RESIDENTIAL REWARDS PROGRAM APPLICATION THIS APPLICATION IS FOR EXISTING SITES ONLY.

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This application is for qualified equipment installed between January 1, 2015 and July 31, 2015. Please return the signed, completed application and copy of sales invoice postmarked within 60 days of installation. Missing information will delay processing.

General Terms and Conditions: Visit focusonenergy.com/terms or call to request a copy be provided to you. Questions? Contact us at 800.762.7077. SECTION 1: UTILITY ACCOUNT HOLDER INFORMATION

Where did you hear about this program?

q Community Association/Agency q Utility q Friend/Neighbor q Contractor q Other________________________________ Name of Electric Utility: (For installation site) Electric Utility Account Number:

Name of Gas Utility: (For installation site) Gas Utility Account Number:

First Name: Last Name:

Phone Number: Email:

FORM SUBMITTAL - Return signed, completed reward application and copy of sales invoice to: Mail: Focus on Energy Rewards, 222 W. Washington Ave., Suite 470, Madison, WI 53703-2793 Email: [email protected] Fax: 888.627.0938 Questions: 800.762.7077

RESIDENTIAL REWARDS PROGRAM

APPLICATION

THIS APPLICATION IS FOR EXISTING SITES ONLY.

SECTION 2: INSTALLATION SITE INFORMATION

Installation Site Address: City: State:

WI

Zip:

SECTION 3: CONTRACTOR INFORMATION

Company/Business Name: Email: Phone:

Address: City: State: Zip:

SECTION 4: PAYMENT INFORMATION

Mailing Address: q Same as installation site City: State: Zip:

Tax Status: (Complete only if Landlord Payee) q Corporation q Partnership q Sole Proprietorship q LLC q Other: _______

Tax ID Number: (Complete one only; Only if Landlord Payee)

FEIN #: - OR SSN: - - SECTION 5: APPLICATION SIGNATURES (Please read the complete reward application and sign)

I, the undersigned, agree that the stated energy efficient measure(s) was (were) installed at the project site address listed above as part of the Focus on Energy offering and that I am authorized to sign this application. I have read and agree to the provisions set forth herein and to the Terms and Conditions posted at

focusonenergy.com/terms. I understand Focus on Energy may revise these Terms and Conditions at any time and I will not be notified in the event changes are made. To the best of my knowledge, the statements made on this application are complete, true and correct, and I have submitted the appropriate supporting documentation to receive a reward. I certify that I am applying under the Residential Rewards Program for the designated reward amount and hereby vacate any opportunity to request that a reward for the equipment noted on this application be processed under the Enhanced Rewards Program. If Trade Ally is checked for payment in Section 4, I have confirmed that the reward has been applied as an instant discount on the invoice.

Site has Central Air Conditioning/ Air Source Heat Pump:

q Yes q No

Fuel Used for Home Heating:

q Natural Gas q Propane q Oil q Electric q Other:____________

This is a(n):

(New construction is not eligible for these rewards)

q Existing Home q New Construction

Make Check Payable to: (First Name and Last Name)

q Customer q Landlord q Trade Ally (participating contractor)

Send Check Attention of: (Complete if needed for mailing) Phone:

Total Requested Cash Back Reward:

q Itemized contractor invoice is attached.

Applicant Signature: Print Name: Date:

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HIGH EFFICIENCY FURNACES

General Requirements for High Efficiency Furnace Cash-Back Rewards: n Furnaces have a multi-stage or modulating burner.

n Furnaces must have an electronically commutated motor (ECM). An ECM is sometimes referred to as a variable speed, airflow, torque, electronically efficient (EEM), or X-13 motor. A permanent split capacitor motor (PSC), single- or multi-speed, does not qualify. A Pre-Qualified Equipment List is available at focusonenergy.com/rewards.

n Furnaces must be a sealed combustion unit.

n Furnaces must be the primary heating source for the home’s living space.

n Chimney liners must be installed where a high-efficiency gas furnace replaces an atmospherically-drafted furnace and only a water heater remains vented through the chimney. The interior opening left by the removed furnace must be closed with a metal cap and sealed with caulk or mortar. q90% AFUE Propane Furnace with ECM - $100 Cash-Back Reward:

n Furnace must have an annual fuel utilization efficiency (AFUE) of 90 percent or greater. n Must be customer of a participating electric utility.

n Propane furnaces are eligible. Electric and natural gas furnaces are not eligible. q95%-96% AFUE Natural Gas Furnace with ECM - $150 Cash-Back Reward:

n Furnace must have an AFUE of 95-96 percent.

n Must be customer of a participating electric utility and a participating natural gas utility. Customer must use natural gas for home heating. n Only natural gas furnaces are eligible.

q97% AFUE Natural Gas Furnace with ECM - $225 Cash-Back Reward: n Furnace must have an AFUE of 97 percent or greater.

n Must be customer of a participating electric utility and a participating natural gas utility. Customer must use natural gas for home heating. n Only natural gas furnaces are eligible.

