PEI Energy Efficiency Loan/Grant Program
Application Form
Freedom of Information and Protection of Privacy
Personal information on this form is collected under section 31(c) of the Freedom of Information and Protection of Privacy Act R.S.P.E.I. 1988,
c. F-15.01, as it relates directly to and is necessary for the provision of the PEI Energy Efficiency Loan/Grant Program. If you have any questions
about this collection of personal information, you may contact the Department of Environment, Energy and Forestry, Office of Energy Efficiency,
31 Gordon Drive, Charlottetown, PE C1A 7N8, (902) 620-3690.
How to apply:
Complete the application form and gather all supporting documentation.
Bring this directly to our office located in Charlottetown or to your local
Access PEI Centre. All information can also be mailed to:
Office of Energy Efficiency
31 Gordon Drive
PO Box 2000
Charlottetown, PE C1A 7N8
For Office Use Only
Date Received:
Date Information Received:
Date of Evaluation:
To be completed by applicant: (Note: all fields must be completed and front and back of application must be signed before the
application can be processed.)
Household Information
Name (include full middle name):
Spouse/Partner:
Civic Address:
Property Tax Number:
Mailing Address:
Cel No.:
E-mail Address:
City/town:
Postal Code:
Please indicate here which you are applying for:
or
o Grant
Low Income Information (Check all that apply to you)
o Loan (attach quotes)
o Decline Loan Insurance
Tel No.:
or
o HELP Program only
(low income households)
Please check to ensure you have included the document listed
below before mailing in your application
I/We have an annual household income less than $35,000
o
Low Income: Your most recent Income Tax Assessment(s),
NCBS or GIS notification
o
I/We receive the National Child Benefit Supplement (NCBS)
(this is different than the Canada Child Tax Benefit)
o
Rental: Rental or Lease agreement if residence
is a rental property.
o
I/We receive the Guaranteed Income Supplement (GIS)
o
For Office Use Only
Date:
Time:
Inspector:
Pre Inspection:
Post Inspection:
Please check which upgrades you are planning to complete. If you are applying for the loan program please include quotes for all upgrades
checked. Work must be completed within 12 months of receipt of application.
Please refer to PEI Energy Efficiency Upgrade List for specific requirements for each upgrade.
Insulation:
Heating Systems:
Hot Water:
Biomass:
Above grade walls
o
Energy Star ® oil boiler
o
Solar HWH
o
EPA Woodstove
o
Below grade walls
o
Energy Star ® oil furnace
o
On-demand gas HWH
o
Pellet Stove
o
Basement header
o
Energy Star ® gas boiler
o
Indirect HWH
o
Masonry heater
o
Attic space
o
Energy Star ® gas furnace
o
Drain water heat recovery
o
Outdoor wood boiler
o
Flat/sloped roof
o
Earth energy heat pump
o
Water Conservation:
Wood boiler
o
Energy Star ® air source heat pump
o
Low Flow toilet
o
Wood Furnace
o
Solar warm air heater
o
Low flow shower head
o
Mobile home furnace
o
Air Infiltration:
Air Sealing
o
Controls:
Ventilation:
Heat recovery ventilator
o
Windows/Doors: (grant only)
Programmable thermostat
o
Energy Star Wind/Skylight
o
Outdoor temp controller
o
Energy Star Door
o
(You must check an insulation
upgrade other than basement
header to include a biomass
option)
The homeowner has the right to allow or deny a particular individual or contractor access to his/her residence for the purpose of performing
these upgrades. Neither the Prince Edward Island Office of Energy Efficiency nor The Government of PEI is responsible for the actions or
work of this or any contractor.
Client Signature/verification
By signing below, the applicant declares that all of the information provided in this application is accurate.
Date
Signature
For further information, contact the Office of Energy Efficiency at (902) 620-3690 or toll-free at 1-877-734-6336.
After April 8, 2010 all applications must be approved by the Office of Energy Efficiency prior to any work commencing.
An inspection prior to work commencing and after work is complete will also be required.
Energy Efficiency Programs Declaration
I/We have read and understand all of the program information provided by the PEI Office of Energy Efficiency which is detailed in the
following information sheets:
- PEI Energy Efficiency Upgrade List
- PEI Energy Efficiency Loan Program
- PEI Energy Efficiency Grant Program
- Home Energy Low-income Program (HELP)
- Financial Assistance for High Efficiency Oil-Fired Heating Systems.
I/We certify that:
1. I/We own the house that is the subject of this application under the PEI Energy Efficiency Loan Program or the PEI Energy
Efficiency Grant Program and that the house is at least 6 months old.
2. The house that is the subject of this application under the PEI Energy Efficiency Loan Program or the PEI Energy Efficiency Grant
Program is registered with the Taxation and Property Records Division of the PEI Department of Finance and Municipal Affairs in
my/our name.
3. The house that is the subject of this application under the PEI Energy Efficiency Loan Program or the PEI Energy Efficiency Grant
Program is my/our primary residence or a year round rental property and that it is not a seasonal recreational property.
4. I/We do not have an existing loan with the PEI Lending Agency or have defaulted on a previous loan with the PEI Lending Agency.
I/We acknowledge that:
5. The eligibility of specific costs under the PEI Energy Efficiency Loan Program and the PEI Energy Efficiency Grant Program shall
be determined by the PEI Office of Energy Efficiency.
6. Any work performed prior to application to the program and completion of a pre-retrofit inspection is not eligible for the PEI
Energy Efficiency Loan Program or the PEI Energy Efficiency Grant Program.
7. Any forgivable portion offered under the PEI Energy Efficiency Loan Program will not be applied until I/We have paid the balance
of the loan.
8. The loan limit per client under the PEI Energy Efficiency Loan Program is $10,000 and the grant limit per property under the PEI
Energy Efficiency Grant Program is $1500. If I/We have received a grant for windows and/or doors this amount will be deducted
from the $1500 maximum grant. I/We may access either a loan or a grant, but not both.
9. The PEI Energy Efficiency Loan Program may only be applied to one property and any additional properties I/We own shall only
be eligible for the PEI Energy Efficiency Grant Program.
10. The grant for windows and doors under the PEI Energy Efficiency Grant Program is $40 per window or door to a maximum of
$500.
11. The Furnace Tune-up Voucher supplied under the HELP Program is non-transferable and has no cash value.
12. Site inspections (prior to and after the completion of work) will be required by OEE staff and I/We agree to allow reasonable
access to my/our residence during normal business hours.
13. I am/We are required to inform the contractor who is completing energy upgrades on my/our house that the contractor must
declare to the Canada Revenue Agency all the funds paid to the contractor for the completion of the work on my/our house.
14. By submitting this application, I/We give consent to the Office of Energy Efficiency or it’s designate to request my/our credit report.
15. The Office of Energy Efficiency reserves the right to decline my/our application under the Energy Efficiency Loan Program based
on the current status of my/our credit report.
16. In the event that I/We default on the loan under the Energy Efficiency Loan Program my/our defaulted account will be forwarded
to a collection agency and if the account is not brought up to date within ninety (90) days that a statement of claim may be filed
which could result in a judgment being issued against me/us.
Applicant
Name (Print)
Photo ID type:
Photo ID #
Signature:
Date:
Witness
Name (Print)
Signature:
Date:
11EG15-31671