Fillable 2021 Customer Rebate Application (Otter Tail Power Company)

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2021 Customer Rebate Application (Otter Tail Power Company)

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2021 Customer Rebate Application
* Denotes REQUIRED fields.
Please read all information on page 3 before completing this form.
Pre-Request _________________
Customer Information (please print)
Request _____________________
Name*_________________________________________Account number (found in the center portion of your bill)*_______________________
Mailing address*___________________________________________ City*________________________ State*______ Zip*__________
Address where equipment was installed (if different)*:___________________________________________________________________
City*________________________________________________________________ State*______________ Zip*___________________
Contact phone*__________________________________ Email__________________________________________________________
Do you have a working dual fuel heating system?*
□
Yes
□
No If Yes, please check one of the following:
Backup heating system fuel*:
□
Fuel Oil □ Natural Gas □ Propane □ Other/None (specify)_________________________
Signature________________________________________________________________________ Date__________________________
Installing Contractor Information
Installer name*______________________________________ Business name*______________________________________________
Street address*__________________________________________________________City*___________________________________
State*_______ Zip*______________ Phone*________________________ Email____________________________________________
Water Heater - rebates for qualifying controlled rates only
Date installed_______________________________ Quantity_______________ Gallons______________ UEF________________
Manufacturer/Brand___________________________________________________
Model Number______________________________
Installed water heater is:
□
Replacing existing controlled electric water heater
□
Adding new controlled electric water heater
Water heater type: □Heat pump □Grid enabled □Standard tank/light duty commercial □Commercial
For Office Use Only: Rate
□ Firm service w/monthly control credit Total kW Commercial Rebate: □
Yes □ No
Thermal Storage Heating or Cooling - rebates for qualifying controlled rates only
Date installed___________________ Quantity_____________ Kilowatts__________
For Office Use Only: Rate______________
Manufacturer/Brand___________________________________________________
Model Number______________________________
Thermal Storage type
:
□
Cooling-Storage
□
Cable
□
Central
□
Hydronic w/boiler
□
Panel
□
Room
□
Central Hydronic
Plenum Heater - rebates for qualifying units on controlled rates only
Date installed___________________ Quantity_____________ Kilowatts__________
For Office Use Only: Rate______________
Manufacturer/Brand___________________________________________________
Model Number______________________________
Boiler Equipment (non-thermal storage) - rebates for qualifying units on controlled rates only
Date installed___________________ Quantity_____________ Kilowatts__________
For Office Use Only: Rate______________
Manufacturer/Brand___________________________________________________
Model Number______________________________
Electric Furnace - rebates for qualifying units on controlled rates only
Date installed___________________ Quantity_____________ Kilowatts__________
For Office Use Only: Rate______________
Manufacturer/Brand___________________________________________________
Model Number______________________________
Electric Vehicle Charging Station - rebates for level 2 units on qualifying controlled rates only
Date installed___________________ Quantity_____________ Kilowatts__________
For Office Use Only: Rate______________
Manufacturer/Brand___________________________________________________
Model Number______________________________
OTP Form 3053 12/20
For Office
Use Only:
By signing this application, I certify the information is true and correct to the best of my knowledge, that the equipment for which I am claiming a rebate is
installed at the address provided. If requested, I will allow an Otter Tail Power Company representative to physically inspect the installation. I have read
and understood all information on the last page of this form and have attached my dated receipt specifying the brand and model number purchased. I
understand Otter Tail Power Company will calculate the value of the rebate based on the information provided.
Complete all sections that apply. All heat pump and water heater rebate applications require equipment AHRI Certificate
or manufacturer specifications sheets to be attached.
CLEAR
click to sign
signature
click to edit
Heat Pumps
Date installed________________________ Tons____________ Quantity____________
For Office Use Only: Rate______________
Manufacturer/Brand_____________________________________________________ Model Number___________________________
Energy Star (if known):
□
Yes
□
No
