RushShelby Energy

Commercial/Industrial Incentive Application
RushShelby Energy
Four Easy Steps to receive your local electric cooperative incentive:
RushShelby Energy provides cash
incentives to help businesses purchase
and install electric energy-saving
equipment. The incentives are
available to all businesses, regardless
of the number of employees. These
programs help you more effectively
manage energy use and lessen the
impact of increasing power costs. We
can offer these programs to reduce the
demand for power at a much lower
cost than building new power plants.
This fillable Acrobat form contains
applications for the installation of
energy efficient lighting, motors and
HVAC equipment. A custom application
is also included for those measures that
do not fit in to any of these categories.
A custom compressed air application
is available on another form. Please
contact us for that specific application.
Incentive Worksheets:
Lighting Incentive Worksheet
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Motors Incentive Worksheet
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• Customer has a valid RushShelby
Energy commercial account in our
electric service territory.
NO
If your total incentive request is less
than $1,000 then pre-approval
is not required. Within 60 calendar
days of installation completion date,
submit your application and a copy of
your paid invoice showing the date,
place of purchase, quantity, model/
part numbers and unit price of the
equipment installed.
YES
If your total incentive request is
greater than $1,000 then preapproval is required. Before you
purchase and install the equipment,
submit your application and a copy of
the vendor’s quote.
• Equipment must be new and installed in a
commercial, industrial, institutional,
educational, or governmental building.
2. Is the equipment you intend
to buy eligible?
• Refer to the Technical Specifications for
planned measures.
3. Complete and sign the application.
• Incomplete applications will delay review
and payment. Please be sure to provide all
requested information.
• The customer’s printed name on Page 2
will act as an electronic signature. Only
the electric customer may sign and submit
this application. Applications submitted by
vendors will be void.
• Attach manufacturer’s technical specification
sheets (“cut sheets”) for each type of eligible
equipment purchased.
Please note:
• Each customer is eligible for maximum
total incentive payments up to $50,000
per calendar year.
• Payment will be made only if all
requirements and specifications are met.
FORM SUBMITTAL:
After completing this fillable form you may print and save it.
To SUBMIT it electronically (recommended) fill out all required sections and then click the
GREEN button after any section.
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HVAC Incentive Worksheet
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4. Does your project require
pre-approval?
1. Is your project eligible?
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Custom Incentive Worksheet
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Click here for measure codes and technical
specs, or go to TeamUpToSave.com/ci.
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Other options:
Print and Mail to:
C&I Program Coordinator,
Hoosier Energy
P.O. Box 908
Bloomington, IN 47402
Email to:
[email protected]
Print and Fax to:
(888) 455-9291
Please read Rules and Requirements
at TeamUpToSave.com/ci.
Thank you for your interest and participation in our Commercial/Industrial Incentive program.
For program information or questions, call (812) 322-7279.
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Commercial/Industrial Incentive Application
RushShelby Energy
This incentive application form is valid when received from Jan. 1, 2016 through Dec. 31, 2016. This program is being coordinated by Hoosier Energy REC, Inc.
SECTION 1: CUSTOMER INFORMATION
Company Name
Electric Account #
Mailing Address
City
State
Zip
Contact Name (print)
Email*
Phone
Customer signature
Date
By typing your name above, you agree that you are electronically signing this application.
Customer hereby certifies that: 1. the form submission is by the electric customer who is solely responsible for the accuracy of the information contained in this application; 2. all equipment installation is complete and
operational prior to submitting payment request; and 3. all Rules and Requirements of this program have been followed as found on teamuptosave.com/ci. Further, the customer acknowledges that participation in this
incentive program shall impose no liability on RushShelby Energy and Hoosier Energy REC, Inc. In particular, RushShelby Energy and Hoosier Energy REC, Inc. shall not be liable for the work performed by the customer’s
engineer, contractor, or vendor.
Pre-approval required for payments greater than $1,000.
*By providing your email address, you are granting RushShelby Energy and Hoosier Energy REC, Inc. permission to send further emails regarding our programs and services.
SECTION 2: PAYMENT INFORMATION
Total Amount Requested
Total Material Cost
$0.00
Attention to:
Tax Status: o Corporation o Exempt o Other
Federal EIN or SSN:
SECTION 3: JOB SITE INFORMATION (where equipment was installed)
Job Site Name
Operating Hours/Year
Job Site Address (physical location)
Project Contact Telephone
City
State
Zip Code
Project Contact Name
Installation Completion Date
Project Contact Email
Type of business where equipment was installed (Check ONE):
q Agriculture
q Grocery/Convenience Store
q Church
q Lodging
q Manufacturing
q Office
q Retail
q Restaurant
q Other, Please Specify
q School
q Warehouse
SECTION 4: CONTRACTOR/INSTALLER INFORMATION (equipment contractor/installer)
Contractor/Installer Business Name
Contractor/Installer Street Address
City
State
Contractor/Installer Contact Person
Contact Telephone
Contact Email
Zip Code
SECTION 5: APPLICATION CHECKLIST
To ensure an efficient and accurate processing of the application, please make sure you have provided the following:
q Completed and Signed Application, Sections 1 – 4, Separate applications must be completed for each installation address.
q Incentive Worksheet Completed.
q Manufacturer’s Technical Specification Sheets are Attached, as required by the Technical Specifications.
q Materials or Vendor Quote Invoice Attached, Must include itemized information including quantity, make and model number, and unit pricing for items installed.
For Office Use
Only:
Pre-Approval by
Pre-Approval Date
Approval for Payment by
Approval for Payment Date
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Commercial/Industrial Incentive Application
RushShelby Energy
Click here for measure codes and technical
specs, or go to TeamUpToSave.com/ci.
