Jackson County REMC

2009 Air-to-Air Heat Pump Incentive Claim Form

In an effort to lower the total system demand of electricity for Jackson County REMC and to delay the
need of new generating capacity for our wholesale power supplier, Hoosier Energy, we are offering the
following energy efficiency incentives for 2009. Incentives apply to equipment installed and operating
in the 2009 calendar year in homes or structures connected to Jackson County REMC. Interpretation of
qualifying equipment and installations are at the sole discretion of Jackson County REMC. Jackson
County REMC reserves the right to modify or discontinue the incentives at any time without notice.

Request forms for incentives must be completed in full and must be accompanied by an
installer’s invoice and a copy of the manufacturer's SEER rating information.

PLEASE CHECK ONE:

Installed in a new home or building or an addition Installed in an existing home or building

PLEASE CHECK ONE:

Adding a heat pump Replacing an existing heat pump

PLEA SE CHECK ONE: Back-up emergency heat system

Electric LP Gas Natural Gas Fuel Oil Other (list)_________________________

PLEASE CHECK ONE: Primary reason for choosing an electric heat pump
Cost of operation Safety REMC Incentive Other (please list) ___________________________

Heat pump brand __________________________________ Date heat pump installed ___________________________

Outdoor unit model # _______________________________ Purchased from __________________________________

SEER rating (14 minimum) __________________________ Installed by (name, address & phone): _________________

ARI Number _____________________________________ _______________________________________________________

Size (tons or Btu’s) ________________________________ _______________________________________________

Backup heat KW (if electric)__________________________ _______________________________________________________

ALL INSTALLATIONS ARE SUBJECT TO A VERIFICATION INSPECTION BY JACKSON COUNTY REMC

I certify that the above described equipment has been installed and is in full operating condition.

REMC Customer signature ______________________________________________________________________________

REMC customer name (please print) _____________________________________________________________________

Mailing address _______________________________________________________________________________________

REMC account # _________________________________ Daytime telephone # ______________________________

 Jackson County REMC
2009 Geothermal Heat Pump Incentive Claim Form
In an effort to lower the total system demand of electricity for Jackson County REMC and to delay the
need of new generating capacity for our wholesale power supplier, Hoosier Energy, we are offering the
following energy efficiency incentives for 2009. Incentives apply to equipment installed and operating
in the 2009 calendar year in homes or structures connected to Jackson County REMC. Interpretation of
qualifying equipment and installations are at the sole discretion of Jackson County REMC. Jackson
County REMC reserves the right to modify or discontinue the incentives at any time without notice.

Request forms for incentives must be completed in full and must be accompanied by an
installer’s invoice and a copy of the manufacturer's SEER rating information.

PLEASE CHECK ONE:

Installed in a new home or building or an addition Installed in an existing home or building

PLEASE CHECK ONE:

Adding a new geothermal heat pump Replacing an existing heating system (not geothermal)

PLEASE CHECK ONE: Back-up emergency heat system

Electric LP Gas Natural Gas Fuel Oil Other (list)_________________________

PLEASE CHECK ONE: Primary reason for choosing an electric heat pump
Cost of operation Safety REMC Incentive Other (please list) __________________________

Heat pump brand __________________________________ Date heat pump installed ___________________________

Heat pump model # _______________________________ Purchased from __________________________________

SEER rating (14 minimum) __________________________ Installed by (name, address & phone): _________________

ARI Number _____________________________________ _______________________________________________________

Size (tons or Btu’s) ________________________________ _______________________________________________

Backup heat KW (if electric)__________________________ _______________________________________________________

ALL INSTALLATIONS ARE SUBJECT TO A VERIFICATION INSPECTION BY JACKSON COUNTY REMC

I certify that the above described equipment has been installed and is in full operating condition.

REMC Customer signature ______________________________________________________________________________

REMC customer name (please print) _____________________________________________________________________

Mailing address _______________________________________________________________________________________

REMC account # _________________________________ Daytime telephone # _______________________________

 Jackson County REMC
2009 Central Air Conditioner Incentive Claim Form
In an effort to lower the total system demand of electricity for Jackson County REMC and to delay the
need of new generating capacity for our wholesale power supplier, Hoosier Energy, we are offering the
following energy efficiency incentives for 2009. Incentives apply to equipment installed and operating
in the 2009 calendar year in homes or structures connected to Jackson County REMC. Interpretation of
qualifying equipment and installations are at the sole discretion of Jackson County REMC. Jackson
County REMC reserves the right to modify or discontinue the incentives at any time without notice.

Request forms for incentives must be completed in full and must be accompanied by an
installer’s invoice and a copy of the manufacturer's SEER rating information.

