Instructions: Complete this form and submit it to the serving electric utility. Incentives are only available for retrofits; new construction projects are not eligible. BUSINESS AND SITE INFORMATION Customer Name Installation Address (Street, City, State, Zip) Customer Phone Number EXISTING EQUIPMENT INFORMATION Existing Equipment Information Space 1 2 Space 3 The space conditioned by the new DHP was heated Yes Yes Yes by either zonal or forced air electric resistance heat No (If project is not No (If project is not No (If project is not “No”, “No”, “No”, as the primary system eligible for incentives) eligible for incentives) eligible for incentives) The conditioned by the new DHP was Yes (If project is Yes (If project is not Yes (If project is “Yes”, “Yes”, “Yes”, previously conditioned by an air source, ground not eligible for incentives) eligible for incentives) not eligible for incentives) No No No source, or ductless heat pump. The space conditioned by the new DHP was previously conditioned by an air source, ground Yes Yes Yes source, or ductless heat pump that is no longer No No No working, and is currently conditioned by backup zonal or forced-air electric resistance heat NEW EQUIPMENT INFORMATION DHP Information Space 1 2 Space 3 The DHP installed is on the Qualified Products List Yes Yes Yes available at: No (If project is not No (If project is not No (If project is not “No”, “No”, “No”, (Note: For multihead systems, the outdoor unit must be eligible for incentives) eligible for incentives) eligible for incentives) listed on the Qualified Products List) Manufacturer Model Outdoor unit cooling capacity (tons) INSTALLER INFORMATION Company Name Installer Signature Total Installed Cost (before rebate) including equipment, labor, and purchase date. Please include invoice with this project form. Date By signing this form, I confirm that the information is correct to the best of my knowledge.
Instructions: Complete this form and submit it to the serving electric utility. Incentives are only available for retrofits; new construction projects are not eligible. BUSINESS AND SITE INFORMATION Customer Name Installation Address (Street, City, State, Zip) Customer Phone Number EXISTING EQUIPMENT INFORMATION Existing Equipment Information Space 1 2 Space 3 The space conditioned by the new DHP was heated by either zonal or forced air electric resistance heat as the primary system Yes No (If “No”, project is not eligible for incentives) Yes No (If “No”, project is not eligible for incentives) Yes No (If “No”, project is not eligible for incentives) The conditioned by the new DHP was previously conditioned by an air source, ground source, or ductless heat pump. Yes (If “Yes”, project is not eligible for incentives) No Yes (If “Yes”, project is not eligible for incentives) No Yes (If “Yes”, project is not eligible for incentives) No The space conditioned by the new DHP was previously conditioned by an air source, ground source, or ductless heat pump that is no longer working, and is currently conditioned by backup zonal or forced-air electric resistance heat Yes No Yes No Yes No NEW EQUIPMENT INFORMATION DHP Information Space 1 2 Space 3 The DHP installed is on the Qualified Products List available at: (Note: For multihead systems, the outdoor unit must be listed on the Qualified Products List) Yes No (If “No”, project is not eligible for incentives) Yes No (If “No”, project is not eligible for incentives) Yes No (If “No”, project is not eligible for incentives) Manufacturer Model Outdoor unit cooling capacity (tons) INSTALLER INFORMATION Company Name Installer Signature Total Installed Cost (before rebate) including equipment, labor, and purchase date. Please include invoice with this project form. Date By signing this form, I confirm that the information is correct to the best of my knowledge.
Ductless%20Heat%20Pump%20Project%20Information%20Form.docx