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Water Heater & Air Source Heat Pump Rebate Form

Water Heater & Air Source Heat Pump Rebate Form

Member Information

Member Mailing Address
Member Mailing Address

Contractor/Installer Information

Air Source Heat Pump

Rebate Checklist


Submission of this form verifies that the applicant has provided accurate information to participate in the program. Applicant further certifies that: 

1. All rules and requirements of this program have been followed. 

2. The rebate equipment has been installed and is operational prior to submission of this application. 

3. Applicant will allow inspection of the rebated equipment (if requested). 

4. Applicant understands applicant will not receive a rebate unless all rebate requirements are met. 

5. The member acknowledges that the performance of the HVAC is the responsibility of the installation contractor (and the member to the extent the installation contractor provides instruction to the member on system operation). Corn Belt Energy is not responsible for the member’s HVAC operating costs or for costs in the event that the HVAC system fails. Corn Belt Energy does not warranty any equipment, or the equipment’s performance. Corn Belt Energy is not responsible for design or construction work performed by any individual or entity other than Corn Belt Energy.

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Submitting an Application

We cannot process applications if required documentation/information is not included. Please read this application carefully and include all information requested. Not submitting requested documents will significantly delay processing and may disqualify the application. Please upload supporting documents below. Make and keep a copy of supporting documents for your records until your rebate has been successfully processed.

Maximum file size: 268.44MB