IMPA Energy Efficiency Program funding approval
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- Elijah Gerard Jenkins
- 6 years ago
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1 funding approval PROJECT SPECS Requested : $ (Refer to project rebate table, pages 3-7) CUSTOMER INFORMATION (all information must match the information on your electric utility bill) Utility Name: Utility Account #: Customer/Company Name: Contact Person: Phone #: How did you hear about this program? (utility, web, word of mouth, newsletter, etc): INSTALLATION ADDRESS MAILING ADDRESS (Same as Installation Address) Address 1: Address 2: City: State: Address 1: Address 2: City: State: Zip: Phone: Zip: Alt. Phone: VENDOR INFORMATION Contractor will be customer/self-installed Company Name: Mailing Address 1: Mailing Address 2: City, State, Zip: Contact Person: Telephone: Fax: FUNDING APPROVAL Items listed below must be submitted prior to funding approval. Failure to agree to provide these items could lead to denial of your application: Completed Funding Approval Form (this form) Appropriate completed rebate table (Pages 3-7) Submit Funding Approval Form prior to project start Agree to Program Rules Copy of most recent utility bill Manufacturer specification sheet or project quote Copy of W-9 form (commercial or industrial rebates only) Send signed funding approval form (this form) all required documents to: IMPA Energy Efficiency Program N. College Ave. Carmel, IN Fax: save@impa.com Questions: Call: or Customer Signature: : This box for internal IMPA use only: Funding Approval Signature: : Project Code: page 1
2 application An application for a rebate through the IMPA Energy Efficiency Program should ONLY be submitted if a prior funding approval form has been submitted approved. If you have not already submitted a funding approval form, please do so prior to starting your project. If you have already submitted a funding approval form have completed your project, please complete the remainder of this form return to IMPA. PROJECT SPECS Final Requested : $ (Refer to project rebate table, pages 3-7) Project Code (from Funding Approval Form): APPLICATION CHECKLIST Include Funding Approval Form Submit application within 30 days of project completion Provide proof of installation (invoices, receipts, etc.) Send signed application all required documents to: IMPA Energy Efficiency Program N. College Ave. Carmel, IN Fax: save@impa.com Questions: Call: or PROGRAM RULES AND EQUIPMENT ELIGIBILITY REQUIREMENTS s will be issued directly to the customer only. Please include payment information when submitting form. By signing below, you agree that you have read hereby agree to the IMPA Energy Efficiency Program Terms Conditions Eligibility Requirements. Customer Signature: Customer Name (printed): Contact Phone #: Tax # (if commercial/industrial): : Payment Information: Routing #: Account #: This box for internal IMPA use only: Final IMPA Approval (Authorized Signature Only): : page 2
3 Please indicate your building type below: Food Sales (1) Food Services (2) Health Care (3) Hotel/Motel (4) Office (5) Public Assembly (6) Public Service (non-food) (7) Retail (8) Warehouse (9) School (10) College (11) Industrial - 1 shift (12) Industrial - 2 shift (13) Industrial - 3 shift (14) Other (15): NOTE: This table must be completed; other forms will not be accepted. Oating T8s with Electronic Ballast, one for one or new construction. = Lamps + Ballast C401 C402 C403 C404 C405 C406 C407 C408 C409 T8 4ft 1 lamp - 25W T8 4ft 2 lamp - 25W T8 4ft 3 lamp - 25W T8 4ft 4 lamp - 25W T8 4ft 1 lamp - 28W $1.00 $1.00 $1.75 $2.25 T8 4ft 2 lamp - 28W T8 4ft 3 lamp - 28W T12 $1.50 T8 4ft 4 lamp - 28W T12 $2.00 T8 Garage W - 100W H $2.00 C410 T8 Garage W - 175W H $4.75 last updated: Page 3
4 Oating T5s with Electronic Ballast, one for one or new construction. = Lamps + Ballast C411 C412 C413 T5 4ft 1 T5 4ft 2 T5 4ft 3 C414 T5 4ft 4 T12 $2.00 C415 T5 Garage 1 75W-100W H $2.25 C416 T5 Garage 2 101W-175W H $3.75 C417 T5 Garage W + H $6.00 C418 Highbay 4ft 2L 150W-175W H $3.75 C419 Highbay 4ft 3L 250W H $6.00 Page 4
5 CFLs, LEDs Plasma, one for one or new construction C420 C421 C422 C423 Highbay 4ft 4L Oating 400W H $11.50 Highbay 4ft 6L 400W H $6.75 Highbay 4ft 5L (10L fixture or 2-5L fixtures) 1000W H $28.75 Highbay 4ft 6L (12L fixture or 2-6L fixtures) 1000W H $24.00 CFLs, LEDs Plasma, one for one C427 LED Auto Traffic Signals - 8 or 12 Green Incescent $4.25 C428 LED Auto Traffic Signals - 8 or 12 Red Incescent $4.50 C429 LED Auto Traffic Signals - 8 or 12 Yellow Incescent $4.25 C430 LED Pedestrian Signal Incescent $4.75 Page 5
6 CFLs, LEDs Plasma, one for one C431 C432 C433 C446 C434 C435 C436 C437 C438 C439 30W (Garage - 70W (Garage - 90W (Garage - LED- Up to 70W 120W 180W (2L) T12, T8- (3L) T12, T8- (4L), T12, T8- (6L), T12, T8-75W - 100W H 101W - 175W H Oating $3.25 $4.50 $5.75 $7.00 $9.75 $ W + H $ W - 175W H $ W H $ W H $30.00 C W 400W H $27.75 Page 6
7 CFLs, LEDs Plasma, one for one C W Oating 1000W H $30.00 C444 Occupancy Sensors - 500W less connected load No Control $10.00 C445 T12 4ft Delamping T12 4ft Lamp $2.00 Page 7
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