Fillable RESIDENTIAL GEOTHERMAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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RESIDENTIAL GEOTHERMAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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The RESIDENTIAL GEOTHERMAL HEAT PUMP Rebate Claim Form (Efficiency Maine) form is 1 page long and contains:

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RESIDENTIAL GEOTHERMAL HEAT PUMP
Rebate Claim Form
Please submit by email: hesp@efficiencymaine.com OR Fax: 207-622-9933 OR Mail: PO Box 219, Brunswick, ME 04011–0219
Please allow 6 weeks for rebate processing.
Rev. 6.1.2021
REQUIREMENTS CHECKLIST all boxes must be checked
☐ 1. Invoice(s) attached, showing:
a. Full model number and manufacturer
b. Cost
c. Completion date
d. Installation site address
☐ 2. Unit Energy Star-rated
☐ 3. Installed in a 1- to 4-unit residential building located in Maine. Larger buildings, including 5 or more attached
condominiums, are not eligible.
☐ 4. Installed in primary living area, not a garage or outbuilding
☐ 5. Rebate claim submitted within:
a. 12 months of installation for upgrades completed on or before 4/30/2021
b. 90 days of installation or upgrades completed on or after 5/1/2021
☐ 6. Installed by a geothermal Efficiency Maine Residential Registered Vendor
☐ 7. Building is principal, year-round residence for occupants, not a seasonal, second, or vacation home
NOTE: Lifetime limit is one rebate per dwelling. Program subject to change without notice.
Homeowner Name:
Installation Address, Town, State, Zip:
Mailing Address, Town, State, Zip:
Email Address:
Phone Number:
Number of dwellings in building:
(A dwelling is a residential unit with a dedicated
kitchen, sleeping area, and bathroom.)
☐ ☐ 1
☐ ☐ 2
☐ ☐ 3
☐ ☐ 4
Replaced Heating Fuel (if any):
☐ Oil ☐ Kerosene ☐ Propane ☐ Natural Gas ☐ Wood ☐ Electricity ☐ Other
Geothermal Heat Pump Manufacturer
Model Number
Installation cost before rebate
$
Rebate (1/3 total project cost up to $3,000)
$
Rebate Recipient:
☐ Homeowner ☐ Registered Vendor
Residential Registered Vendor Company Name:
Registered Vendor Signature:
Date:
Homeowner Signature:
Date:
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RESIDENTIAL GEOTHERMAL HEAT PUMP Rebate Claim Form (Efficiency Maine)

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Completed 23 July 2021

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