• 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
  • Format: (000) 000-0000.
  • Is there a co-applicant?*
  • Format: (000) 000-0000.
  • Is this your primary residence? (where you spend most of your time)*

  • Residence Information

  • Do you own your home?*
  • Property Type*
  • Heat Sources (Check all that apply)*
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  • Household Information

  • Applicant date of birth*
     - -
  • Applicant race/ethnicity*
  • Does the applicant have a disability?*
  • Is the applicant a veteran?*
  • Applicant gender*
  • Does the applicant receive income?*
  • Co-applicant / Household Member 2 date of birth*
     - -
  • Co-applicant / Household Member 2 race/ethnicity*
  • Does the co-applicant / Household Member 2 have a disability?*
  • Is the co-applicant / Household Member 2 a veteran?*
  • Co-applicant / Household Member 2 gender*
  • Does the co-applicant / Household Member 2 receive income?*
  • Household Member 3 race/ethnicity*
  • Household Member 3 date of birth*
     - -
  • Does Household Member 3 have a disability?*
  • Is Household Member 3 a veteran?*
  • Household Member 3 gender*
  • Does the Household Member 3 receive income?*
  • Household Member 4 race/ethnicity*
  • Household Member 4 date of birth*
     - -
  • Does Household Member 4 have a disability?*
  • Is Household Member 4 a veteran?*
  • Household Member 4 gender*
  • Does the Household Member 4 receive income?*
  • Household Member 5 race/ethnicity*
  • Household Member 5 date of birth*
     - -
  • Does Household Member 5 have a disability?*
  • Is Household Member 5 a veteran?*
  • Household Member 5 gender*
  • Does the Household Member 5 receive income?*
  • Household Member 6 race/ethnicity*
  • Household Member 6 date of birth*
     - -
  • Does Household Member 6 have a disability?*
  • Is Household Member 6 a veteran?*
  • Household Member 6 gender*
  • Does the Household Member 6 receive income?*
  • Household Member 7 race/ethnicity*
  • Household Member 7 date of birth*
     - -
  • Does Household Member 7 have a disability?*
  • Is Household Member 7 a veteran?*
  • Household Member 7 gender*
  • Does the Household Member 7 receive income?*
  • Have you applied for, or do you intend to apply for, any other heat pump incentives?*

  • Grant Application Questions

  • Do you currently have heat?*

  • Rebate Application Questions

  • Prior to your heat pump installation, what was your PRIMARY heat source?*
  • Was the address listed on this application your primary residence when the heat pump repair/installation took place? (where you spent the majority of your time)*
  • Did the heat pump replace or supplement your existing heating system?
  • Date of heat pump repair or replacement:*
     - -

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  • 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.

     

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