Equipment Information
(To be completed by dealer/contractor) Complete information for the applicable rebate you are applying for:
Water Heater Replacement
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
Capacity gal.__________________________
BTUH Input_ __________________________
Energy EF Rating_ ______________________
Setback Thermostat
q Self-Installed q Professionally Installed
Thermostat controls:
q Heating System q Gas q Other
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Mail completed application and itemized invoice to:
Black Hills Energy
c/o Energy Savers plus
PO Box 7390
Des Moines, IA 50309
ADDITIONAL INFORMATION
For more information or to download additional applications
visit www.blackhillsenergy.com or call our toll-free Energy Savers
plus hotline at 1-888-567-0799
Innovative Space and
Water Heating
q Drain Heat Recovery
q Multi-Zone Thermostat
q Integrated Space & W/H
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
Rated efficiency
(AFUE/CAE% )_________________________
Furnace Maintenance
Approx age of furnace________________ yrs
Check Below to validate required services
completed
q Inspect fan blower/motor exposed vent/gas
pipe & fittings
q Test/inspect furnace controls
q Clean/adjust burners & pilots
q Inspect & change filter if needed
q Visually inspect Heat Exchanger
q Check thermostat operation & settings
Furnace/Boiler Replacement
q Furnace q Boiler
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
BTUH Input_ __________________________
Rated efficiency
(AFUE/CAE% ) _ _______________________
q Efficient Fan Motor
(Premises with one to four units, and
manufactured homes, are eligible.)
Envelope
Date Installed_ ________________________
Heating Efficiency AFUE_ _________________
Insulation (ceiling) Sq Ft__________________
Initial R-Value_________ Final R-Value_______
IA_660_08a • 12/08
Insulation (wall) Sq Ft_ __________________
Initial R-Value_________ Final R-Value_______
Insulation (foundation) Sq Ft_ _____________
Initial R-Value_________ Final R-Value_______
Door R-Value__________________________
2009 Iowa Residential
Rebate Application
Furnace and Boiler Replacement—Insulation—Doors—Water Heater Replacement—Set Back Thermostats—Furnace Maintenance
Sign Up Now And Save
Installing energy-efficient technology is
a smart way for Residential customers
to lower energy bills and enjoy the long-
term savings and increased comfort by
installing energy-efficient measures.
Rebate Checklist
Get your rebate faster by checking off these easy steps before
mailing your application form. Complete and accurate application
forms mean less delays in getting you your rebate check.
q Audit completed if required
q Application completely filled out
q All receipts attached
q Reviewed Terms and Conditions and signed
and dated application
q Make and retain copies of all documents and application
q Make additional copies of form, total of 3, for dealer,
Black Hills Energy and yourself
q Send all documents to correct address listed on application
q Dealer portion completely filled out and signed
Terms and Conditions
GENERAL ELIGIBILITY
This program offers financial incentives for the purchase of
natural gas heating equipment and other listed energy-efficiency
improvements. To qualify for rebates, an applicant must meet the
following eligibility requirements:
Applicant must be a current Iowa residential customer of Black
n
Hills Energy.
n Purchase and installations must be completed between
Jan.1, 2009 and Dec. 31, 2009. Applications for work done
in 2009 must be received by Jan. 31, 2010.
n Applications will be processed on a first-come, first-served basis.
The program will end when the budget is depleted. Funds are
limited.
n This program is subject to regulatory rules and orders, and Black
Hills Energy reserves the right to change or to end any portion of
this program without notice.
n To avoid delay, the dealer invoice returned with your rebate
application must include manufacturer, model and serial
number, efficiency rating and date of installation. Equipment
cost, labor and tax must be itemized.
n Where applicable, energy-efficiency ratings must comply with
those listed in the Gas Appliance Manufacturers Association
(GAMA) Directory.
n Checks will be made payable to customer shown on invoice.
n To qualify for the rebate, heating equipment must meet
minimum efficiency requirements as listed in this application.
n Financing is offered in lieu of energy efficiency rebates. You
have a choice of low-rate financing or a rebate, not both. For
financing information please call 800-519-3571.
