For converting to ducted air source and variable speed heat pumps. Not necessary if using the Performance Tested Comfort Systems (PTCS) Program. All sections must be completed by the installer at the time of installation. Eligibility: Available for existing single-family and existing manufactured homes Existing heating system type must be an electric forced air furnace (conversion) Heat pumps must be Air-Conditioning, Heating, and Refrigeration Institute (AHRI) rated, and have a minimum of 9.0 Heating Seasonal Performance Factor (HSPF) and 14 Seasonal Energy Efficiency Ratio (SEER) Household & Heat Pump Compressor InformationName* First Last Phone*Electric Utility*Total Heated Area of the Home (Sq Ft)*Date (mm/dd/yyyy)* Date Format: MM slash DD slash YYYY Installation Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address*(If different) Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Type Existing site-built Existing manufactured Number of Sections 1 2 3 Existing Heating System Being ReplacedThis measure doesn’t apply if the existing heating system is an air source heat pump, ground source heat pump, natural gas furnace, or electric zonal—including ductless heat pumps. Please reference the PTCS program. Electric forced air w/out AC Electric forced air w/ AC Other non-electric space heating Other:Heat pump outdoor compressor type Non variable speed Variable speed Documentation to Submit with this Form Purchase receipt or invoice, including the heat pump make and model number AHRI Certificate If a variable speed compressor, include manufacturer documentation that the outdoor compressor includes variable speed or inverter driven technology (e.g. specification sheet, brochure, or screen shot). Note: Including the text “variable speed” on the invoice will not satisfy this requirement. Additional documentation is required. Documentation* Drop files here or $800 Existing home (no new construction) Manufactured home 9.0 HSPF minimum + $200 Variable speed compressor
