Pre-Qualification Rebate Form | Energy Efficiency Rebate Program | WNY Businesses | National Fuel Gas Company Back
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- Copy of facility’s National Fuel utility bill:
- Specification sheets for all equipment proposed for installation:
- Contractor invoice:
- W-9 (Request for Taxpayer Identification Number and Certification):
C.J. Brown Energy, P.C.
4245 Union Road, Suite 204
Buffalo, NY 14225
Attn: NRCIP
Email: NFRebateHelp@cjbrownenergy.com
Phone:1-844-365-3493
Applicant/Company Name*
Contact Name*
Address 1*
Address 2
City*
State*
ZIP*
Day Phone*
Email*
Facility Name
Contact Name
Address 1
City
State
ZIP
Day Phone
Email
AgriculturalCollege/UniversityCommercial/Wholesale/RetailData CenterGovernmentHealthcareHospitalityIndustrialK-12 SchoolMultifamily (5 units or more)Not-for-ProfitOther
National Fuel Account Number
Project Cost
Project Completion Date
Applicant/Company Name
Print Name
Print Title
Applicant Signature
Date
Facility Owner Signature
Be sure to include:
This completed worksheet and any other measure worksheets associated with your project.
Gas utility bill from the last 90 days.
Invoices, including purchase and installation price.
Equipment specification sheets showing manufacturer(s) and model number(s).
Questions regarding the process, incentives, or requirements? Contact a C.J. Brown representative at NFRebateHelp@cjbrownenergy.com or call 1-844-365-3493.
YesNo
If yes, from what type of fuel?*
Equipment Type
Equipment Age
Add Additional Equipment
Measure Code
Manufacturer
Model Number
Input Capacity
Efficiency
Count
Incentive Unit
Total Incentive
Total Incentive Requested
Boiler Measure Code
Boiler Manufacturer
Boiler Model Number
Boiler Input Capacity
Boiler Efficiency
Boiler Count
Boiler Incentive Unit
Boiler Total Incentive
Furnace Tune-Up Count
Furnace Tune-Up Total Incentive
Boiler Tune-Up Count
Boiler Tune-Up Total Incentive
Vent Area
Vent Model
Vent Count
Vent Total Incentive
Water Heater WH5 Count
Water Heater WH5 Total Incentive
Water Heater WH6 Count
Water Heater WH6 Total Incentive
Total Equipment for Natural Gas-Fired Water Heaters Incentive Requested
Duct Dimensions 1
Length of Insulated Ductwork 1
Ductwork Total Incentive 1
Duct Dimensions 2
Length of Insulated Ductwork 2
Ductwork Total Incentive 2
Duct Dimensions 3
Length of Insulated Ductwork 3
Ductwork Total Incentive 3
Total Duct Insulation Incentive Requested
Pipe Contents 1
Pipe Diameter 1
Length of Insulated Pipe 1
Pipe Total Incentive 1
Pipe Contents 2
Pipe Diameter 2
Length of Insulated Pipe 2
Pipe Total Incentive 2
Pipe Contents 3
Pipe Diameter 3
Length of Insulated Pipe 3
Pipe Total Incentive 3
Total Pipe Insulation Incentive Requested
Accessory Count
Accessory Total Incentive
Total Accessory Equipment Incentive Requested
Dryer Count
Dryer Total Incentive
Total Natural Gas Clothes Dryer Incentive Requested
Air Furnaces and Unit Heaters
Boilers
Furnace/Boiler Tune-Ups
Demand-Control Ventilation
Water Heaters
Duct Insulation
Pipe Insulation
Accessory Equipment
Natural Gas Clothes Dryer
Grand Total Natural Gas Efficiency Incentive Requested
All eligible measures must be installed by a licensed contractor, or a contractor that can supply you with either a Federal ID number, or a Certificate of Insurance, or a Business Certificate.
Customer has installed a qualifying product(s) and understands the energy efficiency level of the qualifying product(s) determines the rebate amount (as defined in the Rebate Application Form). A single gas-fired piece of equipment that provides two functions (e.g., heat and hot water) is only eligible for one rebate, that being the higher rebate amount of the two listed amounts. The rebate amount cannot exceed the purchase price. One furnace/boiler tune-up service rebate per furnace/boiler, per year.
I understand that National Fuel is not responsible for items lost or destroyed in the mail/transit.
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