Air Source Heat Pump Conversion Form (w/o PTCS)

For Converting Electric Heating Systems to Heat Pumps

All sections must be completed by the installer at the time of installation.

Eligibility

Available for existing single-family and existing manufactured homes.

Existing heating system type must be electric forced air furnace system.

Heat pumps must be AHRI rated and have a minimum of 9.0 HSPF and 14 SEER.

Household Information

Jefferson County PUD Customer Name(Required)

First Last

PUD Customer Account #(Required)

Available on PUD bill or in Smart Hub App

PUD Customer Phone #(Required)

Mobile or home phone

Installation Address(Required)

Needs to be the same as PUD customer's service address.

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Total Heated Area of the Home(Required)

Installation Date(Required)

Home Type

Existing Site-Built

Yes

Existing Manufactured (Number of Sections)

Existing Heating System Being Replaced(Required)

*This measure doesn't apply if the existing heating system is a ductless heat pump.

Electric Furnace w/AC

Electric Furnace w/o AC

Heat Pump Outdoor Compressor Type

Non Variable-Speed

Variable-Speed

Documentation to submit with this form:

Upload Purchase Receipt or Invoice(Required)

Must include heat pump make and model number.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, doc, docx, Max. file size: 128 MB.

AHRI Certificate(Required)

Please attach.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, doc, docx, Max. file size: 128 MB.

Manufacturer Documentation (if applicable)

If a variable-speed compressor, including manufacturer documentation that the outdoor compressor includes variable-speed or inverter-driven technology (e.g. specification sheet, brochure, or screenshot). Note: Including the test "variable speed" on the invoice will not satisfy this requirement. Additional documentation is required.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, doc, docx, Max. file size: 128 MB.

PRIVACY ACT STATEMENT Basic authority for collecting this information is authorized by 16 U.S.C. §§ 832 et. seq., and 838 et. seq., pursuant to Bonneville Power Administration’s Conservation Program system of records established in 46 FR 31700. This information is primarily intended to further, but is incidental to the performance of, BPA’s overall Energy Efficiency Program, the objective of which is to acquire energy resources through energy efficiency, to determine what cost-effective conservation and direct application renewable resources measures should be installed or adopted under different circumstances, and to provide incentives for the installation of such measures. Other routine issues of this information include: aggregation into a public database on energy efficiency; furnished to authorized personnel for installation/repair of equipment; aggregated into a database for program publicity; and in some instances information regarding buildings will be made available to subsequent purchasers of the buildings. Your disclosure of the requested information is voluntary; however failure to provide requested information means that it will not be possible for you to participate in this BPA Energy Efficiency program.

Direct Mail

Jefferson County PUD, 310 Four Corners Road Port Townsend, WA 98368

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