CompanyThis field is for validation purposes and should be left unchanged.Member InformationName(Required) First Last Account Number(Required)Address where appliance is installed(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Applicant Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Member Electronic Signature (Full Name)(Required)By signing this application, I certify the equipment for which I am claiming a rebate are qualifying ENERGY STAR® rated products and are installed at the address listed above which represents a valid cooperative account.Equipment InformationCentral Air or Air Source Heat Pump ManufacturerCentral Air or Air Source Heat Pump Model NumberASHP ManufacturerASHP Model NumberTonsSEER2 RatingPlease choose: ≥ 8.2 HSPF ≥ 9.0 HSPF ECM Motor ManufacturerECM Motor Model NumberGround Source Heat Pump (GSHP) Model NumberGround Source Heat Pump (GSHP) ManufacturerTonsContractor InformationCompany(Required)City(Required)State(Required)Installer(Required)HVACR Contractor IDor NATE CertificationRebates are available for Central Air/ASHP, Ductless ASHPs, ECM motors, and GSHPs. Rebate submittal must follow the guidelines as outlined by the cooperative. The cooperative is not responsible for inaccurate information supplied by appliance dealers. Rebates will be issued only for products on the current list of ENERGY STAR-rated products as of the purchase date. ENERGY STAR occasionally removes products from qualifying lists, and the cooperative will not rebate products that have been delisted as of the purchase date or are mislabeled as ENERGY STAR. To verify ENERGY STAR certification for ductless air source heat pumps, visit the Cee Directory website. The rebate program is subject to change or cancellation without notice. Call the cooperative to verify the rebate program status. Note: An invoice showing the purchase date, equipment manufacturer, model numbers, and serial numbers along with the AHRI certificate must be submitted with this application. Rebates: $50 for ECM Motor $200 per ton for air source heat pumps (ASHP) >1 ton with SEER2 of 14.3 or higher $400 per ton for ground source heat pumps (GSHP) $50 for Central Air Conditioning Important: Product(s) must be installed within the cooperative’s service territory. Incomplete forms will not be processed. Include a copy of the original dated sales receipt(s). Submit completed rebate form and a copy of the original sales receipt within 90 days of purchase date No rebates will be more than 1/2 the cost of what was paid Rebate program is subject to change or cancellation without notice Submit sales receipt(s) Drop files here or Select files Max. file size: 100 MB.
