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PleaseReturnThisFormTo:

HeatPumpWaterHeaterInstallationFormAllsectionsmustbefilledoutbytheinstalleratthetimeofinstallation.Acopyofthiscompletedformandthepurchasereceiptorinvoicemustbepromptlysubmittedtothehomeowner’sutilityinaccordancewithutilitypolicy.

HouseholdInformationCustomerName InstallationAddress

City State Zip CustomerPhone

MailingAddress,ifdifferent:

HomeType: ExistingSiteBuilt NewConstructionSiteBuilt Manufactured

YearBuilt:

HeatedArea: SqFt

FoundationType(SiteBuilt): Crawlspace FullBasement HalfBasement Slab

ExistingHeatingSystem:

ElectricForcedAir ElectricForcedAirw/AC ElectricZonal AirSourceHeatPump GeothermalHeatPump

DuctlessHeatPump NaturalGasFurnace(GasCompany:_______________) OtherNon-ElectricSpaceHeating:_____________

BackupHeat:None Elec.ForcedAir Elec.Zonal HeatPump DuctlessHeatPump NaturalGasFurnace Non-ElectricSpaceHeating

NumberofWaterHeatersinHome:_____BeforeThisInstallation_______AfterThisInstallation NumberofOccupants:

Informationaboutthewaterheaterbeingreplaced(thisrowonly):

Fuel:Electric Gas* Propane*

Age(years): Size(gallons):

* Inexistinghomes,onlyHeatPumpWaterHeatersreplacingelectrictanksareeligible.

InstallationInformationBrandInstalled: Model: Size(gallons): InstallationDate:

Manufacturer Installation Training Location: DateofTraining:

OtherAppliancesininstallationroom: ClothesDryer Fridge Freezer Furnace Other(specify):__________________

Wherewasthiswaterheaterpurchased? Installer Retailer Online Other(specify):__________________

TotalInstalledCost(beforerebates):$_____________Pleasebreakdowntotalcostintothecategoriesbelow:

Equipment:$_________Labor:$__________Electrical:$__________Other(specify):$__________,for_____________________________

InstallationLocation: InteriorHeatedLocation UnheatedLocation Garage Basement Other__________________

InstallationRoomSize(feet):(length_______)x(width_______)x(height_______)=___________cu.ft.

CompleteforDuctedInstallationsOnly:

COMonitorLocation: Ductedoutofconditionedspace?Yes No

Lengthofintakeduct(ft):______________Lengthofexhaustduct(ft):______________

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RequiredSignaturesThisformmustbesignedbythepersonwhosenameappearsontheelectricutilityaccount.ENERGYINFORMATIONRELEASE:TheundersignedutilitycustomerrequestsandauthorizesthespecifiedutilitytoreleasebillingandusageinformationfortheaccountlistedbelowtoBonnevillePowerAdministration(BPA).Withthisauthorization,BPAcanrequestbillinginformationforuptotwoyearspre-installationandtwoyearspost-installation.Theutilitycustomeralsoherebyreleasestheutilitycompanyfromanyandallliabilityarisingfromorconnectedwithprovidingthisinformation.

Acopyofthepurchasereceiptorinstaller’sinvoiceisincludedwiththisapplication.

ElectricUtility CustomerAccount#

AccountHolderName

AccountHolderSignature Date

Bysigningbelow,theinstallercertifiesthatthisformandanyaccompanyingdocumentationarecompleteandaccurate,andthatallmeasuresassociatedwiththisprojectwerecompletedasofthesignaturedatebelow.Thesignaturecertifiesthattheinstallerislicensed,bonded,insured(orhomeowner)andhasbeentrainedbythemanufactureroftheinstalledproduct.InstallerName

InstallationCompany

ContractorHomeowner/Other

InstallerSignature InstallerPhone#

Date

PRIVACYACTSTATEMENTBasicauthorityforcollectingthisinformationisauthorizedby16U.S.C.§§832et.seq.,and838et.seq.,pursuanttoBonnevillePowerAdministration’sConservationProgramsystemofrecordsestablishedin46FR31700.Thisinformationisprimarilyintendedtofurther,butisincidentaltotheperformanceof,BPA’soverallEnergyEfficiencyProgram,theobjectiveofwhichistoacquireenergyresourcesthroughenergyefficiency,todeterminewhatcost-effectiveconservationanddirectapplicationrenewableresourcesmeasuresshouldbeinstalledoradoptedunderdifferentcircumstances,andtoprovideincentivesfortheinstallationofsuchmeasures.Otherroutineissuesofthisinformationinclude:aggregationintoapublicdatabaseonenergyefficiency;furnishedtoauthorizedpersonnelforinstallation/repairofequipment;aggregatedintoadatabaseforprogrampublicity;andinsomeinstancesinformationregardingbuildingswillbemadeavailabletosubsequentpurchasersofthebuildings.Yourdisclosureoftherequestedinformationisvoluntary;howeverfailuretoproviderequestedinformationmeansthatitwillnotbepossibleforyoutoparticipateinthisBPAEnergyEfficiencyprogram.

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