Commercial Energy Solutions Program

Gas Rebate Application

PART 1: APPLICANT INFORMATION

Indicate Application Phase:

Pre-Approval Application School District

Final Application

Name of Company
(UES Gas Customer) / Business Type:
(Check One)
Name as it Appears on Your Gas Bill / Office
School or College
Retail or Other Service
Hotel / Motel
Medical
Grocery
Warehouse
Light Industry
Heavy Industry
Other Misc.
Utility Customer Account Number
(Printed on Gas Bill)
Name of Contact Person / Title
Telephone # / FAX #
Email Address
Address Where Measures Were Installed
City, State, ZIP
(Where Measures Were Installed)
Mailing Address
City, State, ZIP
(Mailing Address)
Taxpayer ID Number
(SSN/FEIN)
Tax Status
(Individual, Partnership, Corp., Exempt)
Name of Contracting Company
Contractor Contact Name / Contractor Contact #
Contractor Email
Contractor Address

PArt 2: Payment Release Authorization

Complete this section ONLY if incentive payment is to be paid to an entity other than the utility customer of record (listed on the application information).

I am authorizing the payment of the incentive to the third party named below and I understand that I will not be receiving the incentive payment from UniSource Energy Services. I also understand that my release of the payment to a third party does not exempt me from the program requirements outlined in the Measure Specifications and Terms and Conditions.

Authorized By:

Customer Signature
(Utility Customer) / Print Name / Date

Check should be made payable to:

Payee:
Company/Individual Name
Mailing Address
City, State, ZIP
Telephone #
Taxpayer ID Number
(SSN/FEIN of Payee)
Tax Status (Individual, Partnership, Corp., Exempt)

PArt 3: Agreement FORM

As an eligible UniSource Energy Services (UES) gas customer, I certify that I contracted for or purchased and installed the indicated gas energy efficiency measures after February 27, 2008 for use in my business facility and not for resale. I have attached documentation establishing proof of payment for the items installed according to this application. I agree to verification by the utility or their representatives of both sales transactions and equipment installation.

I certify that the information on this application is true and correct, and that the Taxpayer ID Number is representative of the applicant and that UniSource Energy Corporation and DNV GL are not responsible for any taxes that may be imposed on my business as a result of receipt of this incentive. I understand that incentive payment assume related energy benefits over a period of five years or for the life of the product, whichever is less.

I agree that if: (1) I do not install the related product(s) identified in my application, or (2) I remove the related products(s) identified in my application before a period of five years or the end of the product life, whichever is less; then I shall refund a prorated amount of incentive funds to UES on the actual period of time in which the related product(s) were not installed and operating (or the full amount if the product was never installed). This is necessary to assure that the project’s related energy benefits will be achieved.

I understand that the program may be modified or terminated without prior notice. The program has a limited budget. Applications will be processed on a first-come, first-served basis until allocated funds are spent.

I understand that the Final Application and all required documentation must be received by UES within 60 days of project completion. All equipment must be purchased and installed prior to submitting the Final Application. I understand that this project must involve a capital improvement that results in improved energy efficiency. I also understand that all materials removed must be disposed of properly and taken out of service.

In no case will UES pay more than 75% of the incremental measure costs. I understand that UES or its representatives have the right to ask for additional information. The UES Commercial Energy Solutions program will make the final determination of incentive levels for this project.

In return for the payment by UniSource Energy Corporation under the “Commercial Energy Solutions” program, I understand that any energy efficiency credits and all resultant associated environmental credits from the energy efficiency measures for which the rebate is paid, are assigned to UniSource Energy Corporation.

I understand that my company may be recognizedas a program participant in promotional materials; however, project details will not be released without prior consent. If I choose to opt-out of any recognition, I will indicate my choice in a written letter.

I have read and understand the program requirements and Measure Specifications and Terms and Conditions set forth in this application and agree to abide by those requirements. Furthermore, I concur that I must meet all eligibilitycriteria in order to be paid under this program.

Customer SignaturePrint NameDate

3rd Party SignaturePrint NameDate

(If Receiving Incentive)

Total Incentive RequestedProject Completion DateTotal Project Cost

For Final Applications, sign and submit only after all equipment has been installed. A customer signature is required for payment.

