"*" indicates required fields Step 1 of 4 25% For Electrically Heated HomesAll sections must be filled out by the installer at the time of installation. A copy of this completed form and the project invoice must be submitted to Lewis County PUD following the installation of eligible equipment.Household InformationCustomer Name* Service Address* Street Address 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 Customer Phone*Is your mailing address different than your service address?* Yes No Mailing Address* Street Address 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*Existing Site BuiltNew Construction Site BuiltManufacturedYear Built* Conditioned Area* Existing Heating Type*Zonal Heat includes: ceiling cable, baseboards, wall heaters, electric boiler/water heater attached to a hydronic system.Electric Forced AirElectric ZonalWood HeatInstallation InformationInstallation Type*DHPPTCSAHRI Certified Reference #* HSPF* SEER* Install Date* MM slash DD slash YYYY Outdoor Unit Manufacturer* Outdoor Unit Model #* Indoor Unit Model #:*(In main living area) Do you have additional indoor unit models to list?* No Yes Indoor Unit 2 Model #* Do you have a 3rd unit model number to list?* No Yes Indoor Unit 3 Model #* Do you have a 4th unit model number to list?* No Yes Indoor Unit 4 Model #* Total Installed Cost (Before Rebates):*Eligible Rebate Amount: DHP Installation Acknowledgement of Tasks Below Completed:*NoYes Yes, this DHP has been installed on a dedicated electrical circuit I have installed refrigerant line protection on the entire length of exterior, insulated refrigerant lines. I have installed the system in accordance with manufacturer specs, including proper refrigerant charging * New construction site built homes, existing heat pump systems, natural gas and oil furnaces are not eligible for the DHP program.PTCS Installation Acknowledgement of Tasks Below Completed:*NoYes Duct leakage testing completed for systems with more than 40 lineal feet of ducts in unheated space. *Washington State Energy Code Requirement. A copy of the above result has been submitted to the homeowner. Heat pump is sized to provide the homes heating load @ 30˚F outdoor air temperature. Auxiliary heat is locked out above 35˚F outdoor air temperature. A completed PTCS air source heat pump form has been submitted to the registry and Lewis County PUD. Installer Name Installation Company Installation Company Phone NumberType Your Name*I hereby verify the information provided on this form to be true and complete. I understand that by typing my full name below and submitting this information, this form will be stamped with today’s date and authorized by me as if I had signed my signature. I certify under penalty of perjury of the state of Washington that I am the individual named in the electronic signature block. File Upload Drop files here or Select files Max. file size: 30 MB. Privacy Act Statement Basic authority for collecting this information is authorized by 16 U.S.C. §§ 832 et. Seq., and 838 et. Seq., pursuant to Bonneville Power Administration’s Conservation Program system of records established 46 FR 31700.This information is primarily intended to further, but is incidental to the performance of BPA’s overall Energy Efficiency Program, the objective of which is to acquire energy resources through energy efficiency, to determine what cost-effective conservation and direct application renewable resources measures should be installed or adopted under different circumstances, and to provide incentives for the installation of such measures.Other routine issues of this information on include: aggregation into public database on energy efficiency; furnished to authorized personnel for installation / repair of equipment; aggregated into a database for program publicity; and in some instances information regarding buildings will be made available to subsequent purchasers of the buildings. Your disclosure of the requested information is voluntary; however failure to provide requested information means it will not be possible for you to participate in this BPA Energy Efficiency program. PhoneThis field is for validation purposes and should be left unchanged.