Member Address Information (person receiving rebate)
PLEASE complete ALL sections. Sign form and attach proof of purchase to ensure proper and prompt payment of rebate.
Member Information
Enter N/A if not applicable
Equipment Location Information
Equipment Location Address
Account Type
Check if builder/developer
Rebate Types
(Select all that apply)

Air Source Heat Pump

ASHP Questions

Rebate Amount 1

Rebate Amount:
Any Unit        $200/Ton

Installation & Equipment Information

Type Of System Replaced:
Enter N/A if not applicable
Business Name

Heating Equipment Specifications

Round to nearest 0.5 ton

Appliances - Washer & Dryer

Washer/Dryer Questions

Rebate Amount 2

Rebate Amount:
Clothes Washer                $40/Unit
Electric Clothes Dryer     $20/Unit

Installation & Equipment Information

Please include model numbers with your attached proof of purchase.
Program Offer: The program covers products purchased and/or services rendered on or after January 1, 2024.

New Clothes Washer And Dryer Information


Serial Number

Date Installed




Central Air Conditioning

Central Air Conditioning Questions

Rebate Amount 3

Rebate Amount:
Any Unit        $100/Unit

Installation & Equipment Information


Central Air Conditioner Information

The information below can be obtained from your contractor, invoice, or nameplate on unit(s)
Seasonal Energy Efficiency Ratio
Energy Efficiency Ratio

Electric Vehicles & Charging Units

Check all that apply:

Electric Vehicle

EV & Charger Questions

Rebate Amount 4

Rebate Amount:
Level II Charger                 50% of Cost
                                         (up to $750)

Level II Charger Installation and Equipment Information

Charger Information

Business Name
REBATE = 50% of installed cost up to $750.
Installed cost includes contracted labor only and does not
include internal labor.
Attach proof of purchase and corresponding contractor
installation charges.

Electric Vehicle Information

Estimated Daily Miles
Estimated Annual Miles
Check if you
Please make sure to program your vehicle so it will not charge during the peak period of 4-9 PM whenever possible. This will help keep costs down for your Cooperative.

EV Ready

EV Ready Questions

Rebate Amount 8

Rebate Amount:
EV Ready - New Construction          $100
                   (240/208 VAC)

Electric Vehicle Ready

Check to certify that

Electric Forklift

Electric Forklift Questions

Rebate Amount 5

Rebate Amount:
Class I or II Forklift                up to $1,000 each
Class III Hand Lift/Truck        up to $350 each

Equipment Information

Electric Forklift Purchase Type (Please check all that apply)
(Note: Electric equipment replacing existing electric equipment does not qualify for this rebate program.)

Please fill out the following. If additional room is needed, please attach a supplemental table with the relevant information.




Model Number

Serial Number(s)

Cost per Unit

Rebate Amount




Model Number

Serial Number(s)

Cost per Unit

Rebate Amount




Model Number

Serial Number(s)

Cost per Unit

Rebate Amount

The rebate amount for the purchase of eligible new forklifts:
• $1000 per Class 1 or 2 lift
• $350 per Class 3 lift

The rebate amount for eligible leased forklifts will be:
• $1000 per Class 1 or 2 lift with equipment buyout language stated on leased agreement.
• $350 per Class 3 lift with equipment buyout language stated on leased agreement.
• Leased Class 1 or 2 lifts without buyout option(s)stated on lease agreement will receive up to $1000 per lift: (length of contract in years) x $100.
• Leased Class 3 lifts without buyout option(s) stated on lease agreement will receive up to $350 per lift: (length of contract in years) x $35.
Charge Type

Charge Type

Battery Type

Battery Type

Operation Shifts

Operation Shifts

Charging Days

Charging Days

Electric Water Heating

Water Heater Questions

Rebate Amount 6

Rebate Amount:
Heat Pump Water Heater        $350/Unit

Installation & Equipment Information

Business Name

New Water Heater Information



Serial Number

Tank Size (gal.)

Installed Cost


Geothermal Heat Pump

Geo Heat Pump Questions

Rebate Amount 7

Rebate Amount:
New                                                  $300/Ton
Geothermal Unit Only - Existing      $100/Ton

Installation & Equipment Information

Type Of System Replaced:

Heating Equipment Specifications

Round to nearest 0.5 ton

Geothermal Heat Pump Equipment Requirements

1. Equipment must be listed in the AHRI Certification Directory for geothermal equipment. This information can be verified online for a given model number at Data (including capacity) must be obtained from the appropriate section as follows:

2. Size of unit used to determine rebate is based on the cooling capacity listed in the appropriate section of the AHRI Directory.

3. Rebates will be paid per 1/2-ton increment with the capacity determined using the appropriate AHRI rating.

NOTE: Installing contractors should provide Members with the information necessary to complete the application for this program. Prior to installation, the contractor should be made aware of program requirements and you should contact the Cooperative to confirm that the system will qualify for an incentive.

The Cooperative reserves the right to suspend the rate and remove metering equipment owned by the Cooperative if the Member is no longer using the equipment on a regular basis or is in violation of any program requirement.

Terms and Conditions

Program Offer: The Program covers products purchased and/or services rendered on or after January 1, 2024.

