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2012 CONNECTICUT

REsIdENTIal QUalITy INsTallaTION aNd VERIfICaTION REbaTE fOR ExIsTINg HOmEs


Incentives are available to all existing home residential ratepayers (Customer) in the service company territories of (in the case of AC/HP) Connecticut Light and Power, The United Illuminating Company (or in the case of natural gas furnaces); Yankee Gas Company, Connecticut Natural Gas Company or Southern Connecticut Gas Company Customers. This 2012 Connecticut Residential Quality Installation and Verification Rebate for Existing Homes Program (Program) covers eligible system(s) installed by a QIV utility-approved contractor that must be chosen from the website directory on or after January 1, 2012 through December 31, 2012. While an HES assessment is not a requirement of this incentive, the HES assessment is recommended prior to the Quality Installation and Verification (QIV) in order for a customer to be eligible for the full benefit. This application must be postmarked by January 31, 2013. Total incentive cannot be more than 50% of the total installation cost of the qualifying system(s) as indicated in both the New Equipment Information section and under Eligibility on the back of this form. INSTRUCTIONS: Please fill out this form completely, truthfully and accurately and mail it to the below address along with the required documentation listed in the Document Checklist below. Roltay, Inc. Energy Services, 98 Overbrook Road Madison, CT 06443

Customer Information
(Please Print) First Name Last Name Electric Utility (Check One) n CL&P Address (where equipment was installed) City Mailing Address (if different from above) City Telephone Email State Zip Sq. Ft. of Heated Space: State Zip n UI Gas Account Number (as stated on bill) Electric Account Number (as stated on bill)

Gas Company (Check One) n Yankee Gas Services Company n Connecticut Natural Gas n Southern Connecticut Gas Type of Installation (Check One) n New Installation (Existing Home)

n Replacement (of Existing System)

Program Approved HVAC Contractor Information


Approved HVAC Contractor Name Address City Telephone Number Fax Number State Zip Contractor License Number

Supporting Documentation Checklist


This form must be submitted together with the following: n Copy of recent electric bill n 2012 Connecticut Energy Efficiency Fund QIV Workbook for the HVAC Contractor n Copy of Connecticut Energy Efficiency Fund 2012 High Efficiency Rebate Form(s)

E-mail Address

New Equipment Information*


Startup Date AC/HP Outdoor Section Model No. Indoor Fan/Coil Section Model No. Cooling Tons Natural Gas Warm Air Furnace Model No. Incentive $ Per Account

Brand

AHRI Certificate No.

Total QIV rebate at this address Air Conditioning / Heat Pump and Natural Gas Furnace may be added together if appropriate. Check all that apply: n Central Air Conditioning Assembled System Minimum 14.5 SEER, 12 EER Max 65,000 BTU/H n Heat Pump Assembled System Minimum 14.5 SEER, 12 EER, 8.2 HSPF Max 65,000 BTU/H n Natural Gas Furnace CEE Minimum 95% AFUE and Fan Performance Level EEA of 2% or lower Max 225,000 BTU/H n Package Unit (AC) 14 SEER / 11 EER / and if (HP) 8.0 HSPF Max 65,000 BTU/H n Copy of an ACCA manual j design report * Must be Matched AHRI/CEE Rated Assembly If more than two lines are needed for New Equipment, a second rebate form may be used.

SIGN HERE
By signing this form below, I certify that all the information described in the Connecticut Residential Quality Installation and Verification (QIV) Rebate for Existing Homes Program Application and all the documents provided with this rebate Application are accurate and true and that I have read and understand the Connecticut Residential Quality Installation and Verification Rebate for Existing Homes Program Guidelines. By signing this form I further certify that the qualifying System(s) is/are installed for use in the Connecticut residential address stated. Signature of the HVAC Program Approved Contractor below confirms that all Program requirements have been met. Customer Signature (Required) Date: HES Technicians Signature (if applicable) Home Energy Solutions Company: Date: Home Energy Solutions Job Number: CT12You may be eligible for federal tax credits. Please refer to www.energystar.gov for more information.