Qualifying Equipment For Rebates Customer Information Facility Information
(To be completed by customer)

NATURAL GAS WATER HEATING Account Number Located in upper right-hand corner of Black Hills Energy natural gas bill Type of Facility: q New q Existing q Addition
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT Year Built__________________Square Footage____________
Storage Water Heater n 0.62 to 0.79 EF ≥ 40 gallon and ≤ 75,000 BTUH $75 q Own q Rent
Storage/Condensing or Tankless n ≥ 0.80 EF or 90% TE ≥ 40 gallon $300
Homeowner New or Replacement Equipment: q New q Replacement
Name (if different)____________________________________
(Please print) Space Heating Type:
INNOVATIVE SPACE & WATER HEATING TECHNOLOGIES q Forced Air Furnace Approximate Age of unit__________
Name on Account_ ___________________________________
EFFICIENCY REQUIREMENTS EFFICIENCY REQUIREMENTS Rebate Amount q Boiler Approximate Age of unit__________
Installation Address__________________________________
Drain Heat Recovery n Minimum standards $300 q Electric Heat /Other Approximate Age of unit__________
Integrated Space & Water Heater n 84% CAE or above $500 City_________________________State_______ ZIP_ ________
Central Air: q Yes q No
Multi-Zone Thermostats n Minimum standards $300  Approximate Age of unit__________
Telephone (Day)_ ______________(Evening)________________
Water Heating Fuel: q Gas q Electric q Other
Name/Address where rebate check should be sent, if different:  Approximate Age of unit__________
HIGH–EFFICIENCY FORCED AIR FURNACES or BOILERS
Name_____________________________________________
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT Important
City________________________State_______ Zip__________ A final itemized invoice for all materials, labor and taxes related to
Furnace n 92% to 93.9% AFUE natural gas furnace $250
the Rebate Application must be attached. For Envelope Measure
Furnace n 94% to 95.9% AFUE natural gas furnace $325 APPLICANT AGREEMENT Retrofit, a pre-qualifying Black Hills Energy Energy Audit must also
Furnace n ≥ 96% AFUE natural gas furnace $400 I certify that I have read and agreed to the terms and conditions of be attached.
Boiler ≤ 300 kBTUH n 85% to 89.9% AFUE natural gas boiler $150 the Black Hills Energy Energy Savers plus program on the front. I
understand that I must attach invoices and supporting documents VERIFICATION
Boiler ≤ 300 kBTUH n ≥ 90% AFUE natural gas boiler $400 (receipts) with rebate application. The sales receipt indicating date of purchase, dealer/contractor
name, manufacture name and model number of equipment must
Signature___________________________________________ accompany the rebate application. Incomplete applications will be
SETBACK THERMOSTAT & FURNACE/BOILER MAINTENANCE delayed. Black Hills Energy reserves the right to verify sales receipts
Date______________________________________________ and installations. After approval, please allow four to six weeks for
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT delivery of the rebate check.
Setback Thermostat n ENERGY STAR qualified • Self-installed Up to $25 Certification
(To be completed by dealer/contractor or builder) TAX INFORMATION
Setback Thermostat n ENERGY STAR qualified • Professionally installed Up to $50 Rebates may be subject to federal and/or state income tax
We certify that the indicated equipment was installed per the Terms
Furnace/Boiler Maintenance n For natural gas furnaces/boilers Up to $30 reporting. Applicant is responsible for contacting a qualified
and Conditions of this program at the address shown. All Terms
tax advisor to determine tax liability. Black Hills Energy is not
Combined Service n Furnace/boiler maintenance & professionally installed Up to $100 and Conditions of the program have been met. We certify that all
responsible for any tax consequences of the rebate program.
setback thermostat equipment information provided in the application is correct. Black
Hills Energy reserves the right to inspect and verify any equipment
before or after issuing rebates. Attach copy of all invoices and
DISCLAIMER
Black Hills Energy does not guarantee that installation of equipment
related materials to rebate form.
