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The GEO Residential Solar Grant Program

Solar Domestic Hot Water (SDHW) Rebate Reservation Request

APPLICANT INFORMATION
Note: Systems must be installed at applicant’s primary and year-round residence, located in
Colorado, in order to be considered eligible for a rebate through this program.

Applicant name:_________________________________________________________

Colorado Springs Utilities Account Number:___________________________________

Installation address (street, city, zip, county):

______________________________________________________________________

Mailing address, if different, (street, city, zip, county):

______________________________________________________________________

Daytime phone:__________________________________________________________

Email address:__________________________________________________________

Please initial here to indicate that you do agree to manage trees and/or other potential
shade sources in order to prevent future shading of the array______________________

Please initial here to acknowledge Colorado Springs Utilities will and a GEO or CoSEIA
representative may contact you to request access to your property in order to perform a
random visual verification of your system. Permission will be requested, advance notice
will be provided, and care will be taken to minimize any inconvenience to
you:_____________________________

INSTALLATION INFORMATION
Total system size:_______________________
 Please provide calculation of system rated output

Roof or ground mount:____________________________________________________

Azimuth:____________________________ Tilt Angle:___________________________

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

Estimated percentage of optimum orientation production based on actual installation tilt

and azimuth (90% is minimum allowable per program requirements):________________

Is the array free of shade between the hours of 9 am and 3pm? If not completely shade-
free, please indicate the average percentage of shading the array will receive:________

Equipment Information:
If the Solar Domestic Hot Water system is part of a larger installation that will supply
for space heating or other applications, please indicate and provide a brief
description of the larger system, including array size, panel types, estimated energy
production, thermal storage tank size, and total cost: $_______________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

List only the equipment that is dedicated to the solar domestic hot water portion of
the system below:
o Panel brand, model, power rating, quantity:
________________________________________________________________
________________________________________________________________
o Thermal Storage Tank brand, capacity, installation location:
________________________________________________________________
________________________________________________________________

INSTALLER INFORMATION
Installers must be on the approved list of installers for the GEO Solar Rebate Program located at:
http://www.coseia.org/newsite/assets/files/Approved_Contractors.html

Company name:_________________________________________________________

Company phone:______________________ website:___________________________

Company address (street, city, state, zip, county):_______________________________

______________________________________________________________________

Project contact name:_____________________________________________________

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

Project contact phone:_____________________ email:__________________________

Installation warranty term offered:___________________________________________

 Please attach copy of installation warranty policy

Client Service Agreement offered? Yes No

 If yes, please attach copy of service agreement

Payback Analysis performed? Yes No

 If yes, please attach a copy of payback analysis report

Installer Qualifications/Certifications held:_____________________________________

______________________________________________________________________
______________________________________________________________________

ENERGY AUDIT INFORMATION

Customers must obtain an Energy Audit for their home as required by The Governor’s
Energy Office in the SDHW application process. Customers can use a qualified contractor
such as Home Performance with ENERGY STAR ®
http://www.csu.org/environment/conservation_res/energy/home_performance/index.html or
fill out an online Energy Efficiency Profile available at http://www.energydepot.com/cosres/.

Audit performed by (circle):

Program Partner Installer Non-profit Private Company Other

Company name:_________________________________________________________

Company phone:_____________________ website:____________________________

Company address (street, city, state, zip, county):_______________________________

______________________________________________________________________

Project contact name:_____________________________________________________

Project contact phone: _____________________email:__________________________

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

Audit date:______________________________________________________________

Auditor Qualifications/Certifications held:______________________________________

______________________________________________________________________
______________________________________________________________________

Type of audit performed (circle):

Online Walkthrough Blower Door Infrared Scan HERS Rating

 Please attach audit report
REBATE CALCULATION
REBATE CALCULATION
Solar Domestic Hot Water systems must meet the following minimum requirements in order to qualify
for a rebate. If the minimum system requirements have been met, the system qualifies for the flat
rate rebate amount as determined by the Program Partner:

 Program Partner rebate level: $1,500 per minimum system requirements, as follows:
 Minimum of 30,000 BTU/day, based on SRCC rating for clear day/C interval (see
http://www.solar-rating.org/ratings/ratings.htm , download “Summary of SRCC
certified solar collector and water heating system ratings”), with 50 gallon
minimum solar tank size.

