Please check the rebate(s) for which you are applying:

WaterSense Toilet – (Up to $125 rebate)

Insulation & Air Sealing, purchase of $250 to $499 – ($50 rebate) or

Insulation & Air Sealing, purchase of $500 to $999 – ($100 rebate) or

Insulation & Air Sealing, purchase of $1000 or more - ($200 rebate)

ENERGY STAR Qualified Windows, purchase of $250 to $499 – ($50 rebate) or

ENERGY STAR Qualified Windows, purchase of $500 to $999 – ($100 rebate) or

ENERGY STAR Qualified Windows, purchase of $1000 or more – ($200 rebate)

ENERGY STAR Qualified Furnace 90 percent AFUE or higher – ($150 rebate)

ENERGY STAR Qualified Programmable Thermostat – ($15 rebate)

ENERGY STAR Qualified Clothes Washer – ($75 rebate)

ENERGY STAR Qualified Windows for Apartments, purchase of $47 to <$93

– ($9 rebate) or

ENERGY STAR Qualified Windows for Apartments, purchase of $93 to <$186

– ($19 rebate) or

ENERGY STAR Qualified Windows for Apartments, purchase of $186 and

above – ($37 rebate)

Total rebate amount requested________________________________

Please note required minimum purchase amounts________________

Warranty Disclaimer: Colorado Springs Utilities makes no representations or

warranties about any make or model of equipment including any warranties of

merchantability, fitness for a particular purpose or water/energy efficiency.

This rebate program is subject to change and/or discontinuation without notice.

Colorado Springs Utilities reserves the right to inspect installation premises or

request additional information/documentation prior to rebate payment. Colorado

Springs Utilities is not liable or responsible for any act or omission of any

contractor whatsoever.

Does your efficiency product meet the

requirements listed on this form?

Have you filled out the application completely?

Do you have a copy of the receipt(s) and product

requirement verification?

Have you filled out the rebate

worksheet completely?

Is your Colorado Springs Utilities account

number correct?

Have you attached a copy of acceptable

identification to comply with

House Bill 06S-1023?

Have you signed the Affidavit of Lawful

Presence?

Have you taken an online energy or water

profile? (optional)

Have you provided your ENERGY STAR

window sticker with climate zone map

and U-factor?

Colorado Springs Utilities Web site (www.csu.org)

Friend, family member

Bill insert/newsletter

Colorado Springs Utilities employee

Media (newspaper, radio, TV, etc.)

Contractor/local business

Other__________________________

Colorado Springs Utilities account # _____________________________ Name_______________________________________________

Installation address_________________________________________________________________________ Zip_____________________

What is the total square footage of your home?_________________ What year was your home built?______________________________

How many people live at your home?__________________________________________________________________________________

Mailing address_ ______________________________________________________________________________ Zip_________________

Phone __________________Cell phone __________________E-mail address__________________________________________________

Applicant’s signature:____________________________________________________________________________________

Applicant’s name (print):_______________________________________________________ Date:_____________________

I would like to donate all or a portion of my rebate to Project COPE. Your contribution may qualify as a charitable contribution

for income tax purposes. Consult your tax advisor for further information. One hundred percent of donations go to families in need

to help pay their utility bills. Specify your Project COPE donation amount:

For a personalized report on how to better save water

and energy, visit www.csu.org and take our on-line

efficiency profiles. Please note eligibility requirements

for each rebate listed below:

Toilets are the number one water users in the home.

Installing a WaterSense toilet can make a big difference

in your water conservation efforts.

WaterSense toilets use between 1.1 and 1.28 gallons

per flush. A rebate of up to $125 is offered to

Springs Utilities water customers who purchase a

WaterSense toilet (limit 2 per household). The rebate

amount cannot exceed the actual cost of the toilet.

Visit www.csu.org for the approved list of toilets.

By upgrading your insulation, you can save up to

20 percent on your heating and cooling bill and

increase the comfort of your home. ENERGY STAR®

Note: R-values may be achieved through a combination

of cavity insulation and rigid board insulation and are

for insulation only, not whole wall (includes all forms of

insulation methods including SIPS, Structural Insulated

Panel Systems).

