RESIDENTIAL APPLICATION

MN 2009 Water Heater

ND Rebate MN and ND
Before completing this form, it is important that you read all Water Heater rebate qualifications on the back page of this form. Participants of the
ENERGY STAR® New Homes and Home Performance with ENERGY STAR programs are not eligible for Water Heater rebates.

Customer Information (Customer agrees to be bound by the program rules as shown on back.)

Xcel Energy account number where unit was installed - -

Customer name (please print) ___________________________________________________ Daytime Phone (_______)_ ________________________

Mailing address____________________________________ Apt. or Floor #_____ City_ _____________________ State_ _____ ZIP_______________

Installation address_________________________________ Apt. or Floor #_____ City_ _____________________ State_ _____ ZIP_______________
(if different from mailing address)
Customer type _ Homeowner Renter Landord Builder Contractor Commercial Other
Dwelling type Single family Duplex Triplex Fourplex Townhome Condominium Other

Alternate Rebate Recipient (Complete this section only if the rebate should be issued to someone other than the customer named above.)

Name _ ____________________________________________________________________ Daytime Phone ( _______ ) ________________________

Address__________________________________________ Apt. or Floor #_____ City_ _____________________ State_ _____ ZIP_______________

Customer signature__________________________________________________________________ Date_ __________________________________

I authorize the above party to receive the rebate check.

Customer signature__________________________________________________________________ Date_ __________________________________

Customer does hereby certify that: 1. the customer, and not Xcel Energy, is solely responsible for the accuracy of the information contained in this application; 2. all
installation is complete and operational prior to submitting this application; and 3. all rules of this Xcel Energy program (listed on back) have been followed. Further, the
customer acknowledges that participation in this program shall impose no liability on Xcel Energy. In particular, Xcel Energy shall not be liable for the work performed by
the customer’s engineer, contractor or vendor, and 4. the information on this form is correct.

Equipment Information Date of installation ______________________________

Water heater manufacturer __________________________________ Model number (complete) ___________________________________________

Serial number _____________________________________________ Size or Capacity (gallons) _ _________ BTU_ _______ Energy Factor__________

$40 - .62 EF $60 - .64 EF $100 - .80 EF Tankless Water Heater

Contractor Information
The heating, ventilation and air conditioning (HVAC) contractor or builder signature certifies the Xcel Energy customer whose account number is on
this form is aware of the full rebate amount. These signatures also certify that if the rebate check is to be mailed to the HVAC contractor or retailer,
the customer is aware of the full rebate amount and has received full credit or has made arrangements with the contractor to negotiate the full
amount of the rebate.

HVAC contractor name ________________________________________________________ Contact person _ ________________________________

HVAC contractor number ____________________________________________________________________

HVAC contractor address________________________________________ City___________________________ State_ _____ ZIP________________

HVAC water heater

contractor signature_________________________________________________ Date_______________ Phone ( _______ )_____________________
I hereby certify that all information is accurate, including claims of efficiency, size and customer information. I have read all the information on the
back of this form, and Xcel Energy may verify all the information that I have provided.

For Rebate operation use only. Do not write in this area.

Approved by:______________________ Date: _ ____________ Rebate amount:___________Date purchased: ___________ Install date:_ ___________

08-11-210 CRS Mail ID: 677 MN Charge code: 4363 Xcel Energy copy: white Retailer copy: yellow Customer copy: pink
Qualifying Customers
Xcel Energy natural gas residential customers in Minnesota and
North Dakota are eligible for rebates when buying qualifying,
high-efficiency, new natural gas water heaters (reconditioned
equipment is not eligible).
The program is applicable only for the purchase and installation
of qualifying new water heaters sold by participating HVAC
contractors or retailers for installation in new or replacement
applications where natural gas is supplied by Xcel Energy at
Xcel Energy retail rates.
A copy of the dated sales receipt or invoice must accompany
complete information on the front of this form. The product invoice
must specify all required information. Failure to complete this
information will result in a rejection of the application.
We reserve the right to conduct random inspections to verify
installation of the residential water heater at the address indicated
on the front of this form. If we select your application for a random
inspection, the rebate application will not be processed until the
inspection has been satisfactorily completed. Inspections may be
performed after rebate payment at our discretion.

Rebates for new home construction must be negotiated between Limitations

the builder and resident or new home buyer to determine who Rebate quantities are limited; installation by a customer of a
receives the rebate. qualified water heater does not obligate Xcel Energy to pay a
rebate. Rebate qualifications and amounts are subject to change
Equipment Efficiency Rating Rebate any time. Our conservation rebates program may be canceled
Water Heater .62 EF $40 with 30 days notice.
Water Heater .64 EF $60
Tankless Water Heater .80 EF $100 If you are building a new home, you must obtain a sales receipt for
the equipment from your builder or retailer. Only one rebate per
Efficiency ratings are determined using the Gas Appliance water heater will be paid.
Manufacturers Association (GAMA) directory, www.gamapower.org.
Only equipment listed on GAMA site is eligible for rebate. If you have questions while filling out this form, please contact
your HVAC contractor or retailer for assistance. Please allow six
Participants understand they are not eligible to receive a rebate weeks for your rebate to arrive.
for an improvement earned under a different Xcel Energy Rebate
program. Please visit us at xcelenergy.com/homerebates or call 1-800-895-
4999 to determine whether any program changes have occurred.
Rebate Details
Xcel Energy issues cash rebates in the form of checks, not utility Send Complete Applications to:
bill credits. Xcel Energy is not responsible if your HVAC contractor Rebate Operations
provided inaccurate information about the amount and/or condi- P.O. Box 829
tions of the actual rebate or equipment eligibility. Rebate requests Minneapolis, MN 55440-0829
for water heaters within five years of a previous request will not
be accepted. Please include the items listed below on your application form
and purchase receipt. If all of the items are not included the
Application Details application will be returned to the customer.
Qualifying equipment must be purchased and installed between
January 1, 2009 and December 31, 2009. Customers must apply for Your application needs to include:
this rebate by July 31, 2010. Applications must include complete • Xcel Energy Account Number
HVAC contractor or retailer information about water heater • Xcel Energy HVAC Contractor Number
information including: size or capacity, make, model number, (Provided by your contractor)
serial number and efficiency rating. • Your Signature

Failure to complete this information will result in a rejection of the Your Purchase receipt/invoice needs to include:
application. No phone calls will be accepted to provide verification • Customer name
of this information. • Installation address
• Brand
• Model number
• Size or capacity
• Serial number
• Invoice date
• Efficiency level

414 Nicollet Mall | Minneapolis, MN 55401 | 1-800-895-4999 | xcelenergy.com

© 2008 Xcel Energy Inc. | Xcel Energy is a registered trademark of Xcel Energy Inc. | Northern States Power Company - Minnesota, an Xcel Energy Company

08-11-210 CRS Mail ID: 677 MN Charge code: 4363 Xcel Energy copy: white Retailer copy: yellow Customer copy: pink