Smart Thermostat Rebate

Project Information Form

For Single Family, Multifamily, and Manufactured Home Residential Customers

Instructions: Complete this form and submit it to the PUD. Please include invoice/receipt for device and installation if work was performed by a professional HVAC technician.

Household Information

Jefferson County PUD Customer Name(Required)

First Last

PUD Customer Account #(Required)

Customer Mobile Phone #(Required)

Installation Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Type(Required)

Manufactured Home

Multifamily

New Construction

Single Family

Duplex, Triplex, or Fourplex

EXISTING EQUIPMENT INFORMATION

One Smart Thermostat per furnace or heat pump controlled with a limit of two per household

Thermostat 1

What heating system is the thermostat controlling?(Required)

Electric Forced Air Furnace

Air or Water Source Heat Pump

Previous Thermostat Type(Required)

Programmable

Manual

Other

Baseboard and zonal heating systems are ineligible for rebate.

Thermostat 2

What heating system is the thermostat controlling?(Required)

Electric Forced Air Furnace

Air or Water Source Heat Pump

Previous Thermostat Type(Required)

Programmable

Manual

Other

Baseboard and zonal heating systems are ineligible for rebate.

(If previous thermostat contains mercury, contact your local waste management or https://thermostat-recycle.org for disposal locations.)

NEW EQUIPMENT INFORMATION

Thermostat 1

Installation Date(Required)
MM slash DD slash YYYY

Thermostat Manufacturer(Required)

ecobee

NEST

Carrier

Bryant

Other

Thermostat Model #(Required)

Thermostat Serial #(Required)

The thermostat is on the BPA Qualified Products List available at:

Yes

No

Thermostat settings reflect the local geographic area where it has been installed?(Required)

Yes

No

Occupancy detection has been set to "ON"?*(Required)

Yes

No

If the thermostat controls a heat pump, thermostat has been programmed to control a heat pump?*(Required)

Yes

No

*If answered "NO", project is not eligible for incentives.

Reference program Qualified Product List for information on how to properly set occupancy detection.

Reference program Qualified Product List for information on how to properly set auxiliary heat control.

Another Thermostat Installed?

Yes

No

Thermostat 2

Thermostat Manufacturer(Required)

ecobee

NEST

Carrier

Bryant

Other

Thermostat Model #(Required)

Thermostat Serial #(Required)

The thermostat is on the BPA Qualified Products List available at:

Yes

No

Thermostat settings reflect the local geographic area where it has been installed?(Required)

Yes

No

Occupancy detection has been set to "ON"?*(Required)

Yes

No

If the thermostat controls a heat pump, thermostat has been programmed to control a heat pump?*(Required)

Yes

No

Upload receipts or invoices and installation of work performed by a professional HVAC technician(Required)

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, doc, docx, Max. file size: 128 MB.

Did you install yourself?

Yes

No

Where Should the Rebate Check Be Mailed To?

Same as Installation Address

Different

Address
Street Address Address Line 2 City State ZIP Code

INSTALLER INFORMATION

Installer Name(Required)
First Last

Installer Email(Required)

Installer Mobile Phone #(Required)

Installation Company(Required)

Installation Company Phone #(Required)

Installer Signature

By signing this form, I confirm that the above information is correct to the best of my knowlege.

Full Name(Required)
First Last

Date(Required)
MM slash DD slash YYYY

Installer Signature(Required)

Customer Signature

With my signature below, I certify that I meet all of the above rebate requirements and that the information I have provided is accurate and complete.

Customer Signature(Required)

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Comments
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