Rebates will be given for insulation purchased that makes

the ending R-value equal to or greater than the required

R-value. For example: Current home ceiling insulation

is R-11. Customer may purchase R-27 or higher to qualify

for the ceiling insulation rebate.

The expenses that are eligible for the insulation rebate

include: insulation product, air sealing product and

professional installation.

ENERGY STAR qualified windows can help reduce

your heating and cooling bills up to 15 percent and

can also provide protection against sun damage to

fabrics in your home.

Windows must be ENERGY

STAR qualified and have a

U-factor*of 0.35 or below and

must replace existing single pane

windows or single pane sliding

glass doors (standard hinged glass

doors do not qualify) with double

pane or greater windows or sliding

glass doors. Window rebates are

not allowed for new construction

and are only available for electric/

natural gas customers.

* U-factor is the rate of heat transfer through your window.

A lower U-factor means less heat is transferred. Window receipts

must be accompanied by qualified ENERGY STAR U-factor

window sticker and the ENERGY STAR qualified map.

Purchase an ENERGY STAR qualified furnace

with 90 percent Annual Fuel Utilization Efficiency

(AFUE) or higher, and you’ll be on your way to

improved energy efficiency in your home. In fact,

they’re 20 percent more efficient than older furnaces.

A rebate of $150 is offered to Springs Utilities

electric/natural gas customers who purchase a 90

percent AFUE or higher furnace from the approved

list. See www.csu.org for the approved list. Furnace

rebates are not allowed for new construction.

ENERGY STAR qualified programmable

thermostats can save 20 percent to 30 percent on

heating and cooling bills by allowing you to pre-set

the temperature. These thermostats can maintain

two separate programs and up to four temperature

settings for each program.

A rebate of $15 is offered to Springs Utilities

electric/natural gas customers who purchase an

ENERGY STAR qualified thermostat from the

approved list. See www.csu.org for the approved list.

ENERGY STAR qualified clothes washers use up to

50 percent less water and energy per load.

A rebate of $75 is offered to Springs Utilities water

or electric/natural gas customers who purchase an

ENERGY STAR qualified clothes washer from the

approved list. See www.csu.org for the approved list.

• Please read all rules for each rebate before

purchasing and installing any appliance.

• Purchases must be made between Jan. 1, 2009

and Dec. 31, 2009. Purchases prior to Jan. 1,

2009 do not qualify. Rebate applications must be

postmarked by Dec. 31, 2009. Customers who

make purchases in December 2009 have until

Jan. 31, 2010 to submit their applications, provided

funding still exists.

• Rebate participant must be a Colorado Springs

Utilities residential electric, natural gas or water

customer and appliance must be installed in the

Colorado Springs Utilities service area.

• Account must be current and non-delinquent

(i.e. no past due balances) at the time the rebate

application is processed. No rebates will be given

to customers whose accounts are delinquent.

• The qualified appliance and/or materials must

be new and for primary use at a residence located

in the specified Colorado Springs Utilities

service area.

• Customers who pay their utility bill through a

homeowners association, or landlords who

would like to participate in the rebate for their

residential rental property, need to visit csu.org for

special instructions.

• For all rebates, except the insulation rebate, the

purchase cost of a product is the only cost that is

eligible for a rebate. Some of the costs that are not

rebated include, but are not limited to, installation/

labor, tax, and delivery.

• Professional installation of insulation and air

sealing products is eligible for the rebate.

• Rebates are issued as a credit applied to the

Colorado Springs Utilities service account and take

six to eight weeks to process.

• Incomplete applications, worksheets, qualifying

documentation, and those lacking a copy of

appropriate documentation will be denied.

• Installation site is subject to inspection by

Colorado Springs Utilities staff.

• If a property for which a rebate has been issued

is found on inspection not to have the qualifying

product, the amount rebated will be charged back

to the Colorado Springs Utilities account which

was originally credited.

• Rebates are offered on a first come, first serve basis

and subject to availability of funds.

• Unless otherwise stated, rebates are limited to

one per customer every three years (per specific

product rebate offer).

