Ia 10b Residential

8/14/2019 Ia 10b Residential

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ADDITIONAL INFORMATION

Enjoy long-term savings, greater comort and, thanksto Black Hills Energy, a fnancial rebate. All by taking advantage o new, efcient technologies, insulation and air infltration control methods.

Terms And ConditionsGeneral Eligibility

This program oers inancial incentives or the purchase o

natural gas heating equipment and other listed energy-eiciency

improvements. To qualiy or rebates, an applicant must meet the

ollowing eligibility requirements:

n Applicant must be a current Iowa residential customer o

Black Hills Energy.

n Purchase and installations must be completed between

Jan.1, 2010 and Dec. 31, 2010. Applications or work done in

2010 must be received by Jan. 31, 2011.

n Applications will be processed on a irst-come, irst-served basis. The

program will end when the budget is depleted. Funds are limited.

n This program is subject to regulatory rules and orders, and

Black Hills Energy reser ves the right to change or to end any

portion o this program without notice.

n T o avoid delay, the dealer invoice returned with your rebate application

must include manufacturer, model and serial number, efficiency rating

and date of installation. Equipment cost, labor and tax must be itemized.

n Where applicable, energy-eiciency ratings must comply with

those listed in the Gas Appliance Manuacturers Association

(GAMA) directory.

n Checks will be made payable to customer shown on invoice.

n To qualiy or the rebate, heating equipment must meet minimum

eiciency requirements as listed in this application.

n Financing is oered in lieu o energy eiciency rebates. You have

a choice o low-rate inancing or a rebate, not both. For inancing

inormation please call 800-519-3571.

2010 Iowa Residential Rebate Application

Rebate ChecklistGet your rebate aster by checking o these easy steps beore

mailing your application orm. Complete and accurate application

orms mean less delays in getting you your rebate check.

q Audit completed (i required)

q Application completely illed out

q All receipts attached

q Reviewed Terms and Conditions and signed

and dated application

q Made three copies o application or your records, or

Black Hills Energy and or dealer

q Made copies of all other corresponding documents for your records

q Dealer portion completely illed out and signed

q Sent all documents to correct address listed on application

Furnace And Boiler Replacement—Insulation—Doors—Water Heater Replacement—Setback Thermostats—Furnace Maintenance

206_09 • 12/09

Mail completed application and itemized invoice to:

Black Hills Energyc/o Energy Efficiency Programs

PO Box 7390Des Moines, IA 50309

For more inormation or to download additional applications

visit www.BHEhowto.com or call our toll-ree Energy Eiciency

Programs hotline at 888-567-0799



Qualifying Equipment for Rebates

*Black Hills Energy’s Residential Audit Program is necessary for eligibility. Contact Black Hills Energy for details and attach a copy of the audit results to this rebate form.

Call 888-567-0799 to schedule a ree energy audit.

SETBACK THERMOSTAT & NATURAL GAS FURNACE/BOILER MAINTENANCE

EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT

Setback Thermostat n ENERGY STAR® qualified and/or pre-programmed 5-1-1,

5-2 or 7-day (Sel-installed)

Up to $25

Setback Thermostat n ENERGY STAR qualified and/or pre-programmed 5-1-1,

5-2 or 7-day (Professionally installed)

Up to $50

Furnace/Boiler Maintenance n For furnaces/boilers Up to $30

Combined Service n Furnace/boiler maintenance & professionally installed

setback thermostat

Up to $100

ENVELOPE MEASURES RETROFIT*EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT

Insulation (ceiling) n ≥ R-38 70% o cost up to $750

Insulation (wall) n ≥ R-11 70% o cost up to $750

Insulation (oundation) n ≥ R-13 70% o cost up to $750

Iniltration Control n Weather-stripping, caulking, etc. 70% o cost up to $200

Doors n R-5 to R-10 $25

Doors n ≥ R-11 $50

NATURAL GAS WATER HEATING


Storage Water Heater n 0.67 to 0.79 EF, ≥ 40 gallon and ≤ 75,000 BTUH $75

Storage/Condensing Water Heater n ≥ 0.80 EF or ≥ 90% TE and ≥ 40 gallon $300

Tankless Water Heater n ≥ 0.82 EF and ≥ 40 gallon $300

INNOVATIVE SPACE & NATURAL GAS WATER HEATING TECHNOLOGIES


Drain Heat Recovery n Minimum standards $300

Integrated Space & Water Heater n 84% CAE or above $500

Multi-Zone Thermostats n Minimum standards $300

HIGH–EFFICIENCY NATURAL GAS FORCED AIR FURNACES & BOILERS


Furnace n 92% to 93.9% AFUE $250

Furnace n 94% to 95.9% AFUE $325

Furnace n ≥ 96% AFUE $400

Boiler ≤ 300 kBTUH n 85% to 89.9% AFUE $150

Boiler ≤ 300 kBTUH n ≥ 90% AFUE $400



Account Number (Located in upper right-hand corner o Black Hills Energy natural gas bill)

HOMEOWNER

Name (i dierent) ___________________________________(Please print)

Name on Account ___________________________________

Installation Address _________________________________

City ________________________State ______ ZIP ________

Telephone (Day) ______________(Evening) _______________

Name/Address where rebate check should be sent, i dierent:

Name ____________________________________________

Address ___________________________________________

City________________________State ______ Zip _________

E-mail ____________________________________________

Where did you learn about our rebates? q Radio q Print Ad

q Newspaper Article q Word o Mouth: reerral by___________

q Bill insert q E-mail q Event q Billboard q Flyer

q Other ___________________________________________

APPLICANT AGREEMENT I certify that I have read and agreed to the terms and conditions of the EnergyEfficiency Program offered by Black Hills Energy’s Energy Efficient Program on

the front. I understand that I must attach invoices and supporting documents(receipts) with rebate application.

