Step 1 of 3 0% Customer InformationCooperative(Required) Member's Name(Required) First Last Member's Address(Required) 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 Best Contact Phone Number(Required)Customer Type(Required) Residential Commercial Industrial Rebate InformationCheck all that apply(Required) Geothermal Rebate Heat Pump Rebate Electric Water Heater Rebate Electric Vehicle - Level 2 Charger Smart Thermostat Geothermal Rebate Information Minimums: Closed Loop: 17.1 EER, 3.6 COP Open Loop: 21.1 EER, 4.1 COPManufacturer Size (in tons) EER COP Heating Backup(Required) Oil Natural Gas Propane Electric Other Water Heating Option:(Required) Supplemental On-demand Not applicable Loop Type(Required) Horizontal Vertical Pond Open Well Pump & Dump Type of System That Was Replaced(Required) Geo HP Dual Fuel Propane Natural Gas Oil Other Electric New Home Closed or Open Loop(Required) Closed Loop Open Loop Buckeye AC load control switch installed?(Required) Yes No Existing Cool Returns rebate submitted online?(Required) Yes No AC Switch Number Heat Pump Rebate Information ENERGY STAR Minimum - Central System or Ductless Mini Split: Split System: 15.0 SEER, 8.5 HSPF Sgl Pkg Sys: 15.0 SEER and 8.2 HSPFManufacturer Size (in tons) SEER HSPF Heating Backup(Required) Oil Natural Gas Propane Electric Other Type of System That Was Replaced(Required) Geo HP Dual Fuel Propane Natural Gas Oil Other Electric New Home None Ductless Mini-Split System Type Single Zone Multi-Zone Central System Type Split System Single Package System Buckeye AC load control switch installed? Yes No Existing Cool Returns rebate submitted online?(Required) Yes No AC Switch Number Electric Water Heater Rebate Information Standard Storage Tank Units Must be Greater than or Equal to 91% EFManufacturer Tank Size (in gallons) Size of Elements (in watts) EF Type Standard Buckeye AC load control switch installed? Yes No Existing Type of System That Was Replaced(Required) Electric Propane Natural Gas Fuel Oil Other New Home LM Switch Number ENERGY STAR® Logo and rating on EnergyGuide label verified/confirmed Yes No Electric Vehicle - Level 2 ChargerManufacturer Number of Ports Model County Inspection Complete?(Required) Yes No DOCUMENT UPLOAD. Please upload all required documentation. (receipts, specs, etc.)Max. file size: 256 MB.Customer Agreement & ConsentCustomer Consent(Required) I hereby verify the information to be true and complete. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.Customer Electronic Signature (Full Name)(Required)