Program Approved HVAC Installer Signature (Required) Date:

TERMS AND CONDITIONS


ELIGIBILITy: All existing home residential ratepayers (Customer) in the service company territories of (in the case of AC/HP) Connecticut Light and Power, The United Illuminating Company (or in the case of natural gas furnaces); Yankee Gas Company, Connecticut Natural Gas Company or Southern Connecticut Gas Company. New home applicants are encouraged to apply to the Energy Efficiency Fund Residential New Construction program (Program) for a Quality Installation and Verification (QIV) rebate measure. APPLICATION OFFER: This Program covers products purchased and installed by a QIV utility-approved contractor that must be chosen from the website directory on or after January 1, 2012 through December 31, 2012. Details of this Program, including incentive levels, are subject to change or cancellation without prior notice. This Application, with required documentation, must be postmarked by January 31, 2013. If you have any questions about the rebate offer dates of eligibility, please call 1-877-WISE-USE for details. The rebate amount is $500 per system on replaced or new high efficiency rebate qualified AC/HP and/or $100 per system on replaced warm air natural gas furnaces paid to the home owner. Offer is not applicable to emergency replacements. EQUIPMENT REQUIREMENTS AIR CONDITIONING OR HEAT PUMPS: Ducted central air conditioning or heat pumps. When multiple sections are installed simultaneously, a matched assembly shall include the air handler, furnace, coil or other component that is used to determine the rating according to ARI/ISO/ASHRAE 13256-1/2 or ARI 370 published current standards. All systems must be ENERGY STAR certified and meet current Energy Efficiency Fund rebate efficiency requirements which may be found listed at: www. ahridirectory.org. or www.energystar.gov. EQUIPMENT REQUIREMENTS NATURAL GAS WARM AIR FURNACES: Systems must be greater than or equal to 95% AFUE and air handler performance level of EAE 2% or lower a list that may be found in the CEE directory at: www.cee.org. QUALIFyING CENTRAL AIR CONDITIONING, HEAT PUMP AND NATURAL GAS WARM AIR FURNACES: Central AC/HP systems and natural gas warm air furnaces may be installed using a rebate form available on the utility websites. Customers are encouraged to consider a Home Energy Solutions assessment prior to any incentives. An equipment rebate premium and form are provided when an HES contractor identifies an operating central AC/HP or natural gas warm air furnace older than 10 years for retirement. The QIV rebate is additional to Equipment incentives and may be combined with either the AC/HP or natural gas furnace if applicable. The QIV rebate is not applicable to emergency installations. PROOF OF PURCHASE: An installation service invoice itemizing the purchased Equipment must accompany each incentive Application. The invoice copy must indicate the Equipment type, make and model number(s), the installed address, the approved installers name and address and the date of purchase. A copy of a recent electric/gas utility bill, the qualifying 2012 Connecticut Energy Efficiency Fund QIV Workbook for the HVAC Contractor and the applicable Energy Efficiency Fund high efficiency rebate form (air conditioning/heat pump rebate and/or a natural gas warm air furnace early retirement rebate) must also accompany this completed Application. APPLICATION: This Application must be filled out completely, truthfully and accurately. The Customer and Contractor must each sign the completed Application and it must be submitted along with the Proof of Purchase requirements listed above. This Application must be accompanied by a passing 2012 Connecticut Energy Efficiency Fund QIV Workbook for the HVAC Contractor and must indicate a passing Quality Installation. The QIV must be reviewed and approved prior to payment. PAyMENT: Please allow up to 90 days for payment. Payment processing may take longer if information is missing on the application or follow up is needed. APPROVAL AND VERIFICATION: CL&P and UI reserve the right to verify sales transaction and to have reasonable access to your residence to inspect the system(s) installed under this Program prior to issuing incentives for up to one year after date of Application. TAx LIABILITy: CL&P and UI will not be responsible for any tax liability that may be imposed on the Customer as a result of the payment of rebate incentives. ENDORSEMENT: CL&P and UI do not endorse any particular manufacturer, contractor, vendor, product, retailer or system design in promoting this Program. LIMITATION OF LIABILITy: CL&P and UIs liability is limited to paying the rebate incentive specified. CL&P and UI are not liable for any consequential or incidental damages, or for any