ENVELOPE MEASURES RETROFIT* qualifying for rebates will result in reduced energy usage or
Dealer/Contractor Name_ ______________________________ demand, or in cost savings. The Customer will hold harmless
EQUIPMENT TYPE Efficiency Requirement REBATE AMOUNT Black Hills Energy and its officers, directors, shareholders, agents,
Insulation (ceiling) n ≥ R-38 (audit recommendation required) 70% of cost up to $750 Dealer Address_ _____________________________________ employees, and representatives from all claims, liabilities, fines,
interest, costs, expenses, and damages incurred by the Customer,
Insulation (wall) n ≥ R-11 (audit recommendation required) 70% of cost up to $750
City_________________________State_______ Zip__________ for any damage, injury, death, loss or destruction of any kind to
Insulation (foundation) n ≥ R-13 (audit recommendation required) 70% of cost up to $750 persons or property, to the extent the damage, injury, death, loss
Infiltration Control n Weather-stripping, caulking, etc. 70% of cost up to $200 Telephone__________________________________________ or destruction arises out of or is related to the conduct, negligence,
(audit recommendation required) willful misconduct, misrepresentation, breach of warranty or other
Fax_______________________________________________ breach of this rebate form on the part of Black Hills Energy.
Doors n R-5 to R-10 (audit recommendation required) $25
Doors n ≥ R-11 (audit recommendation required) $50 E-mail_____________________________________________

Dealer/contractor signature_ ____________________________

*Black Hills Energy’s Residential Audit Program is necessary for eligibility. Contact Black Hills Energy for details and attach a copy of the audit results to this rebate form.
Call 1-888-567-0799 to schedule free energy audit.
Date______________________________________________
Qualifying Equipment For Rebates Customer Information Facility Information
(To be completed by customer)

NATURAL GAS WATER HEATING Account Number Located in upper right-hand corner of Black Hills Energy natural gas bill Type of Facility: q New q Existing q Addition
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT Year Built__________________Square Footage____________
Storage Water Heater n 0.62 to 0.79 EF ≥ 40 gallon and ≤ 75,000 BTUH $75 q Own q Rent
Storage/Condensing or Tankless n ≥ 0.80 EF or 90% TE ≥ 40 gallon $300
Homeowner New or Replacement Equipment: q New q Replacement
Name (if different)____________________________________
(Please print) Space Heating Type:
INNOVATIVE SPACE & WATER HEATING TECHNOLOGIES q Forced Air Furnace Approximate Age of unit__________
Name on Account_ ___________________________________
EFFICIENCY REQUIREMENTS EFFICIENCY REQUIREMENTS Rebate Amount q Boiler Approximate Age of unit__________
Installation Address__________________________________
Drain Heat Recovery n Minimum standards $300 q Electric Heat /Other Approximate Age of unit__________
Integrated Space & Water Heater n 84% CAE or above $500 City_________________________State_______ ZIP_ ________
Central Air: q Yes q No
Multi-Zone Thermostats n Minimum standards $300  Approximate Age of unit__________
Telephone (Day)_ ______________(Evening)________________
Water Heating Fuel: q Gas q Electric q Other
Name/Address where rebate check should be sent, if different:  Approximate Age of unit__________
HIGH–EFFICIENCY FORCED AIR FURNACES or BOILERS
Name_____________________________________________
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT Important
City________________________State_______ Zip__________ A final itemized invoice for all materials, labor and taxes related to
Furnace n 92% to 93.9% AFUE natural gas furnace $250
the Rebate Application must be attached. For Envelope Measure
Furnace n 94% to 95.9% AFUE natural gas furnace $325 APPLICANT AGREEMENT Retrofit, a pre-qualifying Black Hills Energy Energy Audit must also
Furnace n ≥ 96% AFUE natural gas furnace $400 I certify that I have read and agreed to the terms and conditions of be attached.
