Residential Photovoltaic Rebate Application Form

Use the form below to fill in your account information and information about the rebate program you are applying for. Once you've completed the form, PRINT THE FORM, SIGN IT, and submit it with all applicable receipt copies to:

Riverside Public Utilities - Programs & Services - 3750 University Ave. - 3rd Floor - Riverside, CA 92501

Failure to provide complete customer information, signature(s), model numbers, NEM Agreement, testing reports or receipt copies may result in processing delays. Please allow 4-6 weeks for processing.

Name on Utility Account Account #

Zip CodeInstallation Address Phone

Mailing Address (If different)

Customer Information

PV System Size (in AC kilowatts)Date Bought

I certify that I am the owner(s) or tenant(s) of the real property where the improvements have been installed and that I have not previously received, or applied for, other utility financing or incentives for the improvements on this application. I also certify that the foregoing information is true and correct. I understand and agree that the choice of improvements, the selection of contractors, the purchase of items and acceptance of materials used and work performed and the payments thereof is my responsibility. I understand that I will be fully liable for any damage to person or property that may be caused by the installation and/or operation of the equipment involved. I understand that Riverside Public Utilities does not endorse, recommend or make any representations as to specific brands, products, contractors or dealers nor does it guarantee material or workmanship. I further agree to indemnify and hold harmless the City of Riverside, its officers, employees, and agents from any damages related to the use or installation of the photovoltaic system or related equipment. All renewable energy credits (REC), along with all environmental attributes associated with residential solar installations that have received rebates from Riverside Public Utilities (RPU) will be the property of RPU. Additionally, customers receiving rebates for residential solar installations agree to transfer all rights, titles, and interest thay have to RECs and environmental attributes to RPU.

Signature of Applicant __________________________________ Date __________

Signature of Owner _____________________________________ Date _________ (If Applicant is renter or tenant)

FOR OFFICE USE ONLY

JL Key 6020109080 Object 45604100 Rebate Amount

Certification of Delivery Approved for Payment Approved for Payment

Signature Date Department Head Date Finance Department Date

RPU Inspector Information: Date Inspected ______________ By __________________________ Notes __________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________

Residential Photovoltaic Project InformationPlease submit copies of dated sales receipts or contract, your E-mail proof of online NEM submission, Home Energy Audit, and system information based on Primary Test Conditions (PTC). Rebates are calculated on AC Watts Installed.

5/26/11

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