Invoice for Air Conditioner Service

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					                       Air Conditioner Rebate Application Form

City:     Boulder City                State:           Nevada             Zip:      89005
Home:                                                  Work:                                                 Submission Address:
Installation Address: (if different from above)
                       City:                                State:                       Zip:                      Boulder City Rebate Program
                                                                                                                 City of Boulder City, Public Works
                                                                                                                           PO Box 61350
Please complete this form in its entirety, sign and return to submission address
                                                                                                                       Boulder City, NV 89006
Signature is required for processing.

Submit your Rebate Application with copies of:                                                                   For more information please visit:
   • HVAC contractor invoice or proof of purchase.                                                                     Still have questions? Contact us at:
   • City of Boulder City permit for new AC install.                                                         or 702-293-9200
                                                                                                                                Fax 702-293-9241
Customer Signature and Acceptance
I testify that the information provided on this rebate application is true and accurate. I also agree to abide by the terms and requirements outlined in the
City of Boulder City’s Program. I recognize that all the elements of the program are subject to periodic review and can be amended, altered or
discontinued at the discretion of the City of Boulder City. I also recognize and agree the City may choose to physically inspect the AC Unit and may
disallow payment of a rebate if the AC unit does not meet the program requirements as defined and intended by the City.

Signature:                                                                                                          Date:

                                                                                                     State License Number:
CONTRACTOR/DEALER INFORMATION:                                                                        City License Number:
Name:                                                                                                             Phone:
Address:                                                                         City:                        State:                         Zip:

Old Unit:                                            Type:                        New Unit:                                               Type:
Manufacturer:                                           (please circle one)       Manufacturer:                                             (please circle one)

Model Number:                                                Split AC             Model Number:                                                  Split AC
Size: (tons)                                              Packaged AC             Size: (tons)                                               Packaged AC
SEER:                      EER:                            Heat Pump              SEER:                        EER:                            Heat Pump
Approximate Age:                                                                  ARI #:

                                              Rebate for which the customer is applying:
                                      (Select Only One)      14 SEER             15 SEER               13 SEER
                                        1.5      Ton             $105                $188                   $75
                                         2       Tons            $140                $250                  $100
                                         3       Tons            $210                $375                  $150
                                         4       Tons            $280                $500                  $200
                                         5       Tons            $350                $625                  $250
                                         6       Tons            $420                $750         (mobile homes only)

                              In addition to the City of Boulder City rebate, you may be eligible for a federal tax energy credit.
                           Contact the IRS at 1-800-829-1040 and ask for Form 5695 or find it at``5695.pdf.

Application Approved by:            Skip Spilman                                 Approval Date:
Rebate Amount: $                                                                        Invoice #:                                      FPO #:
                                                    See reverse side for program requirements.
Z:\City of Boulder City\Forms\Rebates\Air Conditioner Rebate Program Rev11.doc                                                            October 14, 2009
                                                                      Available to City of Boulder City
                                                                    Residential Electric Customers Only.

                                 Air Conditioner Rebate Program Eligibility Requirements
    The Air Conditioner Rebate Program is available to all Boulder City residential electric customers with existing central
    air conditioning and heat pump systems. The following eligibility requirements apply:

    1. To be eligible for a rebate, the system must be a new central installation that replaces* an existing central air
       conditioner, heat pump, Gas Pack heating and cooling units in an existing home in the Boulder City electric
       service territory.

    2. The program only applies to central air conditioning, heat pump, and ductless split systems. Window or single-
       room AC units are ineligible to receive incentives.

    3. AC units require installation by a contractor on the “Approved Participating Contractor” list.

    4. Installed HVAC units must be a minimum Seasonal Energy Efficiency Ratio (SEER) rating of 14 and must be
       replacing a unit with a SEER of less than 14.

    5. Rebates in the amount of $50.00 per ton for mobile homes only with a S.E.E.R. rating of 13.0 to 13.9.

    6. A completed rebate application form must be submitted within 60 days of the installation date.

    7. A dated contractor invoice will be required as proof of installation date.

    8. Residential purchasers of qualifying equipment may be subject to an on-site inspection by a Boulder City
       representative to verify equipment is properly installed and operational.

    9. A completed building permit that has been finaled is required.

    10. Rebate amounts are per unit.
    * Replacement is defined as the replacement of the electric-driven cooling system (i.e., condenser, blower, coils, etc.)
    or cooling or heating system in the case of heat pumps.
                          Approved Participating Contractor List                      Phone
                          Boulder City Air Conditioning INC                           293-4436
                          Gibson Air Conditioning Company LLC                         294-0552
                          Knight Air Conditioning                                     596-6096
                          Krauses Air Conditioning Service                            293-2599
                          Lake City Air Conditioning Heating and Sheet Metal          293-4757
                          Silver State Refrigeration HVAC                             433-5008
                          Southwest Air Conditioning Service INC                      876-5444
                          Sahara Air Conditioning & Heating                           796-9677
                          J G Hayden Mechanical Contractor                            293-0807
                          Sierra Air Conditioning INC                                 798-1055
                          Interstate Plumbing and Air Conditioning LLC DBA            367-6064
                          Hacienda Air LLC                                            878-5665
                          Global Warming & Cooling LLC                                579-4822
                          Tropic Air & Mech                                           566-1007
                          ASSAP Appliance                                             877-8880
                          Ice Princess HVAC & Mechanical, LLC                         719-1777
                          Service Max Cooling Heating & Plumbing                      364-5900

Z:\City of Boulder City\Forms\Rebates\Air Conditioner Rebate Program Rev11.doc                               October 14, 2009

Description: Invoice for Air Conditioner Service document sample