Customer Rebate Application Form

2009 LIPA Residential Geothermal Program

Important: Please read the attached instruction page thoroughly before submitting all forms (Keep a copy for your records)

Customer Information
Customer Name: ________________________________________________________ LIPA Electric Account Number at Installation Address:
Installation Address: ______________________________________________________
City: ____________________________________ State: ___________ Zip _________ ………-……-…………-…
Mailing Address (if different): _______________________________________________ Installation Date: ______/______/______
City: ____________________________________ State: ___________ Zip _________ I would like my rebate: (check one):
Daytime Telephone ( ) ____________________ … Credited to my LIPA electric account
… Sent to me as a check

Equipment Information
Unit #1 Size (Tons): ________ EER Rating: ________________ COP Rating: ________________ ARI Reference #_______________
Manufacturer: _________________________ Model No.: _______________________ Serial No.: _______________________
… Closed Loop … New Home … New ENERGY STAR Home … Used for Space Heating
… Open Loop / Well … New Install (existing home) … Replacement Installation … Used for Water Heating

Unit #2 Size (Tons): ________ EER Rating: ________________ COP Rating: ________________ ARI Reference #_______________
Manufacturer: _________________________ Model No.: _______________________ Serial No.: _______________________
… Closed Loop … New Home … New ENERGY STAR Home … Used for Space Heating
… Open Loop / Well … New Install (existing home) … Replacement Installation … Used for Water Heating

Unit #3 Size (Tons): ________ EER Rating: ________________ COP Rating: ________________ ARI Reference #_______________
Manufacturer: _________________________ Model No.: _______________________ Serial No.: _______________________
… Closed Loop … New Home … New ENERGY STAR Home … Used for Space Heating
… Open Loop / Well … New Install (existing home) … Replacement Installation … Used for Water Heating

Unit #4 Size (Tons): ________ EER Rating: ________________ COP Rating: ________________ ARI Reference #_______________
Manufacturer: _________________________ Model No.: _______________________ Serial No.: _______________________
… Closed Loop … New Home … New ENERGY STAR Home … Used for Space Heating
… Open Loop / Well … New Install (existing home) … Replacement Installation … Used for Water Heating

I certify that I purchased the unit(s) described above, and on the enclosed invoice and / or contract, and that they were installed at the location indicated.
I agree to the terms and conditions stated on this application (see eligibility requirements).

______________________________________________ ______ / ______ / ______

Customer’s Signature Date
Contractor Information
Contractor Name: ________________________________________________ Contractor Daytime Telephone: _____________________
Address: ______________________________________ City: _____________________________ State: _________ Zip: __________
I certify that the system has been installed in accordance with ACCA Manual J version 8.0 calculations and that the calculation was performed using ACCA-approved software. I also certify
that I installed the unit(s) described above, and on the enclosed invoice and / or contract, and that they were installed at the location indicated. I agree to the terms and conditions stated on
this application (see eligibility requirements).

Print Contractor Name: _________________________________________ E-mail Address: ____________________________________

Optional

Contractor Signature: _______________________________________ Date: ______ / ______ / ______

Any Questions? Call LIPA’s Infoline at: 1-800-692-2626

or visit LIPA’s Web site for more information at www.lipower.org/Efficiency
 Customer Rebate Application Form
2009 LIPA Residential Geothermal Program
Instructions
1. Customer picks the contractor of their choice
2. Customer, with the help of their contractor, chooses eligible equipment (See incentive chart and eligibility requirements below)
* Verify eligibility of the equipment and of the installation before signing a contract! Many rebate
applications are denied because the equipment is not listed in the ARI directory, or one of the other
eligibility requirements are not met
3. Contractor performs Manual J version 8 calculation
4. Contractor installs properly sized qualifying equipment
5. Customer completes Customer Information section of rebate application
6. Contractor completes Equipment Information and Contractor Information sections of rebate application
7. Both the contractor and customer sign the rebate application and keep a copy for their records
8. Contractor (or customer) submits the rebate application and all required documentation (See eligibility requirements below) to
LIPA at the following address:
LIPA Residential Geothermal Program
25 Hub Drive
Melville, NY 11747

Please Note: 2009 Rebate amounts are paid by the UNIT

2009 Residential Geothermal Customer Incentive
EER New Geothermal Installation Replacement Geothermal Installation
>= 13.0 & < 16.0 $700/unit $200/unit
>= 16.0 & < 19.0 $800/unit $250/unit
>= 19.0 $1,000/unit $350/unit
• Replacement refers to any installation where the previous equipment was a geothermal heat pump

Eligibility Requirements for Residential Geothermal Incentives

1. Units must be installed between January 1, 2009 and December 31, 2009
2. There must be a LIPA residential electric account at the installation site and it must be in the applicant’s name
3. Qualifying units must be listed in the ARI directory at the time of installation
(Visit www.aridirectory.org/ to verify equipment eligibility)
4. Split systems must be installed with the matching pieces specified in the ARI directory at the time of installation
5. These incentives apply to new and replacement total system installations performed during the term of this rebate program (The heat pump unit
and air handler / fan coil must both be installed new. Partial system replacements do not qualify)
6. All qualifying units installed at a residence must be documented on the same application (additional sheets may be attached if necessary)
7. Replacement of systems less than five years old, that were rebated by LIPA, are not eligible for another rebate unless the EER level of the
replacement unit is higher than the existing unit by at least 1 full EER level
8. The Contractor must use an ACCA approved Manual J version 8 software package to perform the load calculation, and then size the unit(s)
accordingly. (Visit http://www.acca.org/software/ for a current list of ACCA approved Manual J version 8 software)
9. Rebate applications must be received within 60 days of installation and contain all required documentation
a. Rebate Application Form
b. ACCA approved Manual J V8 software load calculation printout
c. Invoice or Contract must contain total cost (dollar amount), equipment make, model & serial number as well as customer name,
installation address, and installation date
d. Equipment Spec Sheet printout from the ARI On-Line Directory please indicate ARI Reference # on application
10. LIPA reserves the right to inspect and test the equipment installation, and review the original contract in order to ensure compliance with
program requirements.
* Failure to allow LIPA access to the equipment, or original contract, will result in a denial of the rebate application
11. LIPA is not responsible for lost mail
12. LIPA is not responsible for any tax liability imposed as a result of rebate payments
13. LIPA reserves the right to use the customer rebate to credit accounts in arrears
14. Please allow up to 60 days for the delivery of the rebate check or bill credit
15. LIPA reserves the right to modify or withdraw these incentives, and to adjust the eligibility requirements, at any time

Any Questions? Call LIPA’s Infoline at: 1-800-692-2626

or visit LIPA’s Web site for more information at www.lipower.org/Efficiency