 Program Partner rebate level: $3,000 per minimum system requirements, as follows:
 Minimum of 60,000BTU/day, based on SRCC rating for clear day/C interval (see
http://www.solar-rating.org/ratings/ratings.htm , download “Summary of SRCC
certified solar collector and water heating system ratings”), with 80 gallon
minimum solar tank size.

INSTALLER CERTIFICATION
I acknowledge by my signature that the system which I installed as indicated in this rebate
application and for which this rebate application is being submitted meets the specified
minimum system size and all other specified requirements:

Signature:_________________________________________________________________

Printed name___________________________________________date:_______________

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

CUSTOMER CERTIFICATION
I acknowledge by my signature that the system which I installed as indicated in this rebate
application and for which this rebate application is being submitted meets the specified
minimum system size and all other specified requirements:

Signature:_________________________________________________________________

Printed name___________________________________________date:_______________

APPLICATION SUBMISSION INFORMATION

Program Terms and Conditions

1. Qualifying Systems installed under the SDHW rebate must:
a. Meet minimum system requirements as specified in the Rebate Calculation section of this application
b. Be installed at a premise owned by the Customer. Eligible customers must be individuals that purchase retail
electric or gas service on a residential tariff from Springs Utilities that they use for the purposes of water heating.
c. Customer account(s) must be current and non-delinquent.
d. Be for personal use only, NOT FOR RESALE.
e. Be new, active solar equipment, either flat-plate or evacuated-tube collectors
f. Be purchased and installed from January 1, 2009 to Dec. 15, 2009.
g. Carry manufacturer and/or installer warranties for the product installed, from the date of completion of the work.

2. Qualifying Systems must not be installed prior to inspection and written authorization from Colorado Springs
Utilities.

3. Reservations (and rebates) are non-transferable, subject to availability of funds, and offered on a first come, first
served basis. Rebates are limited to one per premise every three years.

4. Rebate payments may not exceed the total installed cost.

5. Required documentation and Submittal Deadlines – Incomplete Reservation Request form(s) or those lacking a
completed IRS Form W-9 (located at http://www.irs.gov/pub/irs-pdf/fw9.pdf), Affidavit of Lawful Presence in the
United States or copy of an Energy Audit will be denied. Incomplete Rebate Claim form(s) or those lacking an
approved copy and final sign-off of the building permit(s) for the installation and a copy of the final purchase and
installation invoices will be denied. Reservation Requests expire after ninety (90) days, Customers will forfeit their
place in the queue for SDHW funding and will be required to re-apply by submitting a new form.

6. Customer is solely responsible for installation of all equipment/products to the manufacturer’s specifications.
Customer is solely responsible for obtaining related building permits and completing the inspection process as
required by local jurisdiction. Colorado Springs Utilities requires the Customer to submit proof of appropriate
City/County/State building permit for System installation prior to issuing rebate payment.

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

7. Customer agrees that Colorado Springs Utilities reserves the right to inspect the installation premise at any time or
request additional documentation prior to issuing a rebate payment.

8. Colorado Springs Utilities is not a party – The Customer understands and agrees that Colorado Springs Utilities
is not a party to any contract pertaining to the System installation. The Customer agrees to indemnify, to defend,
and to hold harmless Colorado Springs Utilities, its board members, officers, agents and employees against all
claims, loss, damage, expense and liability asserted or incurred by other parties, including but not limited to
Colorado Springs Utilities’ employees, arising out of or in any way connected with the SDHW rebate and the
System, or the System’s installation, operation or performance, and caused by acts, omissions, intent or
negligence, whether active or passive, of Customer, its agents, employees, and suppliers, and excepting only such
loss, damage or liability as may be caused by the intentional act or sole negligence of Colorado Springs Utilities.

8. Disclaimer of warranties – Colorado Springs Utilities makes no representations or warranties, expressed or

implied, regarding the design, sizing, installation, construction, reliability, efficiency, performance, operation,
maintenance, or use of any System or any make or model of equipment analyzed, discussed, selected, rejected,
installed or otherwise considered by the Customer. Any decisions regarding the selection, design, installation, use
and operation of Systems and equipment shall be at the sole discretion and are the sole responsibility of the
Customer. Colorado Springs Utilities is not liable or responsible for any act or omission of any contractor
whatsoever.

