Primary Phone #
Secondary phone #
Office/Work phone #
Found in the upper right-hand corner of billing statement
Types of rebates to choose from
Must be Energy Star rated
Must submit at least 5 bulbs
Must be working at time of recycling
Must be done by a Polk-Burnett approved energy rater
Must have an approved pre-test report on file
Low flow shower heads/faucets
Must test below 3.0 at -50pascals
Wind/Solar/E-Vehicle Charger

Dehumidifier

$

EnergySense - APPLIANCE(S) - 2018

Eligibility and instructions for completing this form (please read)

Rebate not to exceed 20% of the cost of new appliance
Appliance must be purchased or recycled in 2018
Appliance must be installed on Polk-Burnett electric lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will appear as a one-time credit on your electric bill within 1-3 billing cycles after approval
Submit the documentation no later than 6 months after purchase or the end of the year, whichever comes first
Members are encouraged to submit paperwork as soon as possible to ensure rebates

  • Complete this rebate form
  • A copy of your dated receipt or invoice for each item purchased or recycled
  • Yellow Energy Guide, copy or original, showing the Energy Star symbol for each item purchased
  • Dehumidifiers will not have the yellow Energy Guide

Appliance Description

Quantity

EnergySense rebate

Total amount requested

Dehumidifier

$25 each appliance

$

Clothes Washer
 

$25 each appliance

$

Clothes Dryer
 

$25 each appliance

$

Heat Pump Clothes Dryer
 

$25 each appliance

$

Dishwasher
 

$25 each appliance

$

Refrigerator (at least 10 cu.ft.)
 

$25 each appliance

$

Freezer
 

$25 each appliance

$

Recycling - Freezer (must be in working condition)
 

$25 each appliance

$

Recycling - Refrigerator (must be in working condition)
 

$25 each appliance

$

Recycling - Room Air Conditioner (must be in working condition)
 

$25 each appliance

$

EnergySense - LIGHTING - 2018

Eligibility and instructions for completing this form (please read)

Rebate not to exceed 20% of the cost of bulb, fixture, or unit
Night lights, flashlights, and solar lighting are not eligible
Equipment must be purchased new in 2018 and installed on Polk-Burnett lines
Must submit at least 5 bulbs at one time to receive any rebates (all 5 bulbs do not need to purchased a the same time)
Rebates for bulbs/new fixtures will be the grater of the tow, but not both
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will appear as a one-time credit on your electric bill within 1-3 billing cycles after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of your detailed receipt or invoice for each item purchased - may need copy of packaging if more information is needed

Lighting Equipment Description

Quantity

EnergySense rebate allowed

Amount of rebate requested

LED Bulb (must submit at least 5 at a time)
 

20% of cost of bulb not to exceed $1/bulb

$

LED Bulb 

20% of cost of bulb not to exceed $1/bulb

$

LED Bulb 

20% of cost of bulb not to exceed $1/bulb

$

Holiday Lighting (minimum 25 LEDs per string/fixture) 

20% of cost not to exceed $2 each

$

Occupancy Sensor

$5 each sensor

$

LED Exit Sign

$5 each sign

$

LED Hard-Wired Fixture

Total # of Lumens

$1 per 800 lumens

$

LED T5 Fixture (new or retrofit)

#Fixtures

# Bulbs per

$6/lamp/fixture

$

LED T8 Fixture (retrofit only)

# Fixtures

# Bulbs per

$4/lamp/fixture

$

EnergySense - HVAC - 2018

Eligibility and instructions for completing this form (please read)

Rebate not to exceed 20% of the cost of efficiency equipment
Equipment must be purchased new in 2018 and installed on Polk-Burnett lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued as a check 8-12 weeks after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of your detailed receipt or invoice for each item purchased and a copy of the AHRI certificate (required)
  • If purchased anywhere but from a licensed heating / plumbing contractor a copy of the VALID warranty must be included.

Equipment

Specifications

Size
 

EnergySense rebate 

Total amount requested 

Heat Pump - Air Source & Minisplit

SEER 14 or >
HSPF 8.2 or greater
EER 11.5 or greater

$150/ton

$

Heat Pump - Commercial ASHP & PTHPs

Under 20 ton:  EET>=11.5
20-under 60 ton: EER >=105.
60 ton or greater:  EER >=10

$150/ton

$

Heat Pump - Geothermal

(ECM blower is already figured into this rebate amount)

$400/ton

$

New furnace with high efficiency blower

The AHRI certificate must state the unit is either:
- Variable speed (not multi-speed) - or
- Efficiency (AFUE) >=95% & kWh/yr. (Eae) <=670

$150

$

Manufacturer or Brand Name

AHRI Certified Reference #:

Enter SEER number:

EnergySense - Agricultural, Commercial, Industrial - 2018

Eligibility and instructions for completing this form (please read)

Rebate not to exceed 20% of the cost of efficiency equipment
Equipment must be purchased new in 2018 and installed on Polk-Burnett lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued as a check 8-12 weeks after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of your detailed receipt or invoice for each item purchased 
  • Documentation showing the equipment has been installed

Equipment

Specifications

Size

Quantity

EnergySense rebate

Total amount requested

Commercial Vending Machine Controls

(no specific specifications required)

$25

$

Dairy Plate Cooler / Well Water Pre-Cooler

(no specific specifications required)