damages in tort connected with or resulting from participation in this Program. OWNERS CERTIFICATION: Owner certifies that he/she has purchased the Equipment listed on the other side of this Application and the Equipment was installed by a licensed contractor at the defined location and that installation verification contractor is QIV Program approved. Owner agrees that all information is true and that he/she has conformed to all Program and Equipment requirements listed. WARRANTIES: CL&P AND UI DO NOT WARRANT THE PERFORMANCE OF INSTALLED EQUIPMENT, EXPRESSLY OR IMPLICITLY. CL&P and UI makes no warranties or representations of any kind, whether statutory, expressed, or implied, including without limitations, warranties of merchantability or fitness for a particular purpose regarding the heating and/or cooling system or services provided by a manufacturer, contractor or vendor. Contact your Contractor for details regarding Equipment performance and warranties. FORWARD CAPACITy MARkET AND CLASS III CREDITS: By signing this document and as a condition to receiving a rebate pursuant to this Program, Customer hereby assigns to its participating electric utility, either CL&P or UI (as the case may be), any and all payments, benefits and/or credits in connection with the Forward Capacity Market or any currently existing or successor or replacement markets, (including, but not limited to, any and all LICAP, ICAP, transitional credits or payments or any and all other capacity-related credits, payments and/or benefits for which Customer is eligible) and that are associated with or applicable to Customers participation in this Program. Customer hereby assigns to either CL&P or UI (as the case may be) all of its right, title and interest in and to any and all such capacity payments, credits and/or benefits and shall take any and all action, including executing and delivering any and all documents and/or instruments, as requested by either CL&P or UI (as the case may be) to evidence the same. Forward Capacity Market means the market for procuring capacity pursuant to ISO-NE Tariff, FERC Electric Tariff No. 3, Section III, Market Rule 1, Section 13, any modifications to the Forward Capacity Market, or any successor or replacement market/capacity procurement process. In accordance with the Department of Public Utility Controls (DPUC, now known as the Public Utilities Regulatory Authority or Authority) September 29, 2008 decision in Docket No. 05-07-19RE01, DPUC Proceeding to Develop a New Distributed Resources Portfolio Standard (Class III) 2007 Revisions, (as supplemented by the Department February 11, 2010 decision in Docket No. 05-07-19RE02), Customer is not to receive or retain any Class III renewable energy credits in connection with this Program and Customer hereby acknowledges and agrees the same. Customer further acknowledges and agrees that such credits shall be retained by either CL&P or UI (as the case may be) for the benefit of their Customers through the Energy Efficiency Fund. In the event that the Authority amends or modifies the allocation of Class III conservation credits as reflected in its September 29, 2008 decision, then the allocation of such credits utilized by either CL&P or UI (as the case may be) shall be the allocation in effect (per the applicable Authority decision) on the date that the Customer submitted its rebate Application documents to either CL&P or UI (as the case may be). Customer further acknowledges and agrees that Customer is not to retain or receive any environmental credits or benefits that may be ascribed or attributed from time to time to Customers participation in this Program and any and all such benefits or credits shall be retained by either CL&P or UI (as the case may be) for the benefit of their Customers through the Energy Efficiency Fund.

Minimum Efficiency Levels / Incentive Schedule


Equipment Type Natural Gas Furnace1, 3 Central AC/HP QIV
2, 3

Minimum Efficiency for Incentive QIV / AHRI Rated 95% AFUE with air handler Performance Level E AE less than or equal to 2%** AHRI Rated Central Air Conditioning and Air Source Heat Pump Split Systems

Incentive* $100/unit $500/system

1 - Eligible natural gas furnace installation outside of CL&P and UI territory is only eligible for $300 equipment incentive 2 - QIV is not applicable for AC/HP outside CLP and UI service territory 3 - QIV may not be used for emergency installations

* Total rebate amount not to exceed 50% of the total installation cost of the qualifying Equipment. Funding for this rebate Program is limited to the period indicated or while funds last. ** Both measures with applicable eligible efficiency levels must be made to qualify for incentive.

Energize Connecticut programs funded by a charge on customer energy bills. C0189 Rev. 10/12