PLEASE CHECK ONE:

Installed in a new home or building or an addition Installed in an existing home or building

PLEASE CHECK ONE: Type of heating system

Electric LP Gas Natural Gas Fuel Oil Wood Other

PLEASE CHECK ONE: Primary reason for choosing a central air conditioner
Cost of operation Safety REMC Incentive Other (please list) __________________________

Air conditioner brand ______________________________ Purchased from __________________________________

Air conditioner model # _____________________________ Installed by (name, address & phone): _________________

ARI Number _____________________________________ _______________________________________________________

SEER rating (14 minimum) __________________________ _______________________________________________

Size (tons or Btu’s) ________________________________ _______________________________________________

Date equipment installed ___________________________ _______________________________________________________

ALL INSTALLATIONS ARE SUBJECT TO A VERIFICATION INSPECTION BY JACKSON COUNTY REMC

I certify that the above described equipment has been installed and is in full operating condition.

REMC Customer signature ______________________________________________________________________________

REMC customer name (please print) _____________________________________________________________________

Mailing address _______________________________________________________________________________________

REMC account # _________________________________ Daytime telephone # _______________________________

 Jackson County REMC

2009 Heat Pump - Replacing Electric Resistance Heat - Claim Form

In an effort to lower the total system demand of electricity for Jackson County REMC and to delay the
need of new generating capacity for our wholesale power supplier, Hoosier Energy, we are offering the
following energy efficiency incentives for 2009. Incentives apply to equipment installed and operating
in the 2009 calendar year in homes or structures connected to Jackson County REMC. Interpretation of
qualifying equipment and installations are at the sole discretion of Jackson County REMC. Jackson
County REMC reserves the right to modify or discontinue the incentives at any time without notice.

Request forms for incentives must be completed in full and must be accompanied by an
installer’s invoice and a copy of the manufacturer's SEER rating information.

PLEASE CHECK ONE: Type of resistance heat being replaced

Electric furnace Ceiling cable Electric baseboard Other (list)_________________________

PLEASE CHECK ONE: Back-up emergency heat system for new heat pump
Electric LP Gas Natural Gas Fuel Oil Other (list)_________________________

PLEASE CHECK ONE: Primary reason for choosing an electric heat pump
Cost of operation Safety REMC Incentive Other (please list) ___________________________

Heat pump brand __________________________________ Date heat pump installed ___________________________

Outdoor unit model # _______________________________ Purchased from __________________________________

SEER rating (14 minimum) __________________________ Installed by (name, address & phone): _________________

ARI Number _____________________________________ _______________________________________________________

Size (tons or Btu’s) ________________________________ _______________________________________________

Backup heat KW (if electric)__________________________ _______________________________________________________

ALL INSTALLATIONS ARE SUBJECT TO A VERIFICATION INSPECTION BY JACKSON COUNTY REMC

I certify that the above described equipment has been installed and is in full operating condition.

REMC Customer signature ______________________________________________________________________________

REMC customer name (please print) _____________________________________________________________________

Mailing address _______________________________________________________________________________________

REMC account # _________________________________ Daytime telephone # _______________________________

 Jackson County REMC
2009 Water Heater Incentive Claim Form
In an effort to lower the total system demand of electricity for Jackson County REMC and to delay the
need of new generating capacity for our wholesale power supplier, Hoosier Energy, we are offering the
following energy efficiency incentives for 2009. Incentives apply to equipment installed and operating
in the 2009 calendar year in homes or structures connected to Jackson County REMC. Interpretation of
qualifying equipment and installations are at the sole discretion of Jackson County REMC. Jackson
County REMC reserves the right to modify or discontinue the incentives at any time without notice.

Request forms for incentives must be completed in full and must be accompanied by a
purchase invoice and copies of the manufacturer's capacity information and energy factor.

PLEASE CHECK ONE:

Installed in a new home, building or an addition Installed as a replacement in an existing home or building

PLEASE CHECK ONE: Type of water heater replaced (if it is a replacement unit)
Electric LP Gas Natural Gas Other (list) ____________________________________

PLEASE CHECK ONE: Primary reason for choosing an electric water heater
Cost of operation Safety REMC Incentive Other (please list) __________________________

Water heater brand _______________________________ Date unit installed ________________________________

Water heater model # _____________________________ Purchased from __________________________________

Water heater serial #______________________________ Installed by (name, address & phone): _________________

Gallon capacity _________________________________ _______________________________________________

Maximum wattage rating __________________________ _______________________________________________

Energy factor ___________________________________

ALL INSTALLATIONS ARE SUBJECT TO A VERIFICATION INSPECTION BY JACKSON COUNTY REMC

I certify that the above described equipment has been installed and is in full operating condition.

REMC Customer signature ______________________________________________________________________________

REMC customer name (please print) _____________________________________________________________________

Mailing address _______________________________________________________________________________________

REMC account # _________________________________ Daytime telephone # ______________________________