Rewards up to $850 are available through the Enhanced Rewards Program. Call 800.762.7077 or visit focusonenergy.com/enhancedrewards to see if you qualify.

Brand Name: (Furnace #1) Model Number: Installed Date: Installed Cost: Reward Amount:

Brand Name: (Furnace #2) Model Number: Installed Date: Installed Cost: Reward Amount:

ARE YOU ELIGIBLE FOR ENHANCED CASH-BACK REWARDS?

You may be eligible for higher Cash-Back Rewards through the Enhanced Rewards Program. To qualify, your household must have a gross income of less than 80 percent of the state median income (SMI) as determined by the Income Eligibility Self-Screening Tool on page 6.

Note: The Enhanced Rewards Program requires pre-approval and has its own set of applications. Customers cannot receive Cash-Back Rewards from both the Residential Rewards Program and the Enhanced Rewards Program for the same piece of equipment.

HIGH EFFICIENCY FURNACE AND AIR CONDITIONER COMBINATION

95% AFUE Natural Gas Furnace with ECM and 16 SEER Central Air Conditioner - $250 Cash-Back Reward: n Furnaces must have a multi-stage or modulating burner.

n Furnaces must have an ECM. An ECM is sometimes referred to as a variable speed, constant-airflow, constant-torque, EEM, or X-13 motor. A PSC motor, single- or multi-speed, does not qualify. A Pre-Qualified Equipment List is available at focusonenergy.com/rewards.

n Qualified furnace and air conditioner must be installed at the same time and may not be combined with Cash-Back Rewards listed above. n Combination Cash-Back Reward is not available with furnaces that were previously installed.

n If installing a qualified furnace and air conditioner and the condenser cannot be set due to weather: o The evaporator coil must be installed at the same time as the furnace.

o The invoice must include the condenser model and state when the condenser will be installed.

o The reward application must be submitted within 60 days of the furnace and evaporator coil installation. n Furnaces must be a sealed combustion unit.

n Furnaces must be the primary heating source for the home’s living space.

n Chimney liners must be installed where a high-efficiency gas furnace replaces an atmospherically-drafted furnace and only a water heater remains vented through the chimney. The interior opening left by the removed furnace must be closed with a metal cap and sealed with caulk or mortar. n Furnace must have an AFUE of 95 percent or greater.

n Seasonal energy efficiency ratio (SEER) for the combination of furnace, outdoor unit (condenser), and indoor coil must be 16 or greater.

n SEER is determined by the Air Conditioning, Heating, and Refrigeration Institute (AHRI) database. An AHRI number for the system is required and can be found at ahridirectory.org.

n An air source heat pump cannot be used to meet the air conditioner portion of this Cash-Back Reward.

n Must be customer of a participating electric utility and a participating natural gas utility and use natural gas for home heating. n Only natural gas furnaces are eligible.

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AIR SOURCE HEAT PUMP

Air Source Heat Pump 16+ SEER - $300 Cash-Back Reward:

n Air Source Heat Pump with a minimum of 16 SEER and a minimum of 8.4 heating seasonal performance factor (HSPF). n All components (coil and condenser) must be purchased and installed at the same time.

n SEER based on AHRI database, found at ahridirectory.org, for furnace, coil, and condenser.

n Furnace must be LP, oil, or electric fired (natural gas furnaces are not eligible). Furnace must be primary heating source for the home’s living space. n Ductless or mini-split systems cannot qualify for this Cash-Back Reward.

n Cannot combine with Focus on Energy furnace or ECM replacement Cash-Back Rewards. n Must be customer of a participating electric utility.

n Limited to customers who do not have access to natural gas.

