Fillable Weatherization Rebate Claim Form LOW- AND MODERATE-INCOME (LMI) (Efficiency Maine)

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Weatherization Rebate Claim Form LOW- AND MODERATE-INCOME (LMI) (Efficiency Maine)

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LOW- AND MODERATE-INCOME (LMI)
Weatherization
Rebate Claim Form
Please submit by email: Lii@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
Weatherization Reservation Number (Required in advance of claim)
ADDITONAL REQUIREMENTS Check each to confirm all are true. Failure to check all boxes will delay rebate.
1. ☐ Upgrades occurred in primary living area, not a garage or outbuilding
2. ☐ Building is principal, year-round residence for owner, not a rental, seasonal, second, or vacation home
3. ☐ Upgrades installed by Efficiency Maine Residential Registered Vendor qualified in all applicable service categories
4. ☐ No other Efficiency Maine rebate was or will be applied to any aspect of this upgrade
5. ☐ Upgrades were NOT previously completed through the Weatherization Assistance Program (WAP), Maine
Housing, or a local Community Action Agency
NOTE: Program is subject to change without notice. All upgrades are subject to inspection by Efficiency Maine.
Homeowner Name
Site Address, Town, State, Zip
Mailing Address, Town, State, Zip
Email Address
Phone Number
Number of dwellings in building
☐ 1 ☐ 2
Primary Heating Fuel
☐ Oil ☐ Propane ☐ Kerosene ☐ Wood ☐ Electricity ☐ Other
Water Heating
☐ Heat Pump Water Heater ☐ Electricity ☐ Other
Energy Assessment and Air Sealing Rebate (from page 2)
$
Attic Insulation Rebate (from page 2)
$
Wall Insulation Rebate (from page 3)
$
Basement Insulation Rebate (from page 3)
$
TOTAL REBATE AMOUNT:
$
Rebate Recipient
Residential Registered Vendor
HOMEOWNER SIGNATURE
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. I consent to receive program-related email and/or
phone communications from Efficiency Maine.
Homeowner Signature
Date:
RESIDENTIAL REGISTERED VENDOR SIGNATURE
Please certify that all information on this Claim Form is correct by signing below.
Registered Vendor Company Name
Registered Vendor Signature
Date:
LOW- AND MODERATE-INCOME (LMI)
Weatherization
Rebate Claim Form
Please submit by email: Lii@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
ENERGY ASSESSMENT AND AIR SEALING
REQUIREMENTS CHECKLIST All boxes must be checked.
☐ 1. Invoice(s) attached, showing:
a. Minimum six hours of air sealing, independent of any other upgrades in work scope
b. $600 total cost (material and labor), with no charge to homeowner
c. Completion date
d. Installation site address
☐ 2. Upgrade was not part of the construction of a new home or addition
☐ 3. Code-approved fire protection was added to foam insulation or was not applicable
☐ 4. Completed Home Energy Assessment Checklist attached
Rebate
$
ATTIC INSULATION
REQUIREMENTS CHECKLIST All boxes must be checked.
☐ 1. Itemized invoice(s) attached, showing:
a. Cost of attic insulation separated from costs of any other work done
b. Completion date
c. Installation site address
☐ 2. Upgrade was not part of the construction of a new home or addition
☐ 3. Code-approved fire protection was added to foam insulation or was not applicable
☐ 4. Attic air sealed prior to or as part of insulating the attic
☐ 5. Attic not upgraded with batt insulation
☐ 6. All exhaust fans are ducted outside the home
☐ 7. Attic insulated to one or more of following levels:
a. Open attic insulated to at least R-49
b. Enclosed cavities filled to capacity with dense-pack insulation
c. Minimum 5” high density spray foam used to insulate all surfaces
d. High density spray foam applied to within 1.5” of full depth of cavities that were subsequently
enclosed
☐ 8. Upgrade was followed by a BPI Safety Test, including Blower Door Test, conducted by an insulation
Efficiency Maine Residential Registered Vendor (enter results on page 4)
Pre-Upgrade R-Value
Post-Upgrade R-Value
Square Feet Insulated
Installation cost before rebate
$
Rebate (80% of project cost up to $2,000)
$
LOW- AND MODERATE-INCOME (LMI)
Weatherization
Rebate Claim Form
Please submit by email: Lii@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
WALL INSULATION
REQUIREMENTS CHECKLIST all boxes must be checked
☐ 1. Itemized invoice(s) attached, showing:
a. Cost of wall insulation separated from costs of any other work done
b. Completion date
c. Installation site address
☐ 2. Upgrade was not part of the construction of a new home or addition
☐ 3. Walls not upgraded with batt insulation
☐ 4. Walls insulated to one or more of following levels:
a. Enclosed cavities filled to capacity with dense-pack insulation
b. Open cavities filled to capacity with low density spray foam
c. High density spray foam applied to within 1.5” of full depth of cavities that were subsequently
enclosed
d. Walls covered by minimum 2” rigid foam insulation (applied over the studs)
☐ 5. Upgrade was followed by a BPI Safety Test, including Blower Door Test, conducted by an insulation
Efficiency Maine Residential Registered Vendor (enter results on page 4)
Pre-Upgrade R-Value
Post-Upgrade R-Value
Square Feet Insulated
Installation cost before rebate
$
Rebate (80% of project cost up to $2,000)
$
BASEMENT INSULATION
REQUIREMENTS CHECKLIST all boxes must be checked
☐ 1. Itemized invoice(s) attached, showing:
a. Cost of basement insulation separated from costs of any other work done
b. Completion date
c. Installation site address
☐ 2. Upgrade was not part of the construction of a new home or addition
☐ 3. Basement upgraded by insulating:
a. Foundation walls from 2 feet below grade to underside of first floor (including sill and band joist)
with minimum 2” rigid or spray foam
b. Basement or crawlspace ceiling with either dense-pack insulation or minimum 2” of foam
☐ 4. Upgrade was followed by a BPI Safety Test, including Blower Door Test, conducted by an insulation
Efficiency Maine Residential Registered Vendor (enter results on page 4)
Pre-Upgrade R-Value
Post-Upgrade R-Value
Square Feet Insulated
Installation cost before rebate
$
Rebate (80% of project cost up to $2,000)
$
LOW- AND MODERATE-INCOME (LMI)
Weatherization
Rebate Claim Form
Please submit by email: Lii@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
BPI SAFETY TEST
Required for all insulation rebates
Post Upgrade
Blower Door (CFM50)*
BPI combustion safety test
☐ ☐ Pass
☐ ☐ Fail
☐
Carbon monoxide detector present
☐ ☐ Yes
☐ ☐ No
☐
Corrective action recommended:
*Required unless BPI recommends against (mold, asbestos, vermiculite, etc.), please state safety concern observed above.
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Weatherization Rebate Claim Form LOW- AND MODERATE-INCOME (LMI) (Efficiency Maine)

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Completed 23 July 2021

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