Natural Gas Energy Efficient Equipment Rebate Form

1 residential electric and/or Natural Gas Rebate Mail to: Central Hudson Rebate Center 980 Beaver Creek Drive Martinsville, VA 24112(Please do not send this form with your utility bill payment)CUSTOMER INFORMATIONNameCentral Hudson Account NumberInstalled AddressCityStateZIP CodeE-mail AddressHome PhoneWork PhoneTrade Ally Company Name *Trade Ally Phone NumberDate of InstallationWhat type of residence do you live in? Single Family 2 4 Unit Apartment 5+ Unit Apartment Duplex Mobile Townhouse/RowhouseExisting Heating System Type? Furnace Hydronic Boiler Steam Boiler Heat Pump electric Baseboard Space Heater Fireplace/StoveDid you convert to Natural gas from another fuel source?

2 If so, which: Gas Electricity Oil Propane Wood Does your home have central air conditioning? Yes NoHow did you hear about this program? Bill Insert Postcard or Other Mailing Web Site E-mail Radio Newspaper Trade Ally Central Hudson Employee - Name: Family/Neighbor/Friend Other: General Terms and Conditions for residential Customers1. Equipment and services must be purchased January 1, 2016, through December 31, 2018. 2. Work must be completed by a participating Central Hudson SavingsCentral Trade Incentives are available for residential gas and electric customers of Central Hudson replacing Equipment in existing homes.

3 Measures installed in newly constructed homes are not eligible for It is the responsibility of the customer to ensure that all requirements for the Rebate are met and that all required documentation is Rebate payments will be based on the Equipment purchase Failure to provide any of the required information will prevent processing of your Central Hudson reserves the right to review the installations in order to ensure compliance with all program requirements. Central Hudson may choose to review locations to verify completion of the projects and to measure and verify Energy savings. Such reviews will be made at a time convenient to the applicant, with advanced notice given to the applicant.

4 Misrepresentation of installation location or measure eligibility may result in forfeiture of the incentive Program procedures, requirements and Rebate levels are subject to change or cancellation without One Rebate check will be issued to the customer for each approved and completed application. Where applicable, a separate check will be issued to the contractor for each approved and completed Installations must be completed in accordance with all laws, codes and other requirements applicable under federal, state and local You are urged to seek appropriate consultation concerning any tax liabilities that could be associated with the receipt of the Customer verifies that they have not received any other incentives from any other state programs for the same Equipment for which a Rebate is being requested in this Central Hudson is entitled to 100% of the Energy benefits associated with the rebated measures.

5 Excluding the value of Energy cost savings realized by the Central Hudson assumes no responsibility for the performance of the Equipment and Equipment warranty, the quality of the work, labor and/or materials supplied, and/or the acts or omissions of the Trade The Equipment must be purchased new and installed at the above listed customer The customer hereby relieves and indemnifies Central Hudson of any and all liability associated with this I understand that I may be contacted by Central Hudson via survey or questionnaire to provide feedback on my satisfaction with the signing this application, the customer agrees to the terms and conditions of this document.

6 The customer hereby consents to the utilization and release of his or her Energy consumption data and usage by Central Hudson and/or its designees including program administrators and evaluation contractors. These administrators and contractors are obligated to Central Hudson to keep customer information confidential. The release and usage of data will be only for program evaluation, program eligibility determination, Energy savings purposes and analysis and will be kept Signature Date * Self-installs allowed for heat pump water heaters Hudson Gas & electric provides rebates to residential customers for installing high efficiency HVAC Equipment that meets program requirements.

7 Except for heat pump water heaters, all Equipment must be installed by a participating SavingsCentral Trade Ally, all of whom are listed on To receive your Rebate , please fill out this form completely and mail it to the address below with: A copy of your dated sales receipt from a SavingsCentral Trade Ally An AHRI Certification or Manufacturer s specification sheet, including model numbers and performance ratings (provided by your Trade Ally)Central Hudson Gas & electric has evaluated and qualified Energy saving measures listed on this page. For an Energy efficiency measure to be eligible, it must meet the minimum program requirements. If you have questions or need assistance, please call (800) 515-5353 or visit ensure that the product meets the standards in the table below.

8 Trade Ally should complete this side of HVAC SYSTEMSM easures and Rebate LevelsRebate ClaimedSEEREERHSPFM anufacturerCondenser Model # (Outside Unit)Condenser Serial # (Outdoor Unit)Coil Model #AHRI Reference #Air-Source Heat PumpsTier 1 ($350):SEER 15; EER 12 HSPF 2 ($500):SEER 16; EER 13 HSPF 9 Natural GAS HVAC SYSTEMSM easureRebate ClaimedAFUEH eating Capacity (KBTU/hr)ManufacturerModel #Serial #AHRI Reference #Furnace Tier 1 ($200): AFUE 92%; < 225 KBTU/hrTier 2 ($300):AFUE 95%; < 225 KBTU/hrWater Boiler$700: AFUE 90%; < 300 KBTU/hrSteam Boiler$250: AFUE 82%; < 300 KBTU/hr OTHER MEASURESM easureRebate ClaimedQuantityManufacturerModel #Serial #AHRI Reference #ECM Furnace Fan** (Installed on Qualifying Furnace) $200N/AN/AHeat Pump Water Heater Energy Factor and < 55 gallons$450N/AHeat Pump Water Heater Energy Factor and 55 gallons$125N/AIndirect Hot Water Heater (Listed on Sales Receipt)Tank Size: _____ gallons$250N/ABoiler Reset Control (Listed on Sales Receipt)$125N/AN/AWi-Fi Thermostat Max 2 per application**$20N/AN/ATotal Rebate Amount Requested(Incomplete information will delay or disqualify your Rebate )$** ECMs and thermostats must be installed with another qualifying HVAC system.

9 If an ECM is installed on a gas furnace, the AHRI certificate for the furnace must list the ECM.