Residential Equipment Rebate Application

"*" indicates required fields

Contact Info

Property Owner's Name(s)*

Name on VGS Account (if different)

Daytime Phone Number*

Email*

Address Where Equipment is Installed (include unit # if applicable)*

Street Address City ZIP Code

What type of home do you have?*

Check Payable To (if different than property owner)

Name Mailing Address City State ZIP Code

Contractor Info

Installation Contractor's Name*

Installation Contractor's State Gas Certification or License Number*

Available from contractor or: VT Licensed Plumbers

Installation Contractor's Address

Street Address City State

Equipment Info

Type of Equipment*

Equipment Make*

Equipment Model #*

Date Installed*

Rated Efficiency (AFUE or UEF)

Heating Capacity (Input BTUH)

Contractor's Final Invoice (Must include: BTU size, make, model and serial number of the installed equipment.)*

Max. file size: 50 MB.

Notes

Terms & Conditions

Terms And Conditions*

I Acknowledge Rebate Program Terms and Conditions*

1. Rebate requests must be made within 90 days of the completed installation of equipment and must be
installed at a valid Vermont Gas account address.
2. All Equipment must have an active listing with the American Heating and Refrigeration Institute (AHRI) or
Energy Star to be considered for a rebate. Manufacturer’s claims will not be considered.
3. Customers must provide the Contractor’s final invoice to Vermont Gas for
payment. Contractor’s invoice must include: size, make, model and serial number of the installed equipment.
4. Equipment must be installed by a Natural Gas Certified contractor.
5. All required information must be provided to be eligible for a rebate. Incomplete applications, missing data,
or ineligible equipment may result in the delay or disqualification of the rebate.
5. All Equipment must be installed to manufacturers instructions and operating according to all applicable
federal, state and local codes and ordinances. Vermont Gas has not inspected or tested the installation and it
has no responsibility for such compliance. Performance of installed equipment is not guaranteed expressly
or implicitly.
6. Vermont Gas reserves the right to confirm all installations to verify the accuracy of the efficiency rating of the equipment installed.
7. Rebate amounts and conditions are subject to change without notice.

Income-Eligible Bonus Rebate

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

(Income-qualified households may be eligible for a bonus rebate on certain equipment)

Yes

I'd prefer not to share

Number of People in Household	1	2	3	4	5	6+
Chittenden & Franklin Counties	$90,200	$103,200	$116,000	$128,800	$139,200	$146,600
Addison County	$78,700	$89,900	$101,200	$112,300	$121,320	$130,300

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.

Consent*

I hereby certify that I meet the income qualification(s) on this form, and that all the information provided by me on this form is accurate and complete.

I understand that this self‐certification may be subject to further verification by Vermont Gas Systems or the Vermont Department of Public Service. If requested, I agree to provide Vermont Gas Systems or the Vermont Department of Public Service with the information or documentation required to verify my household annual income (e.g., pay stubs, bank account statements, tax returns, etc.).

Type your name to sign this form*

Date

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