Fill - Free fillable NVE Qualified Appliance Replacement Full Form PDF form

1. Verify eligibility

• You must be a current NV Energy customer and

provide one electric bill from within the last 3 months.

• Meet annual income requirements as specified on

page 2.

2. Verify equipment eligibility

• Your current refrigerator and/or dryer must be

electric.

• Your current refrigerator and/or dryer must be at

least ten (10) years old to qualify for replacement.

• Locate the model and serial number on your

equipment and use www.appliance411.com

to verify the age of your appliance.

3. Complete application

• Complete all fields in the document.

• If owning/renting the home, the property

manager/owner will need to complete page 5.

• Offer is available on a first come first serve basis.

4. Attach documentation

• Include current equipment model/serial number

tags, proof of income, and copy of NV Energy bill.

• Send your application and attachments via email to

QAR@nvenergy.com, by mail, or by fax, see page 6.

5. Submit signed application and required documentation.

Qualied Appliance Replacement

Application Instructions

Revised 04/19/2022

Full Form Application, Version 6

Qualified Appliance Replacement - Full Application - April 2022 2

The following qualifications must be met:

• Be a homeowner or renter who currently receives electric services through an NV Energy residential meter.

• Provide a copy of one NV Energy electric bill from within the last 3 months.

• Meet household and annual income requirements below:

Individuals in

Household

Total Combined

Annual Income

1 $25,750

2 $34,840

3 $43,920

4 $53,000

5 $62,080

6 $71,160

7 $80,240

8 $89,320

Each addional person add $9,080

Household Size

To determine your household size, include:

• yourself (and if married, your spouse);

• the number of children who will receive more than half of their support from you during this calendar year. You

may include any unborn children if they will be born during the year; and

• the number of people (not your children or spouse) who live with you and receive more than half of their support

from you, and will continue to receive more than half of their support from you during this calendar year.

Household Income

Household income refers to the combined gross income of all members of a household, defined as a group of people

living together, who are 15 years or older.

You may also qualify if you or someone in your home participates in at least one of the eligible public assistance

programs listed below.

Eligibility Requirements

• Asian Community Resource Center

• Boys and Girls Club Family Resource Center

• CARE Chest

• Community Services Agency Weatherization

Program

• Community Services of Nevada (CSN)

• Division of Welfare and Supportive Services:

Energy Assistance Program

• East Valley Family Service

• HopeLink

• Las Vegas Urban League

• Nevada Rural Housing Authority

• Project REACH (Southern Nevada Energy Assistance

Program)

• Southern Nevada Regional Housing Authority

• Three Square

STOP! If you already participate in any of the above programs, you are pre-qualified for this

offer and should use the SHORT FORM application.

Qualified Appliance Replacement - Full Application - April 2022 3

Equipment Specifications

MODEL: AB12C34100

S/N:1AC2DEF345678G

SERIAL #

MODEL #

Application - Customer Information

NV Energy Account Number _____________________________ Do you rent or own your home? _____________________ _____

Contact Name __________________________________________ Main Phone ____________________________________________

Secondary Phone ________________________________________ Contact Email ___________________________________________

Home Address __________________________________________ City _________________________ State ______ ZIP _____________

How did you hear about Qualified Appliance Replacement? __________________________________________________________

Please complete all fields.

Refrigerator and Dryer

Current refrigerators and dryers must be 10 years or older to qualify for replacement.

Your current refrigerator and/or dryer must be electric.

Refrigerator - To check the age of your refrigerator locate the model/serial number

inside the door of the appliance at the top right side (top left for some models).

Electric Clothes Dryer - To check the age of your dryer locate the model/serial

number on the frame of the dryer after opening the door.

Visit www.appliance411.com to determine the age of your appliance.

Take a photo of your current appliance model/serial number sticker and

include it with your application or type it below.

Refrigerator

Manufacturer ______________________________________

Model Number ______________________________________

Serial Number _______________________________________

Electric Clothes Dryer

Manufacturer ______________________________________

Model Number ______________________________________

Serial Number _______________________________________

Please select your electrical plug:

 3 Prong Electrical Cord  4 Prong Electrical Cord

✔

Qualified Appliance Replacement - Full Application - April 2022 4

Equipment Requested - see specifications on page 3

ENERGY STAR

refrigerator with top freezer:

 None

16.6 cu. ft. = 64.75 H x 28 W x 32.62 D

18 cu. ft. = 66.6 H x 29.53 x 30.94 D

ENERGY STAR

electric clothes dryer:

 None

 7.4 cu. ft = 46 H x 27 W x 30.5 D

i i

Qualified Appliance Replacement

See specifications on page 2

Number of people living in household __________________ Annual Household Income ____________________________

Name __________________________________________________ Relationship ___________________________________________

Equipment Requested

Advanced power strip:  None  1 Power Strip

Eight light emitting diode (LED) bulbs:  None  1 Pack  2 Packs

Dusk to dawn lighting control:  None  1 Controller  2 Controllers

Advanced Power Strip: By plugging in one item in the master port, all others will turn on or off depending on the activity

of the master. Using an advanced power strip will reduce the amount of electricity wasted and save you money on your

electric bill.

Light Emitting Diode (LED) Bulbs: You may receive up to 16 LED light bulbs to replace any light bulbs you may currently

have. LED bulbs use less energy than an incandescent bulb and typically last years longer, saving you money on

replacement bulbs.