Signature __________________________________________

Date _____________________________________________

CERTIFICATION (To be completed by dealer/contractor or builder)

We certify that the indicated equipment was installed per the Terms and

Conditions of this program at the address shown. All Terms and Conditions

of the program have been met. We certify that all equipment informationprovided in the application is correct. Black Hills Energy reserves the right to

inspect and verify any equipment before or after issuing rebates. Attach copy

of all invoices and related materials to rebate form.

Dealer/Contractor Name ______________________________

Dealer Address _____________________________________

City ________________________State ______ Zip _________

Telephone _________________________________________

Fax ______________________________________________

E-mail ____________________________________________

Dealer/Contractor Signature ____________________________

Customer Information(To be completed by customer)

Type o Facility: q New q Existing q Addition

Year Built__________________Square Footage__________

q Own q Rent

Equipment Type: q New q Replacement

Space Heating Type:

q Forced Air Furnace Approximate Age o Unit______

q Boiler Approximate Age o Unit______

q Electric Heat /Other Approximate Age of Unit______

Central Air: q Yes q No

Approximate Age o Unit______

Water Heating Fuel: q Natural Gas q Electric q Other

Approximate Age o Unit______

IMPORTANT A final itemized invoice for all materials, labor and taxes related to the R

Application must be attached. For Envelope Measure Retrofit, a pre-quaenergy audit from Black Hills Energy must also be attached.

VERIFICATION The sales receipt indicating date of purchase, dealer/contractor name,

manufacture name and model number of equipment must accompany t

rebate application. Incomplete applications will be delayed. Black Hills

reserves the right to verify sales receipts and installations. After approvaplease allow four to six weeks for delivery of the rebate check.

TAX INFORMATION Rebates may be subject to federal and/or state income tax reporting.

Applicant is responsible for contacting a qualified tax advisor to determi

tax liability. If you purchase an energy-efficient product or renewable en

system for your home, you may be eligible for a federal tax credit. For minformation, visit www.energystar.gov/taxcredits. Black Hills Energy is no

responsible for any tax consequences of the rebate program.

DISCLAIMERBlack Hills Energy does not guarantee that installation of equipment

qualifying for rebates will result in reduced energy usage or demand, or cost savings. The Customer will hold harmless Black Hills Energy and its

officers, directors, shareholders, agents, employees, and representatives

all claims, liabilities, fines, interest, costs, expenses, and damages incu

by the Customer, for any damage, injury, death, loss or destruction of akind to persons or property, to the extent the damage, injury, death, los

or destruction arises out of or is related to the conduct, negligence, willf

misconduct, misrepresentation, breach of warranty or other breach of threbate form on the part of Black Hills Energy.

Facility Information

2010 Iowa Residential Rebate Application



Water Heater Replacement Innovative Space And Water Heating

Furnace/Boiler Replacement

Date Installed ________________________

Mr. Name ___________________________

Model# _____________________________

Serial # _____________________________

Capacity Gal. _________________________

BTUH Input __________________________

Energy EF Rating ______________________

q Drain Heat Recovery

q Multi-Zone Thermostat

q Integrated Space & W/H

Date Installed ________________________

Mr. Name ___________________________

Model# _____________________________

Serial # _____________________________

Rated Efciency

(AFUE/CAE% ) ________________________

q Furnace q Boiler

Date Installed ______________________

Mr. Name _________________________

Model# ___________________________

Serial # ___________________________

BTUH Input ________________________

Rated Efciency

(AFUE ) __________________________

q Efcient Fan Motor

(Premises with one to four units, and

manuactured homes, are eligible.)

Setback Thermostat Furnace/Boiler Maintenance Envelope Measures

q Sel-Installed q Professionally Installed

Thermostat controls:

q Natural Gas Heating System q Other

Date Installed ________________________

Mr. Name ___________________________

Model# _____________________________

Approx. age of furnace/boiler __________ yrs

Services completed:

q Inspected fan blower/motor exposed vent/gas pipe & ttings

q Tested/inspected furnace/boiler controls

q Cleaned/adjusted burners & pilots

q Inspected & changed lter if needed

q Visually inspected Heat Exchanger

q Checked thermostat operation & settings

Date o Maintenance ___________________

Date Installed ______________________

Heating Efciency AFUE _______________

Insulation (Ceiling) Sq Ft ______________

Initial R Value ________ Final R Value_____

Insulation (Wall) Sq Ft ________________


Insulation (Foundation) Sq Ft ___________


Door R Value _______________________

Equipment Information(To be completed by dealer/contractor.) Complete information for the applicable rebate you are applying for:

Infltration Measures

Type: _______________________________

___________________________________

___________________________________

___________________________________

___________________________________

Ia 10b Residential

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