InstagramThis field is for validation purposes and should be left unchanged. All sections must be filled out by the installer at the time of installation. A copy of this completed form and the purchase receipt or invoice must be promptly submitted to the homeowner’s utility in accordance with utility policy. Eligibility Guide for DHPs and Ducted Mini-Splits: Ducted Mini-Splits do not include homes with whole house centrally ducted systems. See PTCS Air Source Heat Pumps for further information on whole home centrally ducted systems. All systems must: Be installed on a dedicated electrical circuit, Have refrigerant line protection on the entire length of exterior and insulated refrigerant lines, Be installed in accordance with manufacturer specifications, including adherence to proper refrigerant charging and, If installing a single head DHP, the contractor must have received the contractor orientation available at https://goingductless.com/partners. What are you installing?(Required) Single Indoor Head DHP Single Ducted Mini-Split (not whole home centrally ducted) Multi Indoor Head DHPs Multiple Indoor Ducted Mini-Splits (not whole home centrally ducted) Combination DHP/Ducted Mini-Split Eligible Home Type(Required) Existing Single Family Existing Manufactured New Single Family (all states except WA) New Manufactured Eligible Home TypeMulti-head DHPs, multi ducted mini-splits and combination installs in New & Existing Manufactured Homes or New Single Family Homes (in all states except WA) may be eligible for single indoor head DHP or single ducted mini-split incentives. Existing Single Family Eligible Existing Heating System Being Replaced Electric Forced Air Furnace Electric Zonal Household InformationCustomer Name(Required) First Last Customer Electric Utility(Required)Installation Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Same as previous Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Customer Phone(Required)Total Heated Area of the Home (in Sq Ft):(Required)Year Built(Required)Installation InformationAHRI Certified Reference #(Required)HSPF2 Rating(Required)Installation Date:(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Outdoor Unit ManufacturerOutdoor Unit Model(s) #List All Installed Indoor Units and Model NumbersClick + to add more indoor units.Associated Indoor UnitsIndoor Unit Model Number(s) Add RemoveTotal Installed Cost (before rebates)(Required)Additional repair cost (if low income):Invoice showing the purchase date(Required)Max. file size: 3 MB. AHRI Certificate(Required)Max. file size: 3 MB. Additional DocumentationFiles showing that the requirements have been met – manufacturer, model number, type, size of product installed. Drop files here or Select files Max. file size: 12 MB.
