Heat Pump Equipment Lease & Purchase Interest Form

Contact Info

Name*

Please provide your first and last name.

Property Address*

Street Address City State

Do you own the property?*

Are you a VGS customer?*

Yes

VGS Account Number

Daytime Phone Number*

Email Address*

Energy Information

What products are you interested in?*

Home heating & cooling (Electric Heat Pumps)

Home heating (Natural Gas)

Hot water heating

Select all that apply.

What type of heating equipment?*

Please indicate the type of heating equipment you are interested so we can best serve you.

Who is your Electric provider?*

This will help us determine any rebates that you may qualify for, which could reduce your lease or purchase price.

What type of water heater?*

How old is your current water heater?

How do you currently heat your hot water?

Does your electric panel require an upgrade?*

Yes

Uncertain

Are you currently working with an electrician?*

Yes

How do you heat your home?*

How do you currently air condition your home?

Is your furnace located in a basement?*

Furnace Make and Model

This information can be located on the plate of your furnace. You can skip this for now, but it is information that we will need to acquire before we are able to schedule a site assessment.

Furnace Age

Enter age of furnace if known, otherwise enter ‘unknown’.

Dwelling Type*

Square Footage

Enter square footage if known or ‘unknown’ if you are not certain.

Electric Panel Photo

Max. file size: 50 MB.

Optional: Add a photo of your electric panel.

Furnace Photo

Max. file size: 50 MB.

Optional: Add a photo of your furnace.

Household Information

(Income-qualified households may be eligible for additional services and funding options)

Is your household gross annual income less than the amounts listed in the table below?*

Yes

I’d prefer not to share

Number of People in Household	1	2	3	4	5	6+
Chittenden & Franklin Counties	$109,050	$124,600	$140,200	$155,750	$168,200	$180,700
Addison County	$97,500	$111,450	$125,400	$139,300	$150,450	$161,600

Income is defined as the total annual gross income of all family and non-family members 18+ years old living within the household. To calculate income, take the monthly amount from the last one-to-two paychecks for yourself and the people in your household (before taxes) and multiply by 12. Include all wages, including regular salaries and overtime. If you are self-employed, use the previous month of pretax income and multiply by 12.

All sources of income must be counted from all persons in the household based on anticipated income expected within the next 12 months. Possible types of income include but are not limited to: wages, salary, tips, bonuses or commissions payments, public assistance, social security/SSI, child support, regular gifts, unemployment, income earned on assets (savings, IRA, etc.) and some types of financial aid.

Is your household gross annual income less than the amounts listed in the table below or do you qualify for SNAP, Medicaid, the Weatherization Assistance Program (WAP), or Low Income Home Energy Assistance Program (LIHEAP)?

Yes

I’d prefer not to share

Number of People in Household	1	2	3	4	5	6+
Chittenden & Franklin Counties	$72,700	$83,100	$93,500	$103,850	$112,200	$120,500
Addison County	$65,050	$74,350	$83,650	$92,900	$100,350	$107,800

How did you hear about us?*

We’d love to know how you found out about our programs! Your feedback helps us understand which of our marketing efforts are most effective and allows us to improve our services. Please select an option:

What Type of Advertisement*

Direct Mailing

Door to Door Soliciting

Facebook / Instagram

Front Porch Forum

Google Ad

Other

Referral Point*

Contractor

Friend / Neighbor / Family

Realtor

VGS Employee

Other

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