Commercial/Industrial Lighting Systems Incentive Worksheet
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Item
Measure Code
Job Type*
Fixture Type**
Existing
Example
FHPF
RET
Quantity of Fixtures
New
4-lamp 4’ T12
4-lamp 4’ 32W T8
Existing
10
Incentive/Unit
Total Incentive
New
10
$13
$130
1
2
3
4
5
Total Fixture Incentive $0.00
* Job Types: RET = retrofit of functioning equipment, ROB = Replacement of failed or non-functioning equipment, NEW = Addition of new equipment where none existed.
** Fixture Type: Briefly describe the type of fixtures including quantity and type of lamps (e.g. 4-lamp 4’ T12 or 1-lamp 400W metal halide)
Click here for measure codes and technical
specs, or go to TeamUpToSave.com/ci.
Commercial/Industrial Lighting Controls Incentive Worksheet
Item
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Ex.
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1
Measure Code
OSWC
NEW
Watts
Controlled
Fixture Type
Job Type
125
4-lamp 4’ T8
Sensor
Quantity
5
Incentive/Unit
$18
Total Incentive
$90
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2
3
Total Fixture Incentive
Please use for lighting project description and additional info (optional):
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Incentive Worksheets:
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HVAC Incentive Worksheet
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Motors Incentive Worksheet
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Custom Incentive Worksheet
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Commercial/Industrial Incentive Application
RushShelby Energy
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Commercial/Industrial Motor Incentive Worksheet
Click here for measure codes and technical
specs, or go to TeamUpToSave.com/ci.
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A. Three phase electric motors, 10 HP to 500 HP
End use
code +
Manufacturer/ Model#
RPM
ODP or TEFC
Annual Operating
hours
Efficiency
*
Existing
HP
New HP
Qty
Subtotal =
HP x Qty
Incentive per HP
Incentive
NEMA Premium®
Enhanced NEMA Premium
%
0.0
$4
%
0.0
$4
%
0.0
$4
%
0.0
$4
%
0.0
$6
%
0.0
$6
%
0.0
$6
%
0.0
$6
®
Total Section A
B. Variable Frequency Drives (VFD), 1 HP to 200 HP Controlled
End use
code +
Manufacturer
Model #
Annual Operating
hours
HP Controlled
Qty
Subtotal =
HP x Qty
Incentive per HP
0.0
$30
0.0
$30
0.0
$30
0.0
$30
Incentive
Total Section B
(Section A + B)
** Nominal efficiency at full load
+ Motor End Use Application Codes
Please select one of the typical motor end use (codes) below, and include it on your application.
Process
Conveyors
Cooling
Pumps
HVAC Air Handling
Process Non-Cooling (PNC)
Belts (B)
Process Cooling (PC)
Waste Water Pump (WP)
Air Handlers (AH)
HVAC Condensing (HC)
Cooling Pump (CP)
Supply Fans (SF)
Heating Pump (HP)
Exhaust Fans (EF)
Please use for motor project description and additional info (optional):
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Lighting Incentive Worksheet
Incentive Worksheets:
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HVAC Incentive Worksheet
Custom Incentive Worksheet
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Commercial/Industrial Incentive Application
RushShelby Energy
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Click here for measure codes and technical
specs, or go to TeamUpToSave.com/ci.
Commercial/Industrial HVAC Incentive Worksheet
Incentives on a Per Ton Basis
Equipment Type*
Manufacturer and Model Number**
SEER
HSPF
EER
COP
Tons/Unit (cooling)
A
Quantity
B
Incentive/Ton
+C
Incentive =
AxBxC
Total Section A
* Equipment Type:
AC-U Air Cooled Unitary Packaged AC
Air Cooled Split System AC
AC-S HP-U Air-to-Air Heat Pump Packaged
HP-S Air-to-Air Heat Pump Split System
GEO Geothermal Heat Pump
Incentives on a Per Unit Basis
Equipment Type*
Manufacturer and Model Number**
SEER
HSPF
EER
COP
Btuh/Unit (cooling)
Quantity
A
Incentive/Unit
+B
Incentive =
AxB
Total Section B
Total
(Section A + B)
* Equipment Type:
AC-U1
Air Cooled Unitary Packaged AC, Single Phase
AC-S1
Air Cooled Split System AC, Single Phase
HP-U1
Air-to-Air Heat Pump Packaged, Single Phase
HP-S1
Air-to-Air Heat Pump Split System, Single Phase
PTHP
Packaged Terminal Heat Pump
SPMS
Single Phase Mini-Split Heat Pump
T-STAT
Programmable Thermostat
** Split systems must include model numbers for outdoor unit and indoor unit
+ See Technical Specifications for Incentive amounts
Please use for HVAC project description and additional info (optional):
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Lighting Incentive Worksheet
Incentive Worksheets:
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Motors Incentive Worksheet
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Custom Incentive Worksheet
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Commercial/Industrial Incentive Application
RushShelby Energy
Commercial/Industrial Custom Incentive Worksheet
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Use only for measures that do not fit in any of the prescriptive categories.
Project Description
Please give a brief description of the proposed project. Attach spec sheets, price quotes, manufacturer/vendor calculations for energy savings, and any additional information.
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Existing Equipment
Description
Hours of Operation (per day, week):
Calculated or Measured Annual Kilowatt Hours:
Calculated or Measured Monthly Kilowatt Demand:
New Equipment
Description
Hours of Operation (per day, week):
Estimated Annual Kilowatt Hours:
Estimated Monthly Kilowatt Demand:
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Lighting Incentive Worksheet
Incentive Worksheets:
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Motors Incentive Worksheet
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HVAC Incentive Worksheet
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