PART 4: Gas Savings Incentive Worksheet

Space Heating and Water Heating Measures
Equipment Type / Size Category / Qualifying Efficiency / Incentive per Unit
High Efficiency Furnace / 0-60,000 Btuh / 90 AFUE / $200
92 AFUE / $250
94 AFUE / $300
60,001-100,000 Btuh / 90 AFUE / $225
92 AFUE / $275
94 AFUE / $325
>100,000 Btuh / 90 AFUE / $250
92 AFUE / $300
94 AFUE / $350
Energy Efficient Storage Water Heater / ≤ 75,000 Btuh / Energy Factor of 0.64 Higher / $200
> 75,000 Btuh / Thermal Efficiency 85% or Higher / $200
High Efficiency Boilers / Non-Condensing
< 300,000 Btuh / AFUE 84.5% or Higher / $250
per 100,000 Btu
Non-Condensing
≥ 300,000 Btuh / Thermal Efficiency 85% or Higher / $250
per 100,000 Btu
Condensing < 300,000 Btuh / AFUE 94% or Higher / $250
per 100,000 Btu
Condensing ≥ 300,000 Btuh / Thermal Efficiency 94% or Higher / $250
per 100,000 Btu
Commercial Food Service Measures
Equipment Type / Size Category / Qualifying Efficiency / Incentive per Unit
High Efficiency Griddles / ALL / 45% / $300

Please complete the following table with your equipment information.

Equipment Type / Make and Model / Unit Efficiency[*] / Unit Size (Tons) / Unit Size (Btuh) / Incentive per Unit / Quantity / Subtotal Incentive
Total Gas Incentive

PART 5: Specifications for Gas Savings Measures

High Efficiency Furnace
The qualifying Non-Residential central natural gas furnace must have a minimum rating of 90% Annual Fuel Utilization Efficiency (AFUE). Please reference for the furnace efficiency ratings

Energy Efficiency Storage Water Heater
Qualifying gas water heaters must meet the efficiency levels listed below:

Input Rating:

≤ 75,000 Btuh:Energy Factor of 0.64 or Higher

> 75,000 Btuh: Thermal Efficiency of 85% or Higher

High Efficiency Boilers
The qualifying boilers must meet the efficiency levels listed below:

Non-Condensing < 300,000 Btuh:AFUE of 84.5% or Higher

Non-Condensing ≥ 300,000 Btuh:Thermal Efficiency of 85% or Higher

Condensing < 300,000 Btuh:AFUE of 94% or Higher

Condensing ≥ 300,000 Btuh:Thermal Efficiency of 94% or Higher

High Efficiency Griddles
Qualifying griddles must be thermostatically controlled and must have an efficiency level of 45% or greater.

Note: Applicants must provide manufacturer specification sheets in support of claimed efficiency values.

The Commercial Energy Solutions program must verify that your equipment meets the program specifications approved by the Arizona Corporation Commission. Documentation that supports this application must be received by the program in order to process your application. Please use the following checklist to make sure that your application is complete.

PART 6: Application Checklist

Before submitting your application, please use this checklist to ensure it is complete.

This will greatly speed processing time and help us to issue rebate checks in a timely manner.

APPLICANT INFORMATION FORM

Customer Information

Customer name matches the name that appears on the utility bill.

Utility account number is complete and accurate. (If the project is new construction, account information is not required for pre-application, but is required for the final application.)

Taxpayer ID is complete and accurate.

Contractor Information

Full contact information for project contractor is provided. (We may need to contact your contractor to verify project details.)

Incentive Check Information

Indicate whether the customer or a third party is to receive the check.

If a third party will receive the check:

Contact information and Taxpayer ID is complete.

Customer has signed Payment Release Authorization indicating third party payment.

For final application, customer and third party have signed Agreement form.

Incentive worksheets

Incentive worksheet has been completed for each applicable measure.

The measures installed meet the specifications listed in the application.

Terms and Conditions of Application

Customer has read and agrees with the terms and conditions of the Commercial Energy Solutions program.

If customer has agreed to release the incentive check to a third party, they toohave read and agree to the terms and conditions of the Commercial Energy Solutions program.

Agreement Form

The customer has signed, dated, and filled in all sections of the Agreement, including:

  • Project completion date
  • Total project cost
  • Total incentive requested

If customer has agreed to release the check to a third party, both the customer and the third party member have signed and dated the Agreement.

Additional Documentation

Specification Sheets

A manufacturer’s specification sheet is provided for each measure installed.

Specification sheets include all program eligibility requirements for the measure.

Invoices

Invoices are dated after February 27, 2008.

The installation address is listed on the invoice and is in the UES gas service territory.

Invoice shows correct model number for each measure installed.

Invoice indicates that it has been paid by the customer (e.g., show zero balance due, stamped paid, or check number and paid date are included).

Paid for by UniSource Energy Services gas customers and approved by the Arizona Corporation Commission. Version 5-25-16

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