of .93. Larger units must have a minimum of .91. 07/06

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*Clothes Washer ($70)

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Date _________________

Dishwasher ($25)

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Refrigerator ($25)

Manufacturer ______________________ Model # _______________________ Place of Purchase ___________________ Date _____________ *MEF_______

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Electric Water Heater ($25)

Manufacturer ______________________ Model # _______________________ Place of Purchase ___________________ Date _____________ EF _________

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Solar Water Heating “Approved” unit must be installed by an ODOE-certified Bright Way solar contractor. Please ask for a list of approved units and contractors before proceeding.

Weatherization If consumer installed, rebate is calculated on material cost only, not cost of labor.

Windows

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Bright Way Solar Water Heating ($500)

Manufacturer ______________________ Trade Name ____________________ Contractor Name ___________________________ Install Date ____________ System Type __________________________ Model # ___________________

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Floor Insulation

Sq Ft __________ R-Value from ______ to ______

Ceiling Insulation Sq Ft __________ R-Value from ______ to ______ Wall Insulation

Sq Ft __________ R-Value from ______ to ______

Window Size _______________ Quantity _______ Total Sq. Ft. _________ Window Size _______________ Quantity _______ Total Sq. Ft. _________

BPA requires that windows must have a U-Value of .30 or lower.

Window Size _______________ Quantity _______ Total Sq. Ft. _________ Window Size _______________ Quantity _______ Total Sq. Ft. _________ Window Size _______________ Quantity _______ Total Sq. Ft. _________ Window Size _______________ Quantity _______ Total Sq. Ft. _________ Window Size _______________ Quantity _______ Total Sq. Ft. _________

Insulating/Window Contractor _________________________________ Year Home Was Built ________________________ Type of Heating _________________

Site Built _____

Date _____________________ Manufactured Home _____

(Windows) Vinyl Frame ___ Wood Frame ___ U-Value ______

Cost of Total Project _________________ X 25% = Rebate Amount _________________ (Max $350)

Financing

For weatherization and/or heat pump financing, consumer must also complete the above detailed information to be eligible for the special “buy-down” rate.

I certify that all measures and/or appliances have been installed in the Douglas Electric Cooperative service territory. The appropriate documentation has been included and I will allow a utility representative to verify its installation as needed. Signed ________________________________ Date ____________ office use only

Account # ______________________ Rebate Amount ____________ Posted ____________ Authorized Signature _______________ Qualified Purchase

Y N

Date _____________