0120-NGRID RI-1800067-2020 Rebate Forms - V2
844-615-8315 | ngrid.com/rirebates
Residential heat pump water heater rebate application
Form must be completed in its entirety.
2021
Rebates are available to eligible National Grid residential electric customers only. One electric account number per form. Some restrictions
may apply. Rebate offers are subject to change without notice. Please review terms and conditions. Form must be completed in its entirety.
Please submit online at ngrid.com/rirebates or mail completed form with all required documents to:
National Grid RI Electric Heat Pump
Water Heater Rebates
P.O. Box 2528
Manchester, CT 06045
Required documents
Replaced water heater information (if applicable)
Manufacturer Capacity (gallons) Age of water heater
New water heater information
New equipment Manufacturer
Model number
(must be included on invoice)
Retailer where
purchased (if applicable)
Install date
(mm/dd/yyyy)
Quantity Location
55 gallons or less
Greater than 55 gallons
Basement Attic
Garage Other
I hereby request a rebate for the listed work. Attached are copies of all receipts. I certify that new equipment is replacing an existing electric storage tank water heater or is new construction. I certify that all
information above is correct to the best of my knowledge and that I have read and agree to all Terms and Conditions of this rebate. I certify that a licensed contractor has installed the listed energy-efficient
equipment in accordance with Program Guidelines and Terms and Conditions as described on this form. This rebate is for the benefit of Rhode Island residential electric customers of National Grid. This rebate
may not be combined with any other utility or energy efficiency service provider offer and may be subject to change without notice. I understand that some restrictions may apply. National Grid reserves the
right to conduct field inspections to verify installations. Limitation of liability: National Grid does not guarantee the performance of installed equipment expressly or implicitly. National Grid does not endorse any
particular contractor, manufacturer, dealer, materials, product, system design or technology in promoting these offers. Customer agrees that the Energy Efficiency Program Provider (EEPP) has the unilateral right
to apply for any ISO-NE capacity payments or environmental credits resulting from this energy efficiency project, and agrees not to file for such payments or credits either directly or indirectly. Contractors agree
to provide the EEPP with such further documentation as the EEPP may request to confirm the EEPP’s ownership of such benefits. National Grid and the rebate administrator’s liability is limited to paying the
rebate specified. National Grid and the rebate administrator are not liable for 1) the quality, safety, and/or installation of the equipment, including its fitness for any purpose; (2) the estimated energy savings of the
equipment; (3) the workmanship of the installation contractor; and (4) any consequential or incidental damages or for any damages in tort connected with or resulting from participation in these offers. National
Grid will not be responsible for any tax liability that may be imposed on the customer or contractor as a result of the payment of rebates.
• Dated receipt with complete model information
• Dated contractor invoice
• Copy of most recent electric bill
• Complete and signed application
Customer/Account Holder Information —
Form must be completed in its entirety
RI
CUSTOMER/ACCOUNT HOLDER INFORMATION —
FORM MUST BE COMPLETED IN ITS ENTIRETY
EXISTING HEATING FUEL TYPE:
ELECTRIC RESISTANCE
OIL
PROPANE NATURAL GAS
ELECTRIC ACCOUNT NUMBER AT INSTALLATION ADDRESS
ACCOUNT HOLDER FIRST NAME ACCOUNT HOLDER LAST NAME
INSTALL ADDRESS CITY STATE ZIP
EMAIL ADDRESS PHONE
PAYEE INFORMATION —
ADDITIONAL PROCESSING TIME MAY BE REQUIRED IF ACCOUNT HOLDER IS DFFERENT THAN PAYEE NAME
EQUIPMENT INFORMATION
PAYEE FIRST NAME/COMPANY NAME (if different than above) PAYEE LAST NAME
MAILING ADDRESS (if different than above) CITY STATE ZIP
EMAIL ADDRESS PHONE
Equipment Information
HOW DID YOU HEAR ABOUT THIS PROGRAM: (Choose the appropriate ballot box.)
PLUMBER OR CONTRACTOR ENERGY ASSESSMENT
EQUIPMENT SUPPLIER TRADE SHOW SALES REP/ACCOUNT EXECUTIVE
PRINT ADVERTISING
INTERNET
RADIO/TV DIRECT MAIL/E-MAIL OTHER
HOME ENERGY REPORT
RHODE ISLAND ENERGY CHALLENGE: FIND YOUR FOUR!
WORK COMPLETION AND REBATE VALIDATION
DATE NAME (PRINT) CUSTOMER SIGNATURE
X
CONTRACTOR INFORMATION —
THIS INFORMATION MUST ALSO APPEAR ON THE CONTRACTOR INVOICE
CONTRACTOR COMPANY NAME CONTACT NAME
STREET ADDRESS CITY STATE ZIP
EMAIL ADDRESS PHONE
