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Residential Efficiency Rebate Application

Before you begin, please review the Terms and Conditions and have your receipt and ID.

Account Number *

Customer Name *

(Ten-digit number)

(As shown on utility bill)

Service Address

Address *

City *

State *

Zip Code *

Email *

Home Phone *

Cell Phone *

(Either Home Phone or Cell Phone is required.)

How did you hear about the rebate? *

Appliances & Fixtures Rebates

REBATE

UTILITY SERVICE

REQUIREMENTS

REBATE AMOUNT

QUANTITY

EXPECTED REBATE

Dryer

Electric

ENERGY STAR® certified products; limit 1 per service address.

$ 50

Recycled Refrigerator or Freezer

Electric

Must include written receipt provided by recycling vendor (ARCA: Call 888.540.5931 to schedule the pick up); 10 cu. ft. to 32 cu. ft. only; limit 2 per service address.

$ 50 each

Smart Thermostat

Electric or Natural Gas

ENERGY STAR® certified products; limit 2 per service address.

$ 50 each

Do you have central air conditioning? (answer required to qualify for smart thermostat rebate)

YesNo

Electric Heat Pump Water Heater

Electric

Uniform energy factor, UEF, 2.20 for 120V/15A ENERGY STAR certified products; limit 1 per service address.

$ 200

Natural Gas Storage Water Heater

Natural Gas

Tank capacity up to 55 gallons:

Uniform Energy Factor (UEF) must be ≥ 0.64
First-hour rating (FHR) must be ≥ 51 gallons per hour

Tank capacity greater than 55 gallons:

Uniform Energy Factor (UEF) must be ≥ 0.78
First-hour rating (FHR) must be ≥ 51 gallons per hour

ENERGY STAR® certified products; limit 1 per service address.

$ 50

Natural Gas Condensing Furnace

Natural Gas

Annual fuel utilization efficiency (AFUE) ≥ 95%
ENERGY STAR® certified products; limit 1 per service address.

$ 250

Cold Climate Air Source Heat Pump

Electric or Natural Gas

COP @ 5 degrees F of 1.75 or higher (at max capacity operation) NEEP listing in cold climate air source heat pumps; limit 1 per service.

$ 1000

Pikes Peak Regional Building Permit #

Look up your permit number here.

Total of Expected Appliances & Fixtures Rebates:

Insulation Rebates

REBATE

UTILITY SERVICE

R-VALUE

INSTALLED SQ. FT.

REQUIREMENTS

INSTALLATION/
LABOR/
MAT'L COSTS

REBATE AMOUNT
(40% OF JOB COST
UP TO $200 MAX)

PRE

POST

Attic Insulation & Bypass Sealing

Electric or Natural Gas

R49+

Read specific instructions in the qualifications and program rules.

Wall Insulation

Electric or Natural Gas

R13+

Read specific instructions in the qualifications and program rules.

Total of Expected Insulation Rebates:

Water Rebates

REBATE

UTILITY SERVICE

REQUIREMENTS

REBATE AMOUNT

QUANTITY

PURCHASE
PRICE/UNIT

EXPECTED REBATE

Wired Rain Sensor

Water

Sensor must connect to an automated in-ground sprinkler system. Limit 2 per service address.

Up to $25 each

Wireless Rain Sensor

Water

Sensor must connect to an automated in-ground sprinkler system. Limit 2 per service address.

Up to $50 each

High-efficiency Nozzles

Water

Minimum of 5 nozzles, maximum of 80 nozzles per service address.

Up to $4 each

Sprinkler Heads w/ Check Valves or Pressure Reducing Stem

Water

Minimum of 5 heads, maximum of 80 heads per service address.

Up to $5 each

WaterSense Certified Smart Irrigation Controller

Water

Limit 2 per service address.

Up to $50 each

UHE 0.8 Gallon Per Flush Toilet

Water

Limit 3 per service address.

Up to $100 each

Total of Expected Water Rebates:

Grand Total of Expected Rebates:

Please consider a tax-deductible donation to Project COPE. All donations are matched dollar for dollar, up to $500,000, thanks to a matching fund grant from Colorado Springs Utilities. 100% of your contribution assists neighbors with their utility bills.

Donation Amount: $ Donation Amount cannot be greater than Grand Total of Expected Rebates

I swear/affirm under penalty of perjury under the laws of the State of Colorado that I am:
a United States citizen, or
a Permanent Resident of the United States, or
am lawfully present in the United States pursuant to Federal Law.

Date *

Signature Required *

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit or prior to entering a contract with the state. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

*** Attachments ***

Please do not use any special characters when adding attachments

(Characters other than alpha, numeric, spaces and underscores are not allowed.)

Include a copy of your approved photo ID.
Include copies of receipts related to the requested rebate items.

Add Attachment

Signature above also certifies that the account holder 1) is solely responsible for the accuracy of the application; 2) has read and understands the program general requirements and terms and conditions; 3) verifies installation is complete and operational; 4) understands the liability waiver if recycling a refrigerator/freezer; and 5) has included a copy of approved photo ID and receipt(s).

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