Ukiah Pv Application Sb 1 Tax Info

City of Ukiah Solar Energy System Incentive Program Application Form Pursuant to California Senate Bill 1 Please print clearly and complete the information below. This application must be completed and submitted to the City of Ukiah in order to reserve an incentive for installation of a solar photovoltaic system under the City of Ukiah Solar Energy System Incentive Program. A copy of your Solar Energy System Proposal or contractor bid must accompany this application. See City of Ukiah Solar Energy System Incentive Program Requirements Pursuant to California Senate Bill 1 for further details. PURCHASER

FEDERAL TAX ID NUMBER

GENERATING SYSTEM

INSTALLATION ADDRESS

PHOTOVOLTAIC MODULE MANUFACTURER

TELEPHONE NUMBER

MODULE MODEL NUMBER

UKIAH ELECTRIC ACCOUNT NUMBER

CEC MODULE POWER RATING WATTS DC

RETAILER

BUSINESS RESALE NUMBER

TOTAL ARRAY OUTPUT (NO. OF MODULES X CEC MODULE POWER RATING) WATTS DC

ADDRESS

INVERTER MANUFACTURER

TELEPHONE NUMBER

FAX NUMBER

INVERTER MODEL NUMBER

CONTRACTOR CLASS & LICENSE NUMBER

CEC INVERTER EFFICIENCY

INSTALLER (IF DIFFERENT FROM RETAILER)

SYSTEM RATED OUTPUT (TOTAL ARRAY OUTPUT X CEC INVERTER EFF.)

ADDRESS

SYSTEM COST (COST OF SYSTEM BEFORE INCENTIVE)

%

WATTS AC

$ TELEPHONE NUMBER

FAX NUMBER

REBATE ($ varies / WATTAC) X CEC SYSTEM RATED OUTPUT IN WATTSAC)

(Note: Not to excede rebate cap.) $ CONTRACTOR CLASS & LICENSE NUMBER

PLEASE INDICATE WHO WILL RECEIVE THE REBATE

PURCHASER

RETAILER

*

* I understand this rebate/payment to my retailer or contractor will be reported under my Tax Identification Number on IRS Form 1099.

Terms and Conditions: Each of the Undersigned declares under penalty of perjury that: 1) the purchaser has read and understood the program requirements set forth in this application with attachments and has agreed to abide by those requirements; 2) the information provided in this form is true and correct to the best of his or her knowledge; 3) the above described generating system is intended primarily to offset part or all of the purchaser's electrical needs at the site of installation; 4) the site of installation is located within the service territory of the City of Ukiah Electric Utility; 5) the purchaser understands this program may be discontinued at any time by the City of Ukiah, funds are limited and available on a first-come, first-served basis; 6) the purchaser understands that program funds are not guaranteed until the Project Approval Letter authorized by the City of Ukiah is received by the purchaser; 7) the purchaser understands that they have one (1) year from the receipt of their Project Approval Letter to complete the project, or funds will be made made available to other customers. 8) the purchaser agrees to hold the City of Ukiah harmless, that the selection, purchase, and ownership of the Equipment is his or her sole responsibility. The City of Ukiah makes no representation as to the safety, reliability, and/or efficiency of the equipment selected or components thereof. The City of Ukiah makes no warrantee, whether expressed or implied, including warrantee of merchantability or fitness for any particular purpose, use or application of the equipment.

Important Tax Liability Information: You are urged to consult your tax advisor concerning the taxability of rebates. The City of Ukiah is not responsible for any taxes that may be imposed as a result of your receipt of this rebate/payment (directly or indirectly). Rebates in excess of $600.00 may be reported on IRS Form 1099. A completed Form W-9 (Request for Taxpayer ID Number and Certification) must accompany this application to help determine if Form 1099 will be issued by the City of Ukiah.

For Utility Use Only PURCHASER SIGNATURE

DATE

PURCHASER SIGNATURE

DATE

DATE RECEIVED REBATE AUTHORIZED SIGNATURE

REBATE APPROVED

RETURN APPLICATION TO:

City of Ukiah Attn: Efficiency Services PO Box 421 Clackamas, OR 97015

For questions regarding the City of Ukiah Solar Energy System Incentive Program, contact Efficiency Services Group at 1-888-883-9879. 4/7/2008

REBATE DENIED

DATE APPROVED/DENIED

REBATE AMOUNT

WARRANTY, PD RECEIPT, INS DOCUMENTS RECEIVED

YES

NO

W-9 FORM RECEIVED (for non-dwelling units only)

YES

NO