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2. Name*
3. Utilities Account Number*
5. Address*
7. City*
8. US State*
9. Zip*
11. Mailing Address (If different)
13. City
14. US States
15. Zip
17. Phone
18. Email*
20. Type of Installation

    1. New Installation (New Home)
    2. New Installation (Existing Home)
    3. Replacement
21. Location of Heat Pump Water Heater

    1. Garage
    2. Basement
    3. Other
23. Location of Existing / Old Water Heater

    1. Closet
    2. Crawlspace
    3. Garage
    4. Conditional Basement
25. Contractor Information
27. Contractor Federal ID Number*
28. Contractor Company Name*
30. Address*
32. City
33. US States
34. Zip
36. Mailing Address (If different)
38. City
39. US States
40. Zip
42. Phone
43. Email
47. Rebate Payment Method*

    1. Pay directly to contractor
    2. Credit to customer GU/BLP Account
    3. Check to customer
49. New Equipment Information*

    Please include equipment type, install date, model number and energy factor.

51. Uniform Energy Factor (Minimum 3.0)*
53. Existing Equipment Information (If applicable)

    Please include make, model, approximate age and efficiency rating.

55. File Upload

    Upload equipment invoice, installing contractor's invoice, AHRI certificate and recent electric bill. Maximum of 5 documents. Maximum of 20MB combined documents size. Submissions over 20MB will not be processed. Scan documents rather than take a picture to minimize file size.

57. Need to upload more files?

    1. Yes
    2. No
59. File Upload#2
61. File Upload#3
63. File Upload#4
65. File Upload#5
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field