• To comply with state law, all applicants must sign

the Affidavit of Lawful Presence AND provide an

acceptable form of documentation. The acceptable

forms are:

• Colorado Driver’s License

• Colorado ID card

• U.S. Military ID card

• U.S. Military dependent ID card

• U.S. Coast Guard Merchant Mariner card

• Native American Tribal Document

• Review rules and requirements as shown on this page.

• Purchase and install the qualifying product as shown

on this form or from the approved list at www.csu.org.

• Return completed application form/worksheet and a

copy of legible purchase receipts to:

Colorado Springs Utilities

Residential Efficiency Rebates

P.O. Box 1103, Mail Code 1339

Colorado Springs, CO 80947-1339

or scan all documents and e-mail to.

Important note: Purchase receipts must include date

of purchase, purchase price, make and model numbers,

and any special ratings and requirements needed to verify

that they qualify for a rebate. Window receipts must be

accompanied by qualified ENERGY STAR U-Factor

window sticker and the ENERGY STAR qualified map

and window sizes (see page 2 for an example of the

window sticker).

The U.S. Environmental Protection Agency (EPA)

has recognized Colorado Springs Utilities with a

2008 ENERGY STAR Partner of the Year award for

its outstanding contributions to reducing greenhouse

gas emissions. The award recognizes excellence in

delivering information and services to its customers

to increase energy efficiency.

Rebates are offered on a first come, first serve basis and are subject to availability of funds. Certain other

conditions apply. Please read all rules for each rebate before purchasing and installing any appliance or materials.

Colorado Springs Utilities reserves the right to discontinue rebates at any time.

See specific rebate offers for additional eligibility requirements.

Please complete the following for all rebates and the detailed information for the specific rebate you are applying for

# WaterSense

Toilets

# of old toilets

in the home

Gallons per flush

of old toilet

Age of

old toilet

New window

U-factor # Purchased Sizes # of panes

in old window

Where installed Type of Insulation R-Value prior

to installation

Number of

inches installed

Square feet

of area

Total R-Value

(existing+new

installed)

AFUE Capacity (Btu/hr) Fuel Source Capacity of old

furnace (Btu/hr)

Age of old

furnace

AFUE of

old furnace

Temperature

you program

Do you use

program feature?

Do you have

A/C?

Fuel source

for heating?

Gas or Electric How many loads

per week?

Age of old

appliance

Air dry or

machine?

Was it

ENERGY

STAR?

Is this new

landscaping?

How many square

feet are you

irrigating?

Are you

changing the

amount of

irrigated area?

If yes, increasing

or decreasing

area?

How

often do

you adjust

irrigation

schedules?

How old is

your home?

6 6639 CENV

This form is required for all residential applicants and sole proprietors in compliance with Colorado House Bill 06S-1023.

I _______________________________________(print name legibly), swear or affirm under penalty of perjury

under the laws of the State of Colorado that (check one):

I am a United States citizen; or

I am not a United States citizen, but I am a Permanent Resident of the United States; or

I am not a United States citizen, but I am lawfully present in the United States pursuant to Federal law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that

state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit.

I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is

punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503

and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

Applicant’s Signature _______________________________________ _______________________ Date ________________

ATTACH A COPY OF APPLICABLE IDENTIFICATION TO THIS AFFIDAVIT.

(See page 3 for a list of acceptable forms of ID.)

(Do not write in this section. Colorado Springs Utilities will complete this section.)

I _______________________________________ (printed name), an employee of Colorado Springs Utilities, verified the

above named applicant’s proof of lawful presence in the United States in accordance with Colorado law. The applicant

provided the following evidence of lawful presence in the United States:

Colorado Springs Utilities Employee Signature ___________________________________________Date _________________

If the above named applicant’s lawful presence is required by law to be verified through the SAVE Program, such verification

was attempted on ________________ by ________________________. Verification was finalized on ____________________

by ________________________________.

Colorado Driver’s License

U.S. Military Identification Card

U.S. Coast Guard Merchant Mariner Card

I.D. Number: ______________________________

Colorado Identification Card

U.S. Military Dependent Identification Card

Native American Tribal Document

I.D. Expiration Date: __________________