System Information AHRI Number: Installed Cost: Reward Amount:

Indoor Unit (Coil) Brand Name: Model Number: Installed Date:

Outdoor Unit (Condenser)

Brand Name: Model Number: Installed Date:

Furnace/Air Handler (can be existing or new)

Brand Name: Model Number:

HIGH EFFICIENCY BOILERS

Natural Gas Home Heating Boiler 95% AFUE - $400 Cash-Back Reward: n Boiler must have an AFUE of 95 percent or greater.

n Boilers must have an input capacity less than 300 MBH (Thousand British Thermal Units per hour). n Boilers must have a modulating burner and include an integrated outdoor reset.

n Boilers must be a sealed combustion unit.

n Must be customer of participating natural gas utility and use natural gas for home heating. Boilers must be the primary heating source for the home’s living space. Only natural gas boilers are eligible.

n Chimney liners must be installed where a high-efficiency gas boiler replaces an atmospherically-drafted boiler and only a water heater remains vented through the chimney. The interior opening left by the removed boiler must be closed with a metal cap and sealed with caulk or mortar. n If boiler also heats domestic hot water, see indirect water heater or combination boiler.

Brand Name: Model Number: Installed Date: Installed Cost: Reward Amount:

INDIRECT WATER HEATERS

Indirect Water Heater for Home Heating Boiler - $100 Cash-Back Reward:

n Must be installed on a boiler that qualifies for a natural gas home heating boiler Cash-Back Reward (which meets all requirements above). n Installation of the water heater and boiler must occur at the same time, and the qualifying boiler must be included in this application, above. n The total cost (equipment, materials, external labor) must be separated from boiler and listed below.

n If water heater is integrated and has less than 2 gallons of storage, see combination boiler.

ECM REPLACEMENT

ECM Replacement - $125 Cash-Back Reward:

n Must replace a PSC blower motor in an existing furnace or air handler. n Existing furnace must have an AFUE of 90 percent or greater. n Existing furnace must be a sealed combustion unit.

n Must be customer of a participating electric utility.

n Furnace must be the primary heating source for the home’s living space.

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OFFER AVAILABILITY

n Focus on Energy rewards are available to Wisconsin residential customers of participating utilities. Call 800.762.7077 or visit focusonenergy.com to verify eligibility. n Offer is valid for equipment and products purchased and installed between January 1, 2015 and July 31, 2015.

n Rewards may not exceed the total purchase price of the energy efficient equipment. The only costs eligible for rewards are: Materials; Equipment; External Labor. n Allow approximately 8-10 weeks for your completed application to be processed. Incomplete applications cannot be processed. Failure to complete the reward

application in full and provide the required supporting documentation will either delay the payment process or result in your application being denied. Receipt of an application does not guarantee payment of a Cash-Back Reward.

n The program is not responsible for items (i.e. reward applications, supporting documentation, reward checks) lost or damaged in the mail.

n Only single family dwellings and multifamily dwellings with three or fewer units are eligible for the Cash-Back Rewards included in this reward application. Cash-Back Rewards may be available for other customer or property types. Please visit focusonenergy.com for other offerings and reward applications.

n Focus on Energy will only pay one Cash-Back Reward for each piece of equipment. Cash-Back Rewards paid on this application cannot be claimed on another Focus on Energy application. Similarly, rewards can only be paid to one person or entity (i.e., either the resident or landlord, not both).

n All equipment installations are subject to verification inspection by the program to ensure the equipment is properly installed and operating. Participants must allow, if requested, the program or a program representative reasonable access to their home to verify the installed equipment.

n A current list of qualified products for most equipment is available at focusonenergy.com/rewards. If you have a question concerning one of the lists, please email [email protected] with “Equipment” in the subject line.

PROGRAM QUALIFICATIONS

You are only eligible to participate in the Residential Rewards Program if you are:

n A current residential customer of a participating utility in Wisconsin at the time of equipment purchase and installation; or

n A landlord (who is not the utility account holder) who paid for the equipment installed in the residence of a current residential customer of a participating utility in Wisconsin at the time of equipment purchase and installation; and

n Installing qualifying energy efficient equipment in an existing residential dwelling. New construction does not qualify. Your installation of high efficiency equipment is only eligible for a Cash-Back Reward if:

n It meets all equipment-specific, energy efficiency, and program requirements as outlined in this application.

n It is replacing existing equipment used for the same purposes. Equipment additions to a residential dwelling, which are not replacing existing equipment, do not qualify. n It is purchased new. Resale equipment, new parts installed in existing equipment, or equipment that is leased, rebuilt, rented, received from insurance claims, received

from a warranty, won as a prize, or paid for with a grant does not qualify.

n Equipment is installed by a professional contractor with appropriate insurance, permits, and licenses. A valid Wisconsin State professional contractor’s license or credential is required.

n Equipment is installed conforming to all applicable building, local, state and federal codes, standards, ordinances and regulations, and manufacturer specifications. n Equipment is installed and operational prior to submittal of this application at the address listed on the application.

n It is installed in a property owned by the applicant, or the applicant has received permission from the property owner to install the equipment. If you do not own the property where this equipment is installed, as a residing tenant you are responsible for obtaining the owner’s permission to install the equipment for which you are applying for a Cash-Back Reward. Submission of this application indicates that you have obtained this permission.

