Residential Heat Pump Water Heater Rebate Application Asterisks (*) indicate required fields.CUSTOMER INFORMATIONAccount Number* Are you the account holder?* Yes No Relationship to Customer (if not account holder)* Family Member Landlord Tenant Applicant Name* First Last Phone*Email* Installation Address* 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 Do you have a different mailing address?* My mailing address is the same as above I have a different mailing address Mailing Address* 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 HOME INFORMATIONExisting Water Heater Type:* Electric Gas Existing Water Heater must be electric to qualify for the rebate.Home Type:* Site Built Manufactured New Construction Location of the water heater:* Conditioned (heated space) Unconditioned (unheated space) Installer:* Contractor Homeowner Installation Date* MM slash DD slash YYYY (Enter the estimated date if not installed yet)NEW EQUIPMENTRebate(s) will not exceed 100% of the total heat pump water heater cost and does not cover installation costs. Please click the button below to find current rebate amounts and the qualified products list. This will open a new tab. Rebate Amounts Heat Pump Water Heater must be purchased and installed on or after October 1, 2019 to qualify for current rebate amount. Have you already purchased a new Heat Pump Water Heater?* Yes, I have already purchased I have not made a purchase yet If you have not yet purchased a new Heat Pump Water Heater, you may submit this application for preapproval. Submitting for preapproval will confirm your eligibility for the rebate prior to purchasing new equipment.Water Heater Brand* Model Number* Tier Level Tier 1 Tier 2 Tier 3 HiddenNotes Title (Invisible)Application NotesPlease insert any notes that you would like us to review with your application.UPLOAD RECEIPTPlease attach an invoice or receipt for the purchase of your new Heat Pump Water Heater. Receipt must include the brand, model number, cost, and date of purchase.*Max. file size: 20 MB.Please attach an invoice or receipt for the purchase of your new Heat Pump Water Heater. Receipt must include the brand, model number, cost, and date of purchase.SUBMIT YOUR APPLICATIONTerms and Conditions*By clicking "submit," the applicant acknowledges the following: Rebate offer(s) may be changed or discontinued at any time by Modern Electric Water Company. Modern disclaims any warranty, whether expressed or implied, regarding the product(s) listed above for any materials or labor associated with installation, maintenance, repair, or any energy savings associated with use. Rebate offer(s) apply to new product(s) only. Modern reserves the right to inspect installed product(s). Product(s) must meet all program criteria to qualify for rebate(s). I understand the above and certify that I am a customer of Modern, that the product(s) are installed and operating at the location indicated and that this address is within Modern service territory. I agreeRebate Applications are due within six (6) months of purchase to qualify. Allow 8 to 10 weeks for rebate processing after the receipt of all final documentation. Call 888-883-9879 to learn about additional energy efficiency programs.