9. Customer agrees that Colorado Springs Utilities reserves the right to deny an application if the proposed SDHW
System would require modification to existing Springs Utilities facilities or equipment.

10. This SDHW rebate is subject to change and/or discontinuation without notice.

11. Systems installed under this program are intended to offset part of a Customer’s annual electrical needs at the
installation site.

12. Qualifying Systems must remain operational for a minimum of five (5) years. This time period will begin on
the date authorization of rebate is given to the Customer by Colorado Springs Utilities. If the qualifying system does
not remain operational for the minimum 5-year period, then the full amount of the rebate payment will be billed to
the Customer. In the event of a sale of the premises (and its qualifying system) prior to the conclusion of the
minimum 5-year period, the Customer will remain obligated for the operation of the qualifying system and the return
of the rebate payment amount, unless other contractual arrangements are made between the Customer, the new
owner and Colorado Springs Utilities.

13. Certification – By signing the certification below, the Customer certifies under penalty of perjury that:
a. The information provided in this form is true and correct to the best of the Customer’s knowledge.
b. The Customer has read and understood the stated SDHW rebate terms and conditions.
c. The Customer agrees to comply with all provisions of the SDHW rebate.
d. The Customer understands that if the System fails to remain operational within Colorado
Springs Utilities’ service territory for a minimum of five (5) years, the Customer will be billed the rebate
payment amount.

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

APPLICATION CHECKLIST
CHECKLIST ITEM: DATE COMPLETED:

Completed rebate application form___________________________________________

Attachments:

o System output calculation____________________________________________

o One-line Diagram of installation:_______________________________________

o Installation warranty policy:___________________________________________

o Service Agreement (if applicable):_____________________________________

o Payback Analysis (if applicable):______________________________________

o IRS Form W-9: ___________________________________________________

(form located at http://www.irs.gov/pub/irs-pdf/fw9.pdf)
o Affidavit of Lawful Presence in the United States (Page 8):__________________

o Energy Audit report:________________________________________________

Installer Certification signed:________________________________________________

Customer certification signed:______________________________________________

Date application submitted:________________________________________________

o By whom:________________________________________________________

HOW DID YOU HEAR ABOUT THE SDHW REBATE?

Colorado Springs Utilities Web site Direct Mailing
Family/friend Media (newspaper, radio, TV, etc.)
Bill insert/newsletter Other: _______________________
Colorado Springs Utilities employee

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org
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The GEO Residential Solar Grant Program

AFFIDAVIT OF LAWFUL PRESENCE IN THE UNITED STATES

This form is required for all residential applicants in compliance with Colorado House Bill 06S-1023.

I _______________________________________(print name legibly), swear or affirm under penalty of

perjury under the laws of the State of Colorado that (check one):
 I am a United States citizen; or
 I am not a United States citizen, but I am a Permanent Resident of the United States; or
 I am not a United States citizen, but I am lawfully present in the United States pursuant to
Federal law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States prior
to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent
statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as
perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate
criminal offense each time a public benefit is fraudulently received.

Applicant’s Signature _______________________________________ Date ________________

ATTACH A COPY OF APPLICABLE IDENTIFICATION TO THIS AFFIDAVIT.

Note: Upon verification of applicant’s identification, the attached copy will be destroyed.

____________________________________________________________________________________

(Do not write in this section. Colorado Springs Utilities will complete this section.)

I _______________________________________ (printed name), an employee of Colorado Springs

Utilities, verified the above named applicant’s proof of lawful presence in the United States in accordance
with Colorado law. The applicant provided the following evidence of lawful presence in the United States:

Note: Attach copy of all verification documents.

 Colorado Driver’s License  Colorado Identification Card
 U.S. Military Identification Card  U.S. Military Dependent Identification Card
 U.S. Coast Guard Merchant Mariner Card  Native American Tribal Document
I.D. Number: _____________________ I.D. Expiration Date: __________________

Colorado Springs Utilities Employee Signature ____________________________Date ______________

If the above named applicant’s lawful presence is required by law to be verified through the SAVE
Program, such verification was attempted on ________________ by ________________________.
Verification was finalized on ____________________ by ________________________________.

Please submit form to:

COLORADO SPRINGS UTILITIES Phone: 719.668.8509
Deborah Mathis, Program Manager Fax: 719.668.2510
2855 Mesa Road, Colorado Springs, CO 80904 dmathis@csu.org