To be considered complete and eligible for Cash-Back Rewards, all applications must: n Be postmarked no later than 60 days after the installation date.

n Be signed by the purchaser (Utility Account Holder, Landlord, or Applicant signing on behalf of the Utility Account Holder).

TOTAL CASH-BACK REWARD:

Enter the total amount of rewards being requested

$

COMBINATION BOILER

Natural Gas Combination Boiler - $500 Cash-Back Reward n Boiler must have an AFUE of 95 percent or greater.

n Boilers must have an input capacity less than 300 MBH (Thousand British Thermal Units per hours). n Boilers must have modulating burner and include an integrated outdoor reset.

n Boilers must be a sealed combustion unit.

n Domestic hot water storage must be less than 2 gallons.

n Must be a customer of participating natural gas utility and use natural gas for home heating. Boilers must also be the primary heating and domestic water heating source for the home. Only natural gas boilers are eligible.

n Chimney liners must be installed where a high-efficiency gas boiler replaces an atmospherically-drafted boiler and only a water heater remains vented through the chimney. The interior opening left by the removed boiler must be closed with a metal cap and sealed with caulk or mortar. Rewards up to $900 available through the Enhanced Rewards Program. Call 800.762.7077 or visit focusonenergy.com/enhancedrewards to see if you qualify.

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LANDLORD APPLICANTS

By submitting this application, the signatory(ies) and applicant(s) agree to all of the following terms and conditions.

n Landlord Payees: The following certifications are required in order for this form to substitute for the IRS Form W-9. Under penalty of perjury, the Landlord who has signed on Page 1 certifies that:

o The number shown on this form is the correct taxpayer identification number.

o I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends or (c) the IRS has notified me that I am no longer subject to backup withholding.

o I am a U.S. Citizen (includes a U.S. resident alien).

n If the Payee listed on Page 1 is the Landlord (who is not the dedicated utility account holder), by signing and submitting this reward application, he/she is certifying that all equipment was paid for by the Landlord and the tenant (the utility account holder) provided his/her customer information for use in this reward application. n Rewards are taxable and if greater than $600 in a calendar year will be reported to the IRS unless you are exempt. If you have exceeded a total of $600 in rewards, a

W-9 form may be requested if applicable. INSTANT DISCOUNT

Trade Ally Information:

A Trade Ally represents the company who provided/installed the equipment for a project or performed the service for which a customer is seeking a reward. Trade Allies who have signed an agreement with Focus on Energy are allowed to enjoy certain program benefits, one of which is to receive direct payment of rewards at your request. Rewards can only be paid directly to a Trade Ally if they have completed and submitted a Trade Ally Application and W-9.

Trade Allies submitting an application as an instant discount certify that the full reward amount was issued as an instant discount to the customer. The contractor has explained to the customer that the reward he/she qualifies for has been applied as a discount off of the purchase price on the invoice and the customer will not be eligible to receive the reward from Focus on Energy for the same equipment. The full Focus on Energy Cash-Back Reward amount has been displayed on the invoice as a line item deduction from the purchase price.

INCOME ELIGIBILITY SELF-SCREENING TOOL

You may be eligible for higher Cash-Back Rewards from the Enhanced Rewards Program if you meet the following criteria: n Current residential customer of a participating utility (check out the Participating Utility List on focusonenergy.com). n Installing the equipment in a single family or multifamily dwelling with three or fewer units.

n The utility account holder must have a documented gross household income of less than 80 percent of state median income (SMI), as determined by the Upper Limit column in Income Eligibility Chart on the right, according to household size (including only eligible household members). Contact Focus on Energy for households with more than six members.

n Can provide supporting documentation of income for all eligible household members.

Please complete the Income Eligibility Application available at focusonenergy.com/enhancedrewards for fast and confidential pre-approval for Cash-Back Rewards. See the Enhanced Rewards Application for full program requirements.

INCOME ELIGIBILITY CHART

State median income limits by household size (2015)

People in Household

Annual Income Upper Limit

1 $33,534

2 $43,853

3 $54,171

4 $64,489

5 $74,808

6 $85,126