Homeowner Name(Required) First Last Mailing Address(Required) Street Address Address Line 2 City State 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 ZIP Code Site Address(Required) Same as Mailing Address Street Address Address Line 2 City State 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 ZIP Code Home Type(Required) Existing Site Built New Construction Site Built Manufactured Year Built(Required) Heated Area (Square Feet)(Required) Existing Heating System(Required) Electric Forced Air Electric Forced Air with AC Electric Zonal Air Source Heat Pump Geothermal Heat Pump Ductless Heat Pump Natural Gas Furnace Other Gas Company(Required) Back up Heat(Required) None Electric Forced Air Electric Zonal Heat Pump Ductless Heat Pump Natural Gas Furnace Non-Electric Space Heating Number of Water Heaters in Home Before This Installation(Required) Number of Water Heaters in Home After This Installation(Required) Number of Occupants(Required) Information About the Water Heater Being ReplacedFuel(Required) Electric Gas* Propane* Age (years)(Required) Size (gallons)(Required) Installation InformationBrand Installed(Required) Model(Required) Size (gallons)(Required) Installation Date (mm/dd/yyyy)(Required) MM slash DD slash YYYY Manufacturer Installation Training Location(Required) Date of Training (mm/dd/yyyy)(Required) MM slash DD slash YYYY Please specify other appliance(Required) Where was this water heater purchased?(Required) Installer Retailer Online Other Total Installed Cost (before rebates)(Required) Equipment Cost(Required) Labor Cost(Required) Electrical Cost(Required) Other Cost(Required)Please specify what cost was for Installation Location(Required) Interior Heated Location Unheated Location Specific Installation Location(Required) Garage Basement Other Installation Room Length(Required) Installation Room Width(Required) Installation Room Height(Required) Installation Room Size (cubic feet)(Required) Ducted Installation(Required) Yes No Carbon Monoxide Monitor Location(Required) Ducted out of conditioned space?(Required) Yes No Length of intake duct (feet)(Required) Length of exhaust duct (feet)(Required) Upload a copy of the purchase receipt or installer's invoice(Required)Max. file size: 499 MB.Consent(Required)This form must be signed by the person whose name appears on the electric utility account. Energy Information Release: The undersigned utility customer requests and authorizes the specified utility to release billing and usage information for the account listed below to Bonneville Power Administration (BPA). With this authorization, BPA can request billing information for up to two years pre installation and two years post installation. The utility customer also hereby releases the utility company from any and all liability arising from or connected with providing this information. Ravalli Electric Cooperative reserves the right to inspect pre-existing equipment (if applicable) prior to installation and energy efficient measures installed under this program. Ravalli Electric Cooperative reserves the right to terminate the Program and/or modify the incentive/ rebate levels without notice. The Member is responsible for checking with the Co-op to determine whether the Program has been changed or is still in effect. Missing or incorrect information may delay the processing of the rebate. Failure to comply with this Agreement will disqualify the Member from receiving program incentives. This Agreement does not guarantee that the equipment will meet the criteria necessary for program incentives. Members must apply for rebates within 90 days of the purchase date (as shown on the members invoice) and are subject to the current year program. I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Member Account Number(Required) Applicant Electronic Signature (Full Name)(Required) CommentsThis field is for validation purposes and should be left unchanged.
