2024 Residential Heat Pump Electric Resistance Pre-Verification Form ENERGY STAR® Certified Whole House Heat Pump IncentiveQualified "Whole House" systems must meet or exceed 80% of the heat load of the home. Verification is based on two years of fuel use history review.Member Information(Required) First Last Electric Account Number(Required)Installation Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Your Phone(Required)Your Email Address(Required) Total conditioned square footage of the home.(Required)https://energyaudit.nhsaves.com/squarefootageTotal linear feet of baseboard in the home.(Required)Measure every section of baseboard in the home. Add it all up. Round your total to the nearest whole foot. This will give you your total linear feet of baseboard.Annual Heating Fuel UsageIs electric baseboard your primary heating source? (Check one)(Required) Yes No Please include all other heat sources. (Check all that apply)(Required) Oil Kerosene Propane Wood Pellets Wood Does not apply Contractor InformationBusiness Name(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Equipment InformationInstallation Date(Required) MM slash DD slash YYYY Quantity of outdoor unit(s)(Required)AHRI reference number(s)(Required)Total tons to be installed (1 Ton = 12,000 Btu's)(Required)Manufacturer / Brand(Required)Outdoor model number(s)(Required)Total estimate project cost(Required)1. Copy of Contractor Estimate(Required)Max. file size: 1 GB.Must contain Install location, Make and Model Number(s), Contractor Information (Business Name, Address, Phone Email), and Total Project Cost. 2. Photo documentation of all baseboard in the home(Required)Max. file size: 1 GB. 3. Rough Floor Plan(Required)Max. file size: 1 GB.Please include all rooms in the home. (Closets not required) Location of all baseboard. Location of all (new to be installed) interior heads. Location of outside unit(s). Note: Floor plan can be hand drawn and does not have to be to scale.Sign HereDownload Eligible Equipment & Incentives, and read Terms and ConditionsI have read and understand the terms and conditions. I certify that the information I have provided is true and correct and the products(s) and equipment for which I am requesting an incentive meets the requirements in this application.(Required) Yes Customer Digital Signature(Required)Date(Required) MM slash DD slash YYYY Δ