ENERGY STAR Residential Heat Pump Rebate ENERGY STAR Certified Heat Pump Rebate Member InformationName* First Last Installation Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a different mailing address?* Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Electric Account Number* where equipment was installedHow did you first learn about the heat pump rebates?Advertisement inserted in my billButton up WorkshopContractorEmailFriend/ColleagueInternet search (Google, Bing, Yahoo)NHEC WebsiteNHSavesNewsletterNewspaperPostal mailSocial mediaSelect oneTelephone Town HallOtherExisting heating fuel type* Oil Propane Electric Other New Construction Existing heating system type* Furnace Boiler Heat Pump Other New Construction Is the heat pump replacing existing air conditioning units*YesNoCapacity of the AC system being replaced*in BtU'sContractor InformationBusiness name* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Fax NumberEmail Equipment InformationOnly ENERGY STAR® Certified heat pumps meeting the minimum efficiency ratings outlined in the incentives table will be eligible for a rebate. EnergyStar Heat Pump/Mini Split SystemsPlease select your heat pump type Air Source Heat Pump A/C Only Heat Pump Geothermal Heat Pump Install date* MM slash DD slash YYYY Quantity* AHRI Ref#* AHRI Cooling Capacity* Number of Tons (1 Ton = 12,000/BTU/h)* Manufacturer/Brand* Outdoor Model Number* Total Cost*Rebate Amount*SEER* EER* HSPF* Geothermal COP Heating ControlsEquipment WI-FI Thermostat (for Heat Pumps Only)** **WI-FI connections must be enabled. Rebate not to exceed purchase price. Limit one (1) thermostat per Heat Pump zone installed per account. Qualifying equipment must be installed between January 1, 2023 – December 31, 2023 to be eligible for a rebate.Install date MM slash DD slash YYYY QuantityManufacturer/Brand Model Number Total CostRebate AmountFor new Heat Pump and Geothermal systems that offset 80% of the home's total heating load, there is an additional $250 per ton incentive available. Submit with your application: 2 years of heating fuel usage, Type of fuel, Existing heating system equipment efficiency %. Are you applying for the 80% bonus incentive?*YesNoFor homes that have participated in the Home Performance w/ ENERGY STAR program in the last 12 months there is an additional $250 per ton incentive available. Are you applying for the Home Performance w/ ENERGY STAR bonus incentive?*YesNoAre you applying for third party financing?*YesNoPlease attach copies of dated invoices with equipment make and model specifications.* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, xls, xlsx, Max. file size: 1 GB. Sign HereDownload Eligible Equipment & Incentives, and read Terms and ConditionsI have read and understand the terms and conditions. I certify that the information I have provided is true and correct and the products(s) and equipment for which I am requesting an incentive meets the requirements in this application.* Yes Customer Digital Signature* Date* MM slash DD slash YYYY Δ ENERGY STAR Certified Heat Pump Rebate Member InformationName* First Last Installation Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a different mailing address?* Yes No Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Electric Account Number* where equipment was installedHow did you first learn about the heat pump rebates?Advertisement inserted in my billButton up WorkshopContractorEmailFriend/ColleagueInternet search (Google, Bing, Yahoo)NHEC WebsiteNHSavesNewsletterNewspaperPostal mailSocial mediaSelect oneTelephone Town HallOtherExisting heating fuel type* Oil Propane Electric Other New Construction Existing heating system type* Furnace Boiler Heat Pump Other New Construction Is the heat pump replacing existing air conditioning units*YesNoCapacity of the AC system being replaced*in BtU'sContractor InformationBusiness name* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Fax NumberEmail Equipment InformationOnly ENERGY STAR® Certified heat pumps meeting the minimum efficiency ratings outlined in the incentives table will be eligible for a rebate. EnergyStar Heat Pump/Mini Split SystemsPlease select your heat pump type Air Source Heat Pump A/C Only Heat Pump Geothermal Heat Pump Install date* MM slash DD slash YYYY Quantity* AHRI Ref#* AHRI Cooling Capacity* Number of Tons (1 Ton = 12,000/BTU/h)* Manufacturer/Brand* Outdoor Model Number* Total Cost*Rebate Amount*SEER* EER* HSPF* Geothermal COP Heating ControlsEquipment WI-FI Thermostat (for Heat Pumps Only)** **WI-FI connections must be enabled. Rebate not to exceed purchase price. Limit one (1) thermostat per Heat Pump zone installed per account. Qualifying equipment must be installed between January 1, 2023 – December 31, 2023 to be eligible for a rebate.Install date MM slash DD slash YYYY QuantityManufacturer/Brand Model Number Total CostRebate AmountFor new Heat Pump and Geothermal systems that offset 80% of the home's total heating load, there is an additional $250 per ton incentive available. Submit with your application: 2 years of heating fuel usage, Type of fuel, Existing heating system equipment efficiency %. Are you applying for the 80% bonus incentive?*YesNoFor homes that have participated in the Home Performance w/ ENERGY STAR program in the last 12 months there is an additional $250 per ton incentive available. Are you applying for the Home Performance w/ ENERGY STAR bonus incentive?*YesNoAre you applying for third party financing?*YesNoPlease attach copies of dated invoices with equipment make and model specifications.* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, png, xls, xlsx, Max. file size: 1 GB. Sign HereDownload Eligible Equipment & Incentives, and read Terms and ConditionsI have read and understand the terms and conditions. I certify that the information I have provided is true and correct and the products(s) and equipment for which I am requesting an incentive meets the requirements in this application.* Yes Customer Digital Signature* Date* MM slash DD slash YYYY Δ