Moderate-Income Air Source Heat Pump (ASHP) Incentive Application

Please note: Partially completed information cannot be saved, be sure to have all details with you before beginning the form. Upon submission, you will receive a confirmation and a tracking number on your screen to print or save. Refer to this tracking number to check on the status of your request.

This application works best when using the current browser version of Chrome, Firefox, and Safari. If you are using an out-of-date browser or Internet Explorer, you may not experience the full effect when filling out the application.

If you have any questions, contact the study team at ModASHP@nyserda.ny.gov or call (518) 862-1090, ext. 3111.

Energy Audit

Have you either scheduled or completed an energy audit?

Are you interested in an Air Source Heat Pump system that covers your full heating load?

Yes

Any completed entries that include a "No" in this field will be disqualified.

Audit that indicates a need for boiler, furnace, or ASHP upgrade must be completed before entering data on this form.

Contractor Information

Community Campaign

Contractor Name

Contractor Email

Customer Information

Please note that the incentive is offered to the household (not individuals) based on physical address. Any duplicate applications for the same physical address will be deemed by NYSERDA to be ineligible.

Customer Name

Customer Email

Customer NYSERDA ID (if applicable)

Street Address

Street Address 2

County

City

State

Zip/Postal Code

Which is the current main fuel type used for space heating in the customers home?

Other Fuel Type

Which natural gas utility services the customer?

Gas Service Provider - Other

Which is the secondary fuel type used for space heating in the customers home? (if applicable)

Other Fuel Type(Secondary)

Which natural gas utility services the customer(Secondary)?

Gas Service Provider - Other(Secondary)

Which is the current space cooling in customers home?

How many window units?

Other (please describe)

Which electric utility services the customer?

Electricity Service Provider - Other

Do you prefer to have the customers incentive disclosed via mail as well as email?

Yes

Please note that the mailed incentive may take up to 10 business days to be delivered.

Is the the customers mailing address the same as physical?

Yes

Street Address(Mailing)

Street Address 2(Mailing)

City(Mailing)

State(Mailing)

Zip/Postal Code(Mailing)

AttestationBy signing this attestation, I (“Customer”) attest that I am authorized to make this obligation regarding the provided physical address and understand that the information provided through this application will be used by NYSERDA or its authorized Contractor (“Contractor”) to determine Customer eligibility for a reduced cost moderate-income air source heat pump incentive contingent on the Customer’s successful application for NYSERDA Assisted Home Performance. By signing this attestation, Customer also understands that this opportunity is limited to one moderate-income air source heat pump incentive per physical address and that any duplicate applications will be deemed by NYSERDA to be ineligible. I ("Customer") attest that all information provided is accurate and that my response to this form may be used for analysis purposes.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

By entering my name above, I am creating a legally binding signature and confirm that I agree and accept the electronic signature terms and conditions.

Tracking Number

You will be provided with a Tracking Number upon submission.