Heat Pump Rebate and Grant Application

Heat Pump Rebate and Grant Application

All sections must be completed to be considered for the program.
A completed application is not a guarantee of assistance.

PLEASE NOTE: Your application cannot be submitted without the required documents uploaded, listed below. Please have them prepared before beginning the application.

You will be prompted to upload these documents at the end of the application.

Required documents for all applicants:
- Electric Bill
Required documents for grants:
- Estimate (bid) for Heat Pump Installation from a qualified, CCB-accredited contractor
- W9 Tax Form for the contractor you will use, signed in the current year
- Contractor Acknowledgements Form, signed by the contractor you intend to use
Required documents for rebates:
- Invoice from the contractor for the repair/installation
- Proof of payment of the repair/installation (receipt, copy of check, credit card documentation)
- A completed W9 for the intended recipient of the rebate
Applicant name*

First NameLast Name
Applicant phone number*
Applicant email*
example@example.com
Is there a co-applicant?*

YesNo
Co-applicant (if applicable)*

First NameLast Name
Co-applicant phone number*
Co-applicant email*
example@example.com
Physical address of the residence for which you are seeking assistance:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this your primary residence? (where you spend most of your time)*

YesNo
Please explain:*
Total number of people in household, including children*

File Uploads
Please upload a copy of your electric bill (a household member must be the bill payer)*

Cancelof
Please upload a copy of the estimate (bid) for heat pump installation from a qualified, CCB-accredited contractor*

Cancelof
Please upload a copy of the W9 tax form for the contractor you will use, signed in the current year*

Cancelof
Please upload a completed Contractor Acknowledgements Form, signed by the contractor you intend to use. *

Cancelof
Invoice from the contractor for the repair/installation*

Cancelof
Proof of payment of the repair/installation: Receipt, copy of check, credit card documentation *

Cancelof
A completed W9 form for the intended recipient of the rebate (applicant)*

Cancelof

Applicant Disclaimer

I agree to allow use of the information collected for all NeighborImpact programs, utility providers, Oregon Department of Energy, NeighborWorks, its agents, and sub grantees for any legitimate purpose including but not limited to the purpose of deciding eligibility for any and all assistance available, for reporting associated with those programs and for reporting and monitoring associated with those programs.

I certify that the information provided in this application is true and correct. I understand that intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including but not limited to, fine or imprisonment of both under the provisions of Title 18, United States Code, Section 1001, et seq. And liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon misrepresentation which I/we have made this application.
Applicant Name*

First NameLast Name
Applicant Signature*

Clear
Co-Applicant Name*

First NameLast Name
Co-Applicant Signature*

Clear
Should be Empty:

Heat Pump Rebate and Grant Application

Residence Information

Household Information

Grant Application Questions

Rebate Application Questions

File Uploads

Applicant Disclaimer