Fillable RESIDENTIAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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RESIDENTIAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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RESIDENTIAL HEAT PUMP
Rebate Claim Form
Please submit by email: hesp@efficiencymaine.com OR Fax: 207-622-9933 OR Mail: PO Box 219, Brunswick, ME 04011–0219
Please allow 6 weeks for rebate processing.
Rev. 6.1.2021
REQUIREMENTS CHECKLIST all boxes must be checked
☐ 1. Heat pump(s) installed by an Efficiency Maine heat pump Residential Registered Vendor
☐ 2. Heat pump(s) installed in primary living area, not a garage or outbuilding
☐ 3. Heat pump(s) will be used to heat the home throughout the heating season
☐ 4. Heat pump(s) installed in accordance with Efficiency Maine's Heat Pump Installation Requirements Checklist
☐ 5. Homeowner supplied with an owner's manual for the heat pump(s)
☐ 6. Homeowner supplied with a copy of Efficiency Maine Heat Pump User Tips
☐ 7. Homeowner taught how to turn the heat pump on and off, clean the filter, switch between heating and cooling
modes, change the temperature setpoint, adjust airflow direction, and call for service
☐ 8. Homeowner understands electric bill will increase, but overall energy use will decrease if heat pump is used
optimally
NOTE: Lifetime limit is two heat pump indoor unit rebates per dwelling. Program subject to change without notice.
Homeowner Name:
Installation Address, Town, State, ZIP:
Mailing Address, Town, State, ZIP:
Email Address:
Phone Number:
Number of dwellings in building:
☐ 1
☐ 2
☐ 3
☐ 4
A dwelling has a dedicated kitchen, sleeping area, and bathroom.
For larger buildings, including 5 or more attached condominiums, see Commercial Programs
Home has natural gas utility account?
☐ Yes
If yes, eligible only for Tier 1 rebates
Indoor
Unit
MANUFACTURER
OUTDOOR UNIT MODEL #
Tier
(1, 2, LMI)
Install
Date
Installed
Cost
Requested
Rebate Amount
(see table page 2)
First
Second
Rebate Recipient:
☐ Homeowner ☐ Residential Registered Vendor
Rebates for low- and moderate-income customers are sent to vendor
Registered Vendor Company (and branch if applicable):
Name of Registered Technician:
SIGNATURES. Please certify that all information on this Claim Form is correct by signing below. By submitting this claim, I agree to allow Efficiency Maine to
verify installation and perform an inspection. If building access is required for an inspection, I agree to work with Efficiency Maine to schedule a mutually
convenient time. I understand that Efficiency Maine may contact me about my experience on this project and I consent to receive program-related email and/or
phone communications from Efficiency Maine and its service providers.
Registered Vendor Signature:
Date:
Homeowner Signature:
Date:
RESIDENTIAL HEAT PUMP
Rebate Claim Form
Please submit by email: hesp@efficiencymaine.com OR Fax: 207-622-9933 OR Mail: PO Box 219, Brunswick, ME 04011–0219
Please allow 6 weeks for rebate processing.
Rev. 6.1.2021
Use tables below to determine rebate amounts.
For units:
1. Installed by 4/30/2021 and rebate claim submitted within 12 months of installation, or
2. Quoted by 4/30/2021 and rebate claim submitted by 7/31/2021
Tier
Rebate Amounts
Requirements
1st Indoor Unit
2nd Indoor Unit
1
$500
$250
1. AHRI-rated HSPF 12.0 or greater for systems with 1 indoor unit
2. AHRI-rated HSPF 10.0 or greater for systems with multiple indoor units or
a ducted indoor unit
3. Dated quote included with claim form (when applicable)
2
$1,000
$500
1. AHRI-rated HSPF 12.5 or greater
2. Each system is single-zone
3. Wall-mounted indoor unit
4. Home does not have natural gas utility account
5. Dated quote included with claim form (when applicable)
Low- and
Moderate-
Income (LMI)
$2,000
Tier 1 or 2, if
applicable
(see above)
1. AHRI-rated HSPF 13.0 or greater
2. Single-zone system
3. Wall-mounted indoor unit
4. Owner-occupied, 1- or 2-unit building
5. Must be first heat pump at residence
6. Home does not have natural gas utility account
7. Reservation submitted prior to installation
8. Owner receives a LIHEAP benefit or property meets assessed value limit
For all other units:
Tier
Rebate Amounts
Requirements
1st Indoor Unit
2nd Indoor Unit
1
$400
$200
1. AHRI-rated HSPF 12.0 or greater for systems with 1 indoor unit
2. AHRI-rated HSPF 10.0 or greater for systems with multiple indoor units or
a ducted indoor unit
3. Heat pump installed within last 90 days
2
$800
$400
1. AHRI-rated HSPF 12.5 or greater
2. Each system is single-zone
3. Wall-mounted indoor unit
4. Home does not have natural gas utility account
5. Heat pump installed within last 90 days
Low- and
Moderate-
Income (LMI)
$2,000
Tier 1 or 2, if
applicable
(see above)
1. AHRI-rated HSPF 13.0 or greater
2. Single-zone system
3. Wall-mounted indoor unit
4. Owner-occupied, 1- or 2-unit building
5. Must be first heat pump at residence
6. Home does not have natural gas utility account
7. Reservation submitted prior to installation
8. Owner receives a LIHEAP benefit or property meets assessed value limit
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RESIDENTIAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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Completed 23 July 2021

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