General Terms and Conditions

Distributed Generation: Rebates shall be prorated based on the percent of power supplied by the cooperative if the member has distributed generation.

Application Information: Missing or incorrect information on the application may delay processing and delivery of the rebate. An invoice is required and should include specific product information, including the brand, model, serial number, and date of purchase of the energy efficient measures. Other information including manufacturer's equipment performance sheets may be required upon request.

The Cooperative reserves the right to verify sales transactions and to have reasonable access to the member’s facility to inspect preexisting equipment (if applicable) and energy efficient measures installed under this program.

Warranty Information: The Cooperative makes no warranties, expressed or implied, with respect to equipment operation, material, workmanship, or manufacturing. The Cooperative does not guarantee that a certain level of energy or cost savings will result from the use of products covered by this program.

Limitation of Liability: The Cooperative’s liability in connection with this program is limited to paying the rebate specified when all terms and conditions have been satisfied. Under no circumstances shall the Cooperative be liable for any consequential or incidental damages or tax liability resulting from participation in this program.

Participant Certification: Participating Member certifies that he/she purchased and installed the equipment listed on their application at the defined location served by the Cooperative. The Member agrees that all information provided is true and that he/she has conformed to all program requirements. If the equipment and application does not comply with the Cooperative’s rules and qualifications, the rebate amount may be denied or adjusted.

Program Changes/Termination: The Cooperative reserves the right to extend, modify (including incentive levels), or terminate this Program at any time without prior or further notice. The Member is responsible for checking with the Cooperative to determine whether the program has been changed or is still in effect.

Members must apply for rebates within six (6) months of the purchase date (as shown on the Member’s invoice) and are subject to the current year program offer if received after January 31st. Past eligibility, however, does not guarantee that equipment will meet criteria for current programs in effect.

Air Source Heat Pump (ASHP) Requirements

1. Eligible equipment includes air source heat pump, mini-split heat pumps and multi-split heat pumps.

2. Air source heat pumps must meet current federal minimum efficiency requirements and have a minimum capacity of 0.5 tons. Units must be rated in the AHRI Certification Directory (published by the Air-Conditioning Heating & Refrigeration Institute) which is available on-line at

3. When installing a split system (most common type of residential unit) both a new outdoor unit (condenser) and a new indoor A-coil (evaporator) must be installed.

4. Rebates for air source heat pumps are based on the unit capacity for as expressed in cooling tons. The capacity rating provided in the AHRI Directory is expressed in "Btuh." This amount must be divided by 12,000 to determine the number of tons (round to nearest half ton). Installing contractors should have this information or it can be found at

Appliance Requirements

Limit of two (2) clothes washer and/or (2) clothes dryer rebates per home.

Central Air Conditioning Requirements

1. Equipment and Installation Eligibility Requirements:

2. Members must provide a copy of the receipt to verify equipment installation. Invoices should contain size, efficiency and model and serial numbers for all equipment.

3. A maximum of two (2) air conditioner rebates per residence is allowed.

4. Must provide copy of AHRI certificate.

Specific Requirements for Central Air Conditioners

Most residential air conditioning systems are split systems that consist of indoor and outdoor equipment with a SEER (Seasonal Energy Efficiency Ratio) that has been determined for each matching assembly. To be eligible, both a new outdoor unit (condenser) and a new matching indoor A-coil (evaporator) must be installed.

The installing contractor should provide the homeowner with the SEER and EER rating for their specific system. These ratings for matched equipment should also be listed in the online AHRI Unitary Directory at

Electric Vehicles and Charging Units Requirements

Level II Charger:

· Rebate is for a Level II charger requiring a 240/208 volt input supply.

· For Residential applications, one rebate per membership is available.

· For Commercial applications, rebates are available up to four of each.

· The primary location of the charging unit must be at the address provided on this form and served by the cooperative.

· It is recommended that a qualified electrician complete the installation and verify the panel is large enough to accommodate the charger.

EV Ready:

· 240/208 Volt wiring with 50 amp breaker (to support 40 amp charging) box on back or side wall of garage with NEMA 6-50 or 14-50 outlet.

· Rebate is intended for new or remodeled homes that are pre-wired for EV chargers.

· Not intended for concurrent rebate with charger but to lower barriers for future installation.

Electric Forklift:

· Non-residential

· Purchase or lease a Class 1, 2, or 3 electric forklift(s) by December 31st, 2021.

· Meet one of the following 3 requirements: Initial forklift, Addition to existing forklift(s), Replacement of an existing internal combustion forklift.

· Proper documentation is required: Invoice, Lease Agreement, Make, Model, and Year.

Electric Water Heating Requirements:

1. The water heating equipment must be electric.

2. Water heaters must be used for domestic water heating only and cannot be used in conjunction with radiant space heating systems (e.g. boiler for in-floor or baseboard heating).

3. There is a limit of two heat pump water heater rebates per home.


Member Agreement
I verify that the above described equipment was installed on the date and location specified. I agree to all program requirements and that my electric cooperative reserves the right to inspect all equipment and verify information before issuing a rebate.
Sign above

Proof Of Purchase

Attach receipts or proofs of purchase here, or email them to the cooperative at
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