STEP 2: FINAL INCENTIVE REQUEST FORM State of New

State of New Hampshire
Public Utilities Commission
21 S. Fruit Street, Suite 10, Concord, NH 03301-2429
STEP 2: FINAL INCENTIVE REQUEST FORM
FOR INSTALLED RESIDENTIAL SOLAR WATER HEATING SYSTEMS
Step 1 Incentive Part A and, if qualified, Part B Pre-Approval Application must be approved by the PUC
BEFORE SUBMISSION of Step 2.
Because the application requires an original notarized signature, it will not be accepted if submitted
electronically.
Name:
Solar thermal
Application #
System Description: check below
Solar Domestic Hot Water
Date the system became operational:
YES NO
Is the system you installed Solar Rating Certification Corporation (SRCC) approved?
Are all major components new?
CHANGES TO PROJECT INFORMATION
In an attachment to this form please inform the Commission of any changes in total project cost, equipment
used, or solar resources (i.e. more accurate shading estimates or any other changes to the information provided
in the incentive Part A and/or Part B forms prior to installation:
REQUIRED ATTACHMENTS
These items (copies) must be attached to the application:
1.
2.
Paid invoice(s) indicating total costs for parts and labor.
(Invoices may be unpaid only by the amount of the approved incentive payment.)
Documentation that the renewable energy system is SRCC certified
3.
Pictures of the installed solar water heating system
4.
5.
Documentation that the installed system has been inspected by a local building code
official or a NH licensed electrician.
Documentation of the rated annual BTU output of the system.
6.
Building permit or other documentation that the facility meets local zoning
Attached
regulations. (if none, please explain)
7.
A copy of the State Historic Preservation Act approval is included IF YOUR
DWELLING IS OVER 50 YEARS OLD AND REQUIRES THIS APPROVAL.
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√ if applicable
TOTAL REQUESTED INCENTIVE
Annual Estimated System Output
NH Incentive:
Check
Total Incentive
applicable
from Part A, Step 1
box
10,000,000 BTU up to 19,999,999 BTU
$500
20,000,000 BTU up to 29,999,999 BTU
$750
30,000,000 BTU or greater
$875
check if approval received from the PUC
Approval received for Part B, Step 1
$750
Total Incentive requested
Note: Incentives will be issued only after application is judged complete and accurate.
DECLARATION
The Undersigned applicant declares under penalty of perjury that:
1) the applicant has purchased and installed the solar water heating system described above;
2) the applicant will not sell or otherwise transfer the equipment unless as a part of a sale of the affected
property for a period of 10 years;
3) the information provided in both Step 1 and Step 2 applications are true and correct to the best of his or
her knowledge;
4) the applicant understands that program funds are limited and, as a result, there may be a delay in issuing
the incentive payment based on the queue position of the applicant; and,
5) the applicant agrees that the system, interconnection and documents supporting the application may be
audited and inspected by the Commission and that the Commission may request energy production data
from the applicant for a period of ten (10) years.
Applicant’s Signature:
Date:
Must be signed by individual originally applying for incentive payment.
Subscribed and sworn before me this
County of
(day) of
State of
(month) in the year
Notary Public/Justice of the Peace
My Commission expires
For questions regarding this rebate program, see the incentive program FAQ website at ***
http://www.puc.state.nh.us/Sustainable%20Energy/RenewableEnergyRebatesQAs-residential.htm, or contact
Barbara Bernstein at [email protected] or (603)271-6011.
Please submit application and all associated documents to:
Sustainable Energy Division
New Hampshire Public Utilities Commission
Sustainable Energy Division
21 S. Fruit Street, Suite 10
Concord, NH 03301-2429
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Your social security number is required for payment purposes. An IRS Form 1099, report
of miscellaneous income, may be issued for this payment. We are asking for this
information on a separate page to allow this personal information to be separated from
the application and to be held confidentially at the Commission’s offices or the office of
the State Treasurer.
Applicants who do not provide their social security number will not be eligible for
incentive payment. We thank you for your understanding.
Name:
Mailing Address:
Town/City
State
Phone:
Cell:
Email:
SS Number
-
-
Page 3 of 3
Zip Code: