Customer Data Intake Form

Eligibility Requirements:

INSTALLERS/PURCHASERS: Please review the full Terms & Conditions, and confirm each
of the program requirements before proceeding:

Terms & Conditions

✔ This purchase is for a residential retrofit project (New Construction is not eligible)

✔ The end-use customer is a Pacific Gas & Electric (PG&E), Southern California Edison (SCE),
San Diego Gas & Electric (SDG&E), or SoCalGas (SCG) customer in California

✔ For a fuel substitution replacement, the end-user must receive electricity service from
PG&E, SCE, or SDG&E

✔ I'm replacing a Gas Storage or Electric Storage tank

✔ Propane Storage and Tankless replacements are not eligible.

✔ I know, or I�m able to, acquire the homeowner�s email address and phone number

** All fields are REQUIRED and must be ACCURATE.

** Do not use: Characters (e.g. �&�) use �and� instead

** Do not use: All Caps (PLUMBING) use �Plumbing� instead

** Do not use: Inaccurate Inputs such as (None, N/A, Skip, etc.)

End Use Customer Information
End User Customer First Name:
End User Customer Last Name:
End User Customer Email:
End User Customer Phone Number:
Project Intake Information
Building Type:
Existing Equipment Type (equipment being replaced):
Existing Equipment Size
Are you installing more than one water heater in this single-family home?
Multiple Heat Pump Water Heater Install Verification
Please confirm if the 2 or more heat pump water heaters submitted for rebate were part of a 1-for-1 retrofit, replacing 2 or more existing units in the same home, and the old units were properly disposed of by providing this completed form and attaching photos of the newly installed Heat Pump Water Heaters to your distributor.
How Many Heat Pump Water Heaters were installed?
Heat Pump Water Heater 1:
1. Unit, if applicable
2. Serial Number
3. Make and Model
4. Sales Date
Attach Photo's - if available. If not available now, please submit to your distributor, as soon as the install is complete.
Attachment 1:
Attachment 2:
Attachment 3:
Heat Pump Water Heater 2:
1. Unit, if applicable
2. Serial Number
3. Make and Model
4. Sales Date
Attach Photo's - if available. If not available now, please submit to your distributor, as soon as the install is complete.
Attachment 1:
Attachment 2:
Attachment 3:
Heat Pump Water Heater 3:
1. Unit, if applicable
2. Serial Number
3. Make and Model
4. Sales Date
Attach Photo's - if available. If not available now, please submit to your distributor, as soon as the install is complete.
Attachment 1:
Attachment 2:
Attachment 3:
Heat Pump Water Heater 4:
1. Unit, if applicable
2. Serial Number
3. Make and Model
4. Sales Date
Attach Photo's - if available. If not available now, please submit to your distributor, as soon as the install is complete.
Attachment 1:
Attachment 2:
Attachment 3:
*Propane Storage and Tankless water heater replacements are NOT eligible for the Golden State Rebates at this time*
Replacement (NEW) Water Heater Tank Size:
*Once selected, if you need to make changes to the �Replacement (NEW) Water Heater Tank Size� dropdown you will need to refresh the webpage before proceeding*
Purchasing From: (Choose Distributor/Wholesaler)
End User Customer's Utility:
*Once selected, if you need to make changes to the �End User Customer's Utility� dropdown you will need to refresh the webpage before proceeding*
Customer Installation Location Information
Installation Address:
Installation City:
Installation Zip Code
Estimated Installation Date:
Installation Contractor Information
Installation Contractor Business Name:
Installation Contractor First Name
Installation Contractor Last Name
Installation Contractor Address
Installation Contractor City
Installation Contractor Zip Code
Installation Contractor Phone Number:
Installation Contractor Email:
Distributor Invoice Number:
	T&C: By checking the box, I am confirming that I accept the Terms and Conditions of the Golden State Rebates Program.

** All fields are REQUIRED and must be ACCURATE.

** Do not use: Characters (e.g. �&�) use �and� instead

** Do not use: All Caps (PLUMBING) use �Plumbing� instead

** Do not use: Inaccurate Inputs such as (None, N/A, Skip, etc.)

If you have any questions, please contact the program at (866) 258-4937 or email listed below.

Email: info@goldenstaterebates.com

The Golden State Rebates program is funded by California utility customers under the auspices of the California Public Utilities Commission and implemented by CLEAResult under a contract awarded by San Diego Gas & Electric Company (SDG&E�)
and supported by Pacific Gas and Electric Company (PG&E�), Southern California Gas Company (SoCalGas�) and Southern California Edison Company (SCE�).
Program funds, including any fund utilized for rebates or incentives, will be allocated on a first-come, first-served basis until such funds are no longer available. This program may be modified or terminated without prior notice.
Customers who choose to participate in this program are not obligated to purchase any additional goods or services offered by CLEAResult or any other third party. The selection, purchase, and ownership of goods and/or services are the sole responsibility of the customer.
None of the above-mentioned investor-owned utilities (IOUs) make any warranty, whether express or implied, including the warranty of merchantability or fitness for a particular purpose, of goods or service selected by customer.
None of the IOUs endorse, qualify, or guarantee the work of the CLEAResult or any third party. Eligibility requirements apply; see the program conditions for details.