section 6 BUSINESS PROPERTY TYPE Select one only. If applying for both existing and new construction equipment incentives please complete two separate applications. q Equipment Upgrades & Retrofits q New Construction & Major Renovations Select one (1) property type that best describes your business: q Agriculture Producer q Dairy - Traditional q Dairy - Robotic q Other: ________________ q Education q Financial Institution q Government q Grocery/Convenience Store q Health Services q Hotels & Lodging q Information, Technical & Scientific Services q Manufacturing (product): ___________________ q Multifamily q Office q Religious & Spiritual Organization q Restaurant q Retail q Vehicles Sales/Service q Water/Wastewater q Other: __________________ q If Dairy, what is the average number of cows being milked daily? ____________ section 7 INCENTIVE PRODUCT INFORMATION Refer to: • Applicable incentive catalog at focusonenergy.com/catalogs for incentive codes, incentive per unit, and product eligibility requirements. q With K+ Daily Education q No K+ Daily Education
• focusonenergy.com/qpls for qualified products lists. • Your invoice for Manufacturer and Model Number. • Business Incentive Product Information Sheet at focusonenergy.com/catalogs if additional lines are needed.
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PROJECT COMPLETION DATE:
REQUESTED INCENTIVE (A X B)
INCENTIVE CODE
# OF UNITS (A)
INCENTIVE PER UNIT (B)
UNIT MEASURE
MANUFACTURER NAME
MODEL #
(Example) L3111
STARK LIGHTING
LED5VZP
Fixture
10
$ 20.00
$ 200.00
$ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $
Manufacturer Specifications Attached
Subtotal from Incentive Product Information Sheet (if applicable) $
(if applicable): Yes m
Itemized Invoice(s) Attached: Yes m
INCENTIVE TOTAL* $
section 8 CUSTOMER SIGNATURE
I, the undersigned Customer, agree the stated energy efficiency measure(s) was (were) installed at the job site address listed above as part of the Focus on Energy Program. I have read and agreed to the provisions set forth herein and to the Terms and Conditions posted at focusonenergy.com/terms . I understand Focus on Energy may revise these Terms and Conditions at any time, and I will not be notified in the event changes are made. To the best of my knowledge, the statements made on this application are complete, true, and correct, and I have submitted the appropriate supporting documentation to receive an incentive. If the Customer is identified as the Payee in Section 5, the following certifications are required for this form to substitute for the Internal Revenue Service (IRS) form W-9. Under penalty of perjury, I certify that:
• The number shown on this form is the correct taxpayer identification number. • I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. • I am a U.S. person. The IRS does not require my consent to any provision of this document other than the certifications required to avoid backup withholding. ______________________________________________________________________________________________________________ CUSTOMER SIGNATURE NAME (PRINT) DATE
SIGN HERE
Submit applications and supporting documentation to:
*Incentive may be adjusted based on project caps. See measure requirements and Terms and Conditions for more information.
Focus on Energy 725 W. Park Avenue Chippewa Falls, WI 54729 business@focusonenergy.com
MAIL:
6
EMAIL:
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