Dusk to Dawn Lighting Control: Automatically turns your light on at dusk and off at dawn. Compatible with CFL, LED and

incandescent bulbs.

Income Pre-Qualification Information

Please complete all fields.

Include Proof of Eligibility

Please black out social security number prior to submitting documents. Do not hide name, address, or income.

Please include both statements to prove eligibility:

• One NV Energy bill from the past 3 months

• W2(s) or Social Security statement from the past year

Additional Equipment Opportunities

✔

Qualified Appliance Replacement - Full Application - April 2022 5

Property Manager/Owner Acknowledgment Form

Property Manager/Owner Information

Check if customer owns property

Property Management Company/Owner Name (if any) _____________________________________________________________

Contact Name __________________________________________ Contact Title ____________________________________________

Main Phone ______________________________ Ext. ___________ Secondary Phone ________________________________________

Contact Email ___________________________________________

Mailing Address __________________________________________ City _________________________ State ______ ZIP ____________

Tenant Name ____________________________________________

Property Address _________________________________________ City _________________________ State ______ ZIP ____________

My signature certifies that I am aware that the tenant at the address listed above has my permission to replace

appliances in the home that they are leasing.

Property Manager/Owner Name (print) _____________________________________________________________________________

Title ____________________________________________________ Signature ________________________________________________

Date ___________________________________________________

• I understand that PowerShift by NV Energy (“NVE”)

is conducting Qualified Application Replacement

(“Offer”). This Offer is at no cost to me. The Installer

may install a free dryer and refrigerator. I may also

receive LED light bulbs, advanced power strip and

dusk to dawn lighting control, but in no event will the

Installer repair any appliances or fixtures. I authorize the

Installer to enter my property and perform services to be

rendered under the Offer and I understand that there is

no guarantee that the installation of these devices will

achieve energy savings.

• I understand that in order to receive the new

appliance(s) the Installer must remove and dispose

of the old appliance(s). I am aware that in no

circumstance will the old appliance(s) be left on the

premises.

• I am fully aware that the Installer is not an employee

of NV Energy and is a third party contractor who has

entered into a contract with NV Energy to provide

certain services for the benefit of their customers. I elect

to voluntarily participate in the Offer and assume all risk

of loss, damage, or injury that sustained by property or

by me in the performance of services by the Installer.

• To the maximum extent allowed by law, I acknowledge

and agree that NV Energy (including their employees

and contractors) shall not be liable for any loss,

damage or injury that may be sustained by me or

my property arising from or in connection with any act

or omission of the Installer or the Installer’s agents or

subcontractors in performing the Offer. I hereby waive

any and all claims against NVE that may arise in

connection with the Offer.

• I agree to maintain the energy saving appliance and

products in my home for 5 years.

• By signing below, I certify that I have read, understand,

and agree to the above terms and conditions.

 By typing my name above I certify that this is my digital signature.

Please complete all fields.

Qualified Appliance Replacement - Full Application - April 2022 6

Qualified Appliance Replacement Participation Agreement 2022

• I understand that PowerShift by NV Energy (“NVE”) is conducting

Qualified Application Replacement (“Offer”). This

Offer is at no cost to

me. The Installer may install a free dryer

and refrigerator at no cost. I

may also receive LED light bulbs,

advanced power strip and dusk to

dawn lighting control.

• I understand that in order to receive the new appliance(s) the Installer

must remove and dispose of the old appliance(s). I am aware that in no

circumstance will the old appliance(s) be left on the premises.

• I agree to install the LED light bulbs, advanced power strip and dusk to

dawn lighting control prior to the delivery of my

appliances. I also

agree to send before and after photos of

the products installed.

• In no event will the Installer repair any appliances or fixtures. I authorize

the Installer to enter my property and perform services

to be rendered

under the Offer and I understand that there is no guarantee that the

installation of these devices will achieve energy savings.

• am fully aware that the Installer is not an employee of

NVE and is a third party contractor who has entered into a contract with

NVE to provide certain services for the benefit of their customers. I elect

to voluntarily participate in the Offer and assume all risk of loss, damage,

or injury that sustained by property or by me in the performance of

services by the Installer.

• To the maximum extent allowed by law, I acknowledge and agree

that NVE (including their employees and contractors) shall not be

liable for any loss, damage or injury that may be sustained by me or

my property arising from or in connection with any act or omission of

the Installer or the Installer’s agents or subcontractors in performing

the Offer. I hereby waive any and all claims against NVE that may

arise in connection with the Offer.

• By signing below, I certify that I have read, understand, and agree to

the above terms and conditions.

• I agree NV Energy is not responsible for minor cosmetic scratches or

dents that may arise during delivery from the manufacturer to NV

Energy’s third party contractor.

Applicant Name (print) _________________________________ Applicant Signature _____________________________________

Date ___________________________________________________

FOR OFFICIAL USE ONLY

1-833-513-0960 | QAR@nvenergy.com | nvenergy.com/QAR

3 Ways to Submit Your Application

Email your completed

application to:

QAR@nvenergy.com

Fax your completed

application to:

833-524-3373

Mail your completed

application to:

Qualified Appliance Replacement

6655 W. Sahara Ave. Ste A-214

Las Vegas, NV 89146

When submitting please include all required documentation: completed application, proof

of income, copy of NV Energy bill, and image of current appliance model/serial tags.

 By typing my name above I certify that this is my digital signature.

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