Installed heat pump is: □ Replacing existing electric heating system □ Adding new electric heating system
Installed in a newly constructed building or addition: □ Yes □ No If No, please check one of the following:
Primary heating system fuel prior to heat pump installation:
□
Electric
□
Fuel Oil
□
Natural Gas
□
Propane
□
Other________________
Air Source or Cold Climate Heat Pump
Configuration:
□
Ducted
□
Ductless
EER________
For Office Use Only: SEER:15 HSPF:8.5
SEER________ HSPF________ EER________
For ND Installations Only (not applicable to Cold Climate): Also installing other new supplemental electric heat on a controlled rate?
□
Yes
□
No If Yes, type installed:
□
Plenum Heater
□
Electric Boiler
□
Baseboard
□
Heat Storage
□
Other____________________
For Office Use Only: If no, last year's monthly average controlled electric heating usage Dec & Jan __________
kWh
Geothermal Heat Pump - North Dakota systems must be on an controlled rate
Check one:
□
Closed loop
□
Open loop
Check one: □Water to air □Water to water
□Direct exchange
Type
Air Source
Cold Climate (Efficiency)
Cold Climate (Energy Control)
Package Terminal/
Rooftop
Geothermal
Limit one rebate per heat pump installation.
OTP Form 3053 12/20
If prior primary heating = natural gas, not
Direct exchange 3.6 COP, 16 EER
Water to water-closed 3.1 COP, 16.1 EER
Energy Star or
On Dual Fuel, Deferred Load, or RDC Rate
12 EER
Premise must include supplemental
On Dual Fuel, Deferred Load, or RDC Rate
DUCTED: 9 HSPF
DUCTED: 9 HSPF
On Dual Fuel, Deferred Load, or RDC Rate
DUCTLESS: 10 HSPF
DUCTLESS: 10 HSPF
If prior primary heating = natural gas, not eligible for
rebate
electric heating such as plenum heater,
boiler, baseboard, or heat storage
DUCTED: Energy Star and 9 HSPF or
If prior primary heating = natural gas, not eligible for
rebate
15 SEER/9 HSPF
N/A
DUCTLESS: Energy Star and 10 HSPF or
15 SEER/10 HSPF
eligible for rebate
If prior primary heating = natural gas, not eligible for
rebate
electric heating such as plenum heater,
boiler, baseboard, or heat storage
12 EER
Energy Star or
On Dual Fuel, Deferred Load, or RDC Rate
qualifying COP and EER:
Water to air-open 4.1 COP, 21.1 EER
Water to air-closed 3.6 COP, 17.1 EER
Water to water-open 3.5 COP, 20.1 EER
Energy Star or On Dual Fuel, Deferred Load, or RDC Rate
15 SEER/8.5 HSPF/12.5 EER
Premise must include supplemental
Heat Pump Basic Qualifiers
MN Location
ND Location
Package Terminal or Roof Top Heat Pump
COP________ EER________
Customer Rebate Application
Please read all information on this page before completing the form on pages one and two.
Rebate Application Details
- New equipment must be installed where electricity is supplied by Otter Tail Power Company.
- A dated sales receipt must be submitted with this rebate request. Bids, quotes, or purchase orders do not qualify as a sales receipt.
- Customer rebate requests may require review by local Energy Management or Service Representatives.
- Allow 6-8 weeks for processing.
- Must meet rebate eligibility requirements visit www.otpco.com or call our Idea Center at 800-493-3299 to verify program requirements.
- Otter Tail Power Company is not responsible for inaccurate information supplied by equipment dealers or contractors.
Incomplete rebate applications will be returned and no rebate will be issued until all required information is provided.
Did you include the following?
□
Your Otter Tail Power Company account number (found on your energy bill)
□ Your receipt or invoice
□ All equipment information required
□ Proof of efficiency levels, where required
□ Your signature
OTP Form 3053 12/20
If you are installing a new heating or cooling system you may also be eligible for our Smart Thermostat rebates. Visit our
website at www.otpco.com or call our Idea Center at 800-493-3299 for more information and/or for rebate forms.
Otter Tail Power Company reserves the right to deny any rebate that does not meet program qualification requirements.
Rebate programs may be discontinued or modified at any time.
- Rebate requests must be received for installations completed during the calendar year no later than March 31 of the following calendar
year or will not be accepted.
- Customers must provide proof that equipment installed meets the company's currently available rebate program requirements for
efficiency level, size, and/or controlled service rate application.
- Accepted proof of efficiency, where applicable, includes an AHRI certificate or manufacturer specification sheet showing efficiency
levels or Energy Star rating for the model installed.
- Pre-approval is required if rebate amount expected is $10,000 or more. Rebate limits apply. Rebate programs are subject to change or
cancellation without notice. Acceptance of this application does not guarantee payment. You will be notified if your applications is not
accepted.
Idea Center
Otter Tail Power Company
PO Box 496
Fergus Falls, MN 56538-0496
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2021 Customer Rebate Application (Otter Tail Power Company)

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Completed 22 July 2021

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