Washington State Department of Commerce
State Home Electrification and Appliance Rebates Program Reporting Form
Instructions:
Grantees must provide Commerce quarterly reports with an official expenditure report for all expenses claimed for funding from the State Home Electrification and Appliance Rebates Program.
For each rebate or incentive provided to an eligible household or adult family home please provide the following information in the Reporting tab. If an eligible household or adult family home receives multiple rebates or incentives, please create a separate entry for each rebate or incentive.
Eligible rebate recipient type - Select either household or adult family home.
Site information - Provide an address, city, and zip code, for where the eligible high-efficiency electric equipment or appliance was installed.
Household Income or Adult Family Home verification - Please describe how the household income or adult family home was verified to determine that the household or adult family home met the following eligibility criteria:
Household income below 80% of AMI
Household income between 80% and 150% of AMI
Adult Family Home licensed by DSHS
Fuel type of existing equipment - Provide the fuel type of the existing equipment that will be replaced by high-efficiency electric equipment.
Type of equipment or appliance being installed - Equipment or appliance must be from the list of eligible high-efficiency electric equipment in the scope of work.
Brand and Model Number of the equipment or appliance -For heat pumps with outdoor and indoor unit, you may enter two model numbers. For electrical service upgrade and wiring equipment, this information is not required.
Efficiency Ratings - Provide efficiency information for eligible high-efficiency electric equipment (except for electrical service upgrades and wiring). Use the following metrics for eligible equipment:
Equipment Efficiency Rating
Air-source Heat PumpsSEER2/EER2/HSPF2
Heat Pump Water HeatersUniform Energy Factor (UEF)
Heat Pump Dryers Combined Energy Factor (CEF)
Induction cooking equipmentkWh/Year
Certification of the equipment or appliance - All equipment (except for electrical service upgrades and wiring equipment) must meet either:
AHRI CEE North Region (Heat Pumps and Heat Pump Water Heaters)
Cold climate certification of heat pumps - All air source heat pumps must meet either:
Northeast Energy Efficiency Partnership ccASHP
ENERGY STAR Cold Climate Criteria
Low Global Warming Potential (GWP) Refrigerant Use - If the equipment or appliance uses refrigerants, indicate if it uses low GWP refrigerants as listed on either:
California Air Resources Board (CARB)
Applicable building or electrical permit number if required for installation of eligible equipment or appliances.
Date that equipment or appliances were purchased or installed.
Date rebate or incentive was issued.
Amount of the rebate or incentive that was paid using State HEAR funds.
Amount of costs associated with installation of eligible equipment - Other costs incurred to install high-efficiency electric equipment such as necessary MEP costs or permitting fees.
Method of Rebate or Incentive Delivery - Describe how the household or adult family home received the rebate, such as through check, retailer, or some other method.