Boiler ≤ 300 kBTUH n 85% to 89.9% AFUE natural gas boiler $150 the Black Hills Energy Energy Savers plus program on the front. I
understand that I must attach invoices and supporting documents VERIFICATION
Boiler ≤ 300 kBTUH n ≥ 90% AFUE natural gas boiler $400 (receipts) with rebate application. The sales receipt indicating date of purchase, dealer/contractor
name, manufacture name and model number of equipment must
Signature___________________________________________ accompany the rebate application. Incomplete applications will be
SETBACK THERMOSTAT & FURNACE/BOILER MAINTENANCE delayed. Black Hills Energy reserves the right to verify sales receipts
Date______________________________________________ and installations. After approval, please allow four to six weeks for
EQUIPMENT TYPE EFFICIENCY REQUIREMENTS REBATE AMOUNT delivery of the rebate check.
Setback Thermostat n ENERGY STAR qualified • Self-installed Up to $25 Certification
(To be completed by dealer/contractor or builder) TAX INFORMATION
Setback Thermostat n ENERGY STAR qualified • Professionally installed Up to $50 Rebates may be subject to federal and/or state income tax
We certify that the indicated equipment was installed per the Terms
Furnace/Boiler Maintenance n For natural gas furnaces/boilers Up to $30 reporting. Applicant is responsible for contacting a qualified
and Conditions of this program at the address shown. All Terms
tax advisor to determine tax liability. Black Hills Energy is not
Combined Service n Furnace/boiler maintenance & professionally installed Up to $100 and Conditions of the program have been met. We certify that all
responsible for any tax consequences of the rebate program.
setback thermostat equipment information provided in the application is correct. Black
Hills Energy reserves the right to inspect and verify any equipment
before or after issuing rebates. Attach copy of all invoices and
DISCLAIMER
Black Hills Energy does not guarantee that installation of equipment
related materials to rebate form.
ENVELOPE MEASURES RETROFIT* qualifying for rebates will result in reduced energy usage or
Dealer/Contractor Name_ ______________________________ demand, or in cost savings. The Customer will hold harmless
EQUIPMENT TYPE Efficiency Requirement REBATE AMOUNT Black Hills Energy and its officers, directors, shareholders, agents,
Insulation (ceiling) n ≥ R-38 (audit recommendation required) 70% of cost up to $750 Dealer Address_ _____________________________________ employees, and representatives from all claims, liabilities, fines,
interest, costs, expenses, and damages incurred by the Customer,
Insulation (wall) n ≥ R-11 (audit recommendation required) 70% of cost up to $750
City_________________________State_______ Zip__________ for any damage, injury, death, loss or destruction of any kind to
Insulation (foundation) n ≥ R-13 (audit recommendation required) 70% of cost up to $750 persons or property, to the extent the damage, injury, death, loss
Infiltration Control n Weather-stripping, caulking, etc. 70% of cost up to $200 Telephone__________________________________________ or destruction arises out of or is related to the conduct, negligence,
(audit recommendation required) willful misconduct, misrepresentation, breach of warranty or other
Fax_______________________________________________ breach of this rebate form on the part of Black Hills Energy.
Doors n R-5 to R-10 (audit recommendation required) $25
Doors n ≥ R-11 (audit recommendation required) $50 E-mail_____________________________________________

Dealer/contractor signature_ ____________________________

*Black Hills Energy’s Residential Audit Program is necessary for eligibility. Contact Black Hills Energy for details and attach a copy of the audit results to this rebate form.
Call 1-888-567-0799 to schedule free energy audit.
Date______________________________________________
Equipment Information
(To be completed by dealer/contractor) Complete information for the applicable rebate you are applying for:
Water Heater Replacement
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
Capacity gal.__________________________
BTUH Input_ __________________________
Energy EF Rating_ ______________________
Setback Thermostat
q Self-Installed q Professionally Installed
Thermostat controls:
q Heating System q Gas q Other
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Mail completed application and itemized invoice to:
Black Hills Energy
c/o Energy Savers plus
PO Box 7390
Des Moines, IA 50309
ADDITIONAL INFORMATION
For more information or to download additional applications
visit www.blackhillsenergy.com or call our toll-free Energy Savers
plus hotline at 1-888-567-0799
Innovative Space and
Water Heating
q Drain Heat Recovery
q Multi-Zone Thermostat
q Integrated Space & W/H
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
Rated efficiency
(AFUE/CAE% )_________________________
Furnace Maintenance
Approx age of furnace________________ yrs
Check Below to validate required services
completed
q Inspect fan blower/motor exposed vent/gas
pipe & fittings
q Test/inspect furnace controls
q Clean/adjust burners & pilots
q Inspect & change filter if needed
q Visually inspect Heat Exchanger
q Check thermostat operation & settings
Furnace/Boiler Replacement
q Furnace q Boiler
Date Installed_ ________________________
Mfr. Name____________________________
Model#______________________________
Serial #______________________________
BTUH Input_ __________________________
Rated efficiency
(AFUE/CAE% ) _ _______________________
q Efficient Fan Motor
(Premises with one to four units, and
manufactured homes, are eligible.)
Envelope
Date Installed_ ________________________
Heating Efficiency AFUE_ _________________
Insulation (ceiling) Sq Ft__________________
Initial R-Value_________ Final R-Value_______
IA_660_08a • 12/08
Insulation (wall) Sq Ft_ __________________
Initial R-Value_________ Final R-Value_______
Insulation (foundation) Sq Ft_ _____________
Initial R-Value_________ Final R-Value_______
Door R-Value__________________________
2009 Iowa Residential
Rebate Application
Furnace and Boiler Replacement—Insulation—Doors—Water Heater Replacement—Set Back Thermostats—Furnace Maintenance
Sign Up Now And Save
Installing energy-efficient technology is
a smart way for Residential customers
to lower energy bills and enjoy the long-
term savings and increased comfort by
installing energy-efficient measures.
Rebate Checklist
Get your rebate faster by checking off these easy steps before
mailing your application form. Complete and accurate application
forms mean less delays in getting you your rebate check.
q Audit completed if required
q Application completely filled out
q All receipts attached
q Reviewed Terms and Conditions and signed
and dated application
q Make and retain copies of all documents and application
q Make additional copies of form, total of 3, for dealer,
Black Hills Energy and yourself
q Send all documents to correct address listed on application
q Dealer portion completely filled out and signed
Terms and Conditions
GENERAL ELIGIBILITY
This program offers financial incentives for the purchase of
natural gas heating equipment and other listed energy-efficiency
improvements. To qualify for rebates, an applicant must meet the
following eligibility requirements:
Applicant must be a current Iowa residential customer of Black
n
Hills Energy.
n Purchase and installations must be completed between
Jan.1, 2009 and Dec. 31, 2009. Applications for work done
in 2009 must be received by Jan. 31, 2010.
n Applications will be processed on a first-come, first-served basis.
The program will end when the budget is depleted. Funds are
limited.
n This program is subject to regulatory rules and orders, and Black
Hills Energy reserves the right to change or to end any portion of
this program without notice.
n To avoid delay, the dealer invoice returned with your rebate
application must include manufacturer, model and serial
number, efficiency rating and date of installation. Equipment
cost, labor and tax must be itemized.
n Where applicable, energy-efficiency ratings must comply with
those listed in the Gas Appliance Manufacturers Association
(GAMA) Directory.
n Checks will be made payable to customer shown on invoice.
n To qualify for the rebate, heating equipment must meet
minimum efficiency requirements as listed in this application.
n Financing is offered in lieu of energy efficiency rebates. You
have a choice of low-rate financing or a rebate, not both. For
financing information please call 800-519-3571.