Name and Address of Equipment Purchaser



Name and Address of Property Owner COPIES OF INVOICES REQUIRED

____________________________________________ __________________ ________________

Property Owner’s Name Home Telephone Work Telephone

_________________________________________________ __________________ _____ ________

Mailing Address City State Zip Code

Name of Customer and Address of Installed Equipment (if different than above)

____________________________________________ __________________ ________________

Customer Name Home Telephone Work Telephone

________________________________________________ ____________________ ______ ________

Installation Address City State Zip Code

_____________________________________________ ________________________________

Owner Signature Date Signed

Dealer Information

_______________________________________ ____________________________________ _______________

Dealer Name Contact Telephone

Central Air Conditioner

______________________ ________________________ _______________________ ________________

Make Model Number Indoor Coil Number Install Date

_________________ ___________ _________________

S.E.E.R Rating Nominal Size ARI No. (required)

(14 or greater) (Tons Cooling)

Mini-Split Ductless Air Conditioner (Minimum SEER 16)

_________________________ ________________________ ________________

Make Model Number Install Date

Electric Heat Pump □ Air-to-air □ Geothermal

______________________ ________________________ _______________________ ________________

Make Model Number Indoor Coil Number Install Date

_________________ ____________ __________ ___________ __________ ___________________

S.E.E.R Rating Nominal Size HSPF E.E.R. Rating C.O.P. rating ARI No. (required)

(14.5 or greater) (Tons Cooling)

Mini-Split Ductless Heat Pump (Minimum SEER 16)

_________________________ ________________________ ________________

Make Model Number Install Date

ATTACH COPIES OF ALL INVOICES RELATED TO THIS INSTALLATION. REBATES WILL NOT BE PROVIDED WITHOUT PROPER DOCUMENTATION.

PLEASE COMPLETE BOTH SIDES OF THIS FORM TO ENSURE PROMPT PROCESSING.

Indicate what equipment was replaced (Mandatory):

_________________________ __________________________ _________________________ __________

Make Model Number Indoor Coil Number Approx. Age

________________________ ________________________

S.E.E.R Rating Nominal Size (Tons Cooling) Or check here _____ if new installation.

Building Type: ____ Single-Family _____ Multi-Family _____ Commercial ______ Approx. Age:_____ years

Primary Heating Fuel prior to installation: ___________ after installation:_________ Type Heating System:_____________

Reason for replacement: _____ New _____ Replacement _____ Added capacity _____

Program Details

This program is available to any AMU customer who purchases and installs energy efficient cooling equipment at Residential or Small Commercial locations served by Atlantic Municipal Utilities. Eligible equipment includes central air conditioners (minimum 1 & 1/2 cooling tons) with SEER ratings of 14 and higher; and electric heat pumps, either air-to-air or geothermal, with SEER ratings of 14.5 and higher. The installation of a geothermal heat pump system shall also be eligible for an additional rebate of $500.00 if a ground-loop system is installed.

Conditions: Heat loss/heat gain calculations must be completed on all facilities where equipment is to be installed. The heating and cooling dealer should perform these calculations. AMU will inspect facilities for proper installation and to verify sizing. Heat pumps will be checked for size, model number, and matching coils. In addition, heat pumps will be inspected for performance within the parameters of the manufacture specifications. Heat pumps must be utilized for heating as well as cooling, with controls which will allow the heat pump to be the primary source of space heating until outside ambient temperatures fall below 20 degrees F. AMU will withhold payment if any discrepancies exist, until the dealer makes necessary corrections. Property owner and customer agree to allow AMU access to any and all affected equipment for the purposes of inspection and verifications.

All information requested on this Application form must be provided, including information on all equipment being replaced, and copies of all invoices related to the installation.

AMU reserves the right to discontinue this program at any time, without notice, and to make minor adjustments to the program requirements from time to time, as deemed necessary to clarify or improve the program. Rebates may be limited to 5 ton systems or smaller. Customers with larger or specialized systems should consult AMU prior to purchasing equipment.

Atlantic Municipal Utilities Use Only

Date Ap. Received____________________ Date Inspected________________ Customer Rate Code _______

Central Air Conditioner Rebate:

SEER rating: __________ = $_________rebate (SEER =>14 = $100, SEER =>16 = $300)

Heat Pump Rebate:

SEER rating: __________ = $________ rebate (SEER =>14.5 = $100, =>16=$200; =>18 or Geothermal=$300)

PLUS: _______________________ X $100 / Ton= $___________ ,

Nominal Size (Tons Cooling)

PLUS: Ground Loop Rebate ($500 if applicable) = $___________ Total HP Rebate $__________________

_____ Mini-Split Ductless Air Conditioner Rebate (Minimum SEER 16) = $100.00

_____Mini-Split Ductless Heat Pump Rebate (Minimum SEER 16) = $200.00

Total Rebate PAID $_____________ Date Rebate Paid _____________ Date Rate Changed ____________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download