Water Heaters & Clothes Washers Purchased at Retail
Energy Trust Products l Incentive Application l Form 920C
Want your incentive faster?
Apply online!
Visit www.energytrust.org/apply
Customer Information (Required for payment)
Are you applying as:
Homeowner
Business or Rental
Property Owner*
Renter
*If site is used for income or a business, a W-9 is required. Visit www.energytrust.org/w9
How to apply:
1 Purchase a qualifying product.
Product must qualify at time of
purchase to be eligible.
2 Complete entire application, including:
Customer Information
Installation Address Information
New Product Information
Your signature
An itemized receipt or invoice with:
o
o
o
o
o
Purchase Date
Retailer Name
Model Number
Purchase Price
Proof of Payment
If purchased from The Home Depot,
please include the Special Services
Customer Invoice (SSCI) in addition to
the register receipt.
3 Submit completed application, and a copy
of the itemized sales receipt via mail, fax or
email within 60 days of purchase. Please
allow 6-8 weeks to receive check by mail.
Energy Trust of Oregon
Products
PO Box 2445
Spokane, WA 99210
1.877.501.9629 fax
[email protected]
Customer Name
Installation Address
City
State
Zip
Mailing Address for Check
City
State
Zip
Home
Work
Primary Phone
Home
Work
Cell
Other Phone
Cell
Email Address (please print legibly)
Installation Address Information (Choose one from each)
Who is your electric utility?
Who is your gas utility?
PGE
Pacific Power
NW Natural
Cascade Natural Gas
Avista
None
New Product Information
Water Heater*
Other
Clothes Washer
Brand
Model
Purchase Price
Purchase Date
$
How do you heat your water?
(Required for clothes washers)
Electricity
Natural Gas
Other
*For water heaters installed by a professional, please use Form 320C
Qualified Product
Efficiency Requirements
Incentive Amount
Heat Pump Water Heater
NEEA Advanced Water Heater Specification Tier 1
$150
(less than 55 gallons)
NEEA Advanced Water Heater Specification Tier 2
$300
NEEA Advanced Water Heater Specification Tier 3
$300
Energy factor (EF) 0.67 or greater; ENERGY STAR® qualified
$100
IMEF of 2.38 or greater; ENERGY STAR® qualified
$75
Heat Pump Water Heater
(any capacity)
Gas Tank Water Heater
Front-Load Clothes Washer
(2.5 cu ft or larger)
Additional qualifications may apply; see our website for more details. www.energytrust.org/hotwater or www.energytrust.org/appliances
Acceptance of Terms and Conditions
By signing below, I certify that all information on this form is true and correct to the best of my knowledge. I represent that I have read, understood and
agreed to the terms and conditions herein. I also agree that Energy Trust may contact my retailer regarding any information that my application might
be missing in order to expedite application processing.
Customer Signature
Date
Measures and Incentives are subject to change. Do not use this form for appliances purchased after December 31, 2017.
Form 920C v2017.2 170119 — Page 1 of 2
Water Heaters & Clothes Washers Purchased at Retail
Energy Trust Products l Incentive Application l Form 920C
TERMS AND CONDITIONS
APPLICATION: This application must be filled out
completely, truthfully and accurately. Customers are advised
to retain a copy of this application and any accompanying
documentation submitted to Energy Trust under this
program. Energy Trust will not be responsible for lost
documentation pertaining to this application request.
Products program must receive applications within 60
days from the date of purchase. Incentive offers are
subject to funding availability and may change. Incentive
amounts are valid through December 31, 2017. Please
allow six to eight weeks for incentive processing.
ELIGIBILITY: Incentives are available to Oregon customers
of Portland General Electric, Pacific Power, NW Natural,
Cascade Natural Gas and Avista and are payable to the unit
owner. Incentives for energy-saving measures are available
to PGE and Pacific Power customers who heat their water
with electricity and to NW Natural, Cascade Natural Gas or
Avista customers who heat their water with natural gas.
Participants who have already received an
Energy Trust incentive at time of purchase are not eligible
for an additional incentive on that product.
ELIGIBLE PRODUCTS: Products must meet Energy Trust
energy efficiency specifications. Energy Trust will refer to the
water heater requirements posted on
www.energytrust.org/hotwater and qualified models list
posted on www.energytrust.org/appliances when approving
applications for all water heaters and clothes washers. If you
are not sure of the specifications, please call Energy Trust
before proceeding.
PAYMENT: Incentives will be paid after timely submission of
all required documentation of products purchased.
Incentives will be paid directly to Participant. Participants
who are commercial businesses or landlords must submit a
completed W-9 to receive an incentive.
PROOF OF PURCHASE: All participants must submit an
itemized receipt showing that the product was purchased
new. Itemized receipts must be legible and contain the
following information:
• Purchase date
• Retailer name
• Model number
• Purchase price
• Proof of payment
If purchased from The Home Depot, please include the
“Special Services Customer Invoice” (SSCI) in addition
to the register receipt.
INCENTIVE AMOUNT: Energy Trust will not pay incentives
on products received due to any of the following
circumstances, including but not limited to:
• Resale, used or refurbished
• Leased or rented
• Products received due to a warranty claim, recall or
exchange
• Products won as a prize or given as a gift
In no event will incentive amounts equal or exceed the price of
the product purchased.
NO ENDORSEMENT: In promoting ENERGY STAR products,
Energy Trust does not endorse any particular manufacturer.
The fact that the names of particular manufacturers, equipment
or systems may appear on applications does not constitute an
endorsement. Manufacturers, equipment or systems not
mentioned are not implied to be unsuitable or defective in any
way.
TAX LIABILITY: Energy Trust is not responsible for any tax
liability, which may be imposed on the Participant as a result of
payment of any incentives. Energy Trust is not providing tax
advice, and any communication by Energy Trust is not intended or
written to be used, and cannot be used, for the purpose of
avoiding penalties under the Internal Revenue Code.
PROPERTY RIGHTS: Participant represents that Participant has
the right to install the energy-saving products on the property on
which those products are installed and that any necessary
landlord's consent has been obtained.
ENERGY INFORMATION RELEASE: Participant will allow Energy
Trust access to electric and natural gas utility account and usage
information for the physical address of the property in which the
product was installed. Participant agrees to provide other
reasonable assistance to Energy Trust to obtain such information.
Participant also acknowledges that Energy Trust will treat all
information about services provided and participant’s resulting
energy savings as confidential, but may report such information in
the aggregate as part of reports or other documentation regarding
its programs.
DISCLAIMER / NO LIABILITY: Participant understands that, while
Energy Trust is providing funding for the incentives payment,
Energy Trust is not supervising work performed for Participant nor
is Energy Trust responsible in any way for proper product
installation, completion of that work or proper performance of any
product purchased. Energy Trust is simply providing funding to
assist Participant in implementing energy-efficiency measures.
Participant assumes the risk of any loss or damage(s) that
Participant may suffer in connection with installation of the
products. Energy Trust does not guarantee any particular energysavings results by its approval of the Application or by any other of
its actions. Energy Trust will not be held responsible for any claims
made by a retailer regarding the amount of the incentive and the
eligibility of the purchase.
Resources
Get your incentive faster, apply online:
www.energytrust.org/apply
Link to W-9
www.energytrust.org/w9
Contact Us
Email [email protected] call 1.877.283.0702
Measures and Incentives are subject to change. Do not use this form for appliances purchased after December 31, 2017.
Form 920C v2017.2 170119 — Page 2 of 2