$500

$

Dairy refrigeration heat
recover with electric backup

Used with controlled electric water heater

$300

$

Low/Zero Use Energy Livestock Waterer

500 watts or less, insulated tank

$50

$

Exhaust Fan

Fans under 36" must be >= to 18 cfm/watt @ .05" SP
Fans 36" & over must be >= to 21 cfm/watt @ .05"SP
Fans must be AMCA or University of Illinois BESS Lab rated

$1/inch diameter

$

Circulation Fan

Fans under 36" must be >= to 18 lb force/kW
Fans 36" & over must be >= to 21  lbs force/kW
Fans must be AMCA or University of Illinois BESS Lab rated

$1/inch diameter

$

Scroll Refrigerant Compressor

Maximum $1000/compressor

$30/HP

$

Variable Frequency Drive (VFD)

Minimum of 1 HP to qualify
Maximum $1000/drive

$30/HP

$

EnergySense - Renewable - Solar & Wind - 2018

Eligibility and instructions for completing this form (please read)

Equipment must be purchased & connected to grid in 2018
Equipment must be installed on Polk-Burnett lines
A site assessment is strongly recommended by a site assessor certified by the Midwest Renewable Energy Association (MREA).  Visit www.the-mrea.org for a list of certified site assessors
Submit a copy of the site assessment with the co-generation application form
PV solar projects must be installed by a contractor with NABCP certification or is working toward certification
PV solar equipment must be UL listed and commercially available
Wind turbine eligibility- approved wind turbines can be found at www.smallwindcertification.org
Rebate for wind and solar projects are capped at $750 per project; call first to make sure there are still fund available
lRebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued a s a check 8-12 week after approval
Submit a copy of the rebate form and a copy of your detailed invoice no later than 3 months after grid connection or January 1, 2019, whichever comes first.  However, members are encouraged to sumit as soon as possible to ensure rebate.

Solar and Wind Systems

Size (kW)

EnergySense rebate allowed

Total amount requested

Name of installer/company

Phone # of installer

Solar PV

$250/kW not to exceed $750

$

Wind Turbine

$250/kW not to exceed $750

$

EnergySense - E-Vehicle - 2018

Eligibility and instructions for completing this form (please read)

Equipment must be purchased & installed in 2018
Equipment must be installed on Polk-Burnett lines
Must be connected to load management and controlled as a storage load
Qualifies for off-peak (dual fuel_rates but not required
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued a s a check 8-12 week after approval
Submit a copy of the rebate form and a copy of your detailed invoice no later than 3 months after grid connection or January 1, 2019, whichever comes first.  However, members are encouraged to submit rebates as soon as possible

E-Vehicle Charger

Requirement:  Hard-wired 240 Volt
Must be connected to load management program

EnergySense rebate allowed: $250 each

$

EnergySense - Conservation - 2018

Eligibility and instructions for completing this form (please read)

Rebate not to exceed 20% of the cost of efficiency equipment
Equipment must be purchased new in 2018 and installed on Polk-Burnett lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will appear as a one-time credit on your electric bill within 1-3 billing cycles after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of your detailed receipt or invoice for each item purchased - may need copy of packaging if more information is needed

Equipment Description

Specifications

Quantity

EnergySense rebate allowed

Total amount requested

Flow Restrictors - Faucets

1.5 gallon per minute or less

$1 per faucet

$

Flow Restrictors - Shower

2.5 gallon per minute or less

$5 per shower

$

Smart Strips 

If receipt is not specific please include a copy of the package front and back

$5 each

$

EnergySense - Home Performance Test - 2018

Eligibility and instructions for completing this form (please read)

Rebate is limited to $300 and cannot exceed the cost of the test
Audit must be performed by a certified energy rater with BPI or HERS certification.  Call Polk-Burnett, ext. 595, for a list of raters
Building undergoing audit must be on Polk-Burnett's lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued as a check 3-6 weeks after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • Dated invoice

Rebate amount:  $300

Were you satisfied with the home performance test?
Was the home performance test what you expected?
Do you plan on air sealing and/or insulating the home as per audit recommendations?
Would you recommend the home performance test to other members?
$

EnergySense - Home Improvement Measures - 2018

Eligibility and instructions for completing this form (please read)

Audits must be performed by a certified energy rater with BPI or HERS certification.  Call Polk-Burnett for a list of raters
A pre-test performed by a certified energy rater must be on file with Polk-Burnett
A post-test performed by the same certified energy rater must show a reduction in the air infiltration rate to qualify f or the rebate
Rebate is limited to 30 of the cost of improvement measures; rebate not to exceed $1000
Building undergoing audits and improvements must be on Polk-Burnett's lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued as a check 8-12 weeks after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of your dated detailed receipt or paid detailed invoice for each implemented measure

Date of audit (pre-test)

Date of audit (post-test)

Name of Auditor

Phone #

What is the water heater fuel type?
What is the home heating fuel type?

EnergySense - Compressed Air Audit - 2018

Eligibility and instructions for completing this form (please read)

Rebate is limited to 20% of the cost of the audit, not to exceed $500
Ausit must be performed by a professional engineer, certified energy manager, or a cooperative approved partner
Building undergoing audit must be on Polk-Burnett lines
Rebates are in place through December 31, 2018 or until funds are depleted
Rebates will be issued as a check 8-12 weeks after approval
Submit the documentation listed below no later than 3 months after date of purchase or January 1, 2019, whichever comes first
Members are encouraged to submit as soon as possible to ensure rebates

  • This rebate form
  • A copy of the audit showing date of audit, cost of audit, and deemed savings

Date of Audit: