TO APPLY, FOLLOW THESE STEPS:

1. Your new heat pump water heater must be purchased between January 1, 2016 and December 31, 2016 and replace an existing electric storage water heater.

2. Read the Terms and Conditions on the back of this form to ensure you qualify.3. Complete this form and send along within 90 days of purchase:

Purchase Receipt/Invoice Manufacturer’s Installation Checklist (found in the product manual)4. Homeowner and installer must sign and date the rebate form and send all attachments to:

MAILSeattle City Light — HPWH Rebate700 Fifth Ave, Suite 3200PO Box 34023Seattle, WA 98124

FOR MORE INFORMATION Website: seattle.gov/appliancesQuestions? Call (206) 684-3800

All information below is REQUIRED for processing. Please print in block letters.

CUSTOMER INFORMATION

Name Phone (with area code)

Installation Address

City State Zip

Mailing Address

City State Zip

Email Year Built Heated Area (sq ft)

Heating System Electric furnace Zonal electric resistance Ductless heat pump Fireplace/Woodstove/Pellet stove Gas furnace Oil furnace Other (specify) :

Air Conditioning None Central Zonal (window and/or wall units) Evaporative cooler

Number of Occupants in Home Number of Water Heaters in HomeInformation about the water Age (years) Size (gallons) Functional? heater being replaced (this row only) Yes No INSTALLATION INFORMATION

Manufacturer Model Serial Number Date Installed

Other appliances in installation room Clothes Dryer Fridge Freezer Furnace Other (specify) :

Where was the water heater purchased? Installer Retailer Online Other (specify) :Total installed cost (before rebates) : $______________ Break down the cost into the categories below:Equipment $______________ Labor $______________ Electrical $______________ Other $______________ (specify) :Installation Location Conditioned Space Unconditioned Space (Conditioned space is defined as space that is heated.) Specify Garage Basement Closet Utility Room Laundry Room Other (specify) :

Installation room size (feet) length ______________ x width ______________ x height ______________ = ______________ cu. ft.Information about CO Monitor location Ducted out of conditioned Length of intake duct (ft) ducted installations (this row only) space Yes No Length of exhaust duct (ft)

(See Reverse)

Get a $500 rebate on qualified models.

By signing below, installer certifies that this form and any accompanying documentation are complete and accurate; that all measures associated with this project were completed as of the signature below; that all equipment was installed according to the manufacturer’s specifications and any additional specifications required by Seattle City Light; and that the unit is functional and operational prior to submission of this rebate form.

Manufacturer Training Location Date of Training

Installer Name

Installer Phone Installed by: Contractor Non-contractor/Homeowner

Installer Signature Date

ASSIGNMENT OF REBATE PAYMENT

Heat Pump Water Heater Program rebate funds belong to the individual homeowner. However, the homeowner may direct Seattle City Light to issue the rebate check to the contractor who performed the work. IF YOU WOULD LIKE US TO ISSUE THE REBATE CHECK TO YOUR CONTRACTOR, FILL OUT THIS SECTION. YOU MUST ALSO PROVIDE A COPY OF THE CONTRACTOR’S W-9 FEDERAL TAX ID NUMBER.

Payee Name

Tax ID Number

Mailing Address

City State Zip

TERMS AND CONDITIONS

Please refer to the following terms and conditions prior to signing acceptance:

• You must be a customer of Seattle City Light and the installation address is in the Seattle City Light service area. New construction and existing single family residences (1-4 units) qualify. Only common areas in multifamily buildings qualify.

• One rebate per household please.• This rebate request application must be postmarked within 90 days of the heat pump water heater purchase date. • The installed heat pump water heater must meet the following qualifications: – New heat pump water heater must be purchased between Jan. 1, 2016 and Dec. 31, 2016 and replace an existing electric

storage water heater. – ENERGY STAR rated and on the list of qualified models available at seattle.gov/appliances. – Installed in accordance with manufacturer’s specifications by an installer who has received manufacturer training.

A manufacturer’s checklist must be completed and submitted with this rebate form. Manufacturer checklists are available in the installation manual.

• All information must be complete and a copy of receipt or invoice, and manufacturer’s checklist must be enclosed to be considered for payment.

Seattle City Light (“SCL”) will review the rebate request application (“Request”) and determine whether the installed Heat Pump Water Heater product qualifies for the rebate. If the installed Heat Pump Water Heater product qualifies, SCL will mail the appropriate rebate within (60) days of SCL’s receipt of the Request. Only one rebate is available per home. By signing this Request and accepting any rebate, Owner (1) represents and warrants that the Heat Pump Water Heater product has been installed in compliance with all applicable federal, state and local laws, codes, and ordinances, including all building energy and accessibility codes and in compliance with the procedures specified by SCL; and (2) acknowledges and agrees that: (a) SCL is a sponsor of the rebate program only and has not and does not make any representations or promises with respect to the Heat Pump Water Heater product, the energy consumption, and/or energy savings from the installed Heat Pump Water Heater product; and (b) that SCL MAKES NO IMPLIED OR EXPRESS WARRANTIES REGARDING THIS PROGRAM, ITS POLICIES, PROCEDURES, INSPECTIONS AND/OR ANY OWNER INSTALLED HEAT PUMP WATER HEATER, AND SPECIFICALLY DISCLAIMS ANY WARRANTY OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.

ACCEPTANCE OF TERMS AND CONDITIONS

Owner certifies that all information provided herein is true and correct. Owner acknowledges and accepts SCL’s right to inspect the installed Heat Pump Water Heater products listed on the attached receipt/invoice. Owner acknowledges that the Rebate Program is a limited offer and subject to the availability of funds, and that rebate amounts may be subject to change.

Customer Signature Date

seattle.gov/appliances

OUR MISSIONSeattle City Light is dedicated to exceeding our customers’ expectations in producing and delivering environmentally responsible, safe, low-cost and reliable power.