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TO RECEIVE YOUR REBATE, READ THE PROGRAM REQUIREMENTS ON REVERSE BEFORE PROCEEDING.
Please fill out this form completely and mail it to the address on the reverse side. You must include a copy of the
contractor’s invoice, paperwork showing the purchased equipment type, make and model numbers, and a copy of a recent
electric utility bill. These items must accompany each incentive Application.
CUSTOMER INFORMATION
(PLEASE PRINT) Customer First Name Last Name Electric Utility
(circle one) CL&P UI
Address (where equipment was installed) City State Zip
Type of Installation: (check one) New Installation (New Home) How did you hear about this Program? (check one)
New Installation (Existing Home) Radio Print Ad Manufacturer Ad
Replacement (of Existing System) Bill Insert Website Other:
EQUIPMENT INFORMATION
(THIS SECTION TO BE COMPLETED BY CONTRACTOR)
EQUIPMENT AHRI Total Incentive
C = Central A/C Install Manufacturer/ Model Numbers
Tonnage SEER EER HSPF Incentive Reference (Incentive x #
H = Heat Pump Date Brand (Condenser, Coil & Fan) No. of Units)
TOTAL $
CONTRACTOR INFORMATION
Contractor Name Telephone Number
( )
Address Fax Number
( )
City State Zip E-mail Address
I HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS ON THE REVERSE SIDE OF THIS APPLICATION.
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT AND THE PRODUCT(S) AND EQUIPMENT FOR
WHICH THE APPLICANT IS REQUESTING AN INCENTIVE MEETS THE REQUIREMENTS IN THIS APPLICATION.
SIGN
HERE Customer Signature: X ________________________________________ Date: / /
You may be eligible for federal tax credits. Please refer to www.energystar.gov for more information.
APPLICATION INFORMATION
Applications cannot be processed unless all of the appropriate fields on the front side of this application are complete. Please be sure you have
read the Terms and Conditions of this application. Attach a copy of the Contractor’s Invoice listing the condenser and evaporator model and serial
numbers and a copy of a recent electric utility bill.
CL&P and UI customers:
Please send your completed Connecticut Residential HVAC Incentive Application To:
EFI-CT HVAC REBATES
40 Washington St., Suite 2000
Westborough, MA 01581
1-877-364-4217
Connecticut’s Energy Efficiency Programs are funded by a Charge on Customer energy bills. The Programs are designed to help customers
manage their energy usage and cost.
C0036 Rev 01/10