Application Checklist
Take these steps:
Complete the Energy Audit Checklist (you must complete to qualify for rebates)
Decide which energy conservation measures you want to install
Have a licensed contractor complete the work or do the work yourself
Complete and sign the Energy Rebate form
Mail in these documents:
Energy Audit Checklist
Energy Rebate form; and
Copies of invoices or receipts that show the cost paid for each measure included
on the rebate application
Mail to:
Oregon Department of Energy
625 Marion Street NE
Salem, OR 97301-3737
The Department of Energy must receive the request within one year of when the work was
done. You will receive your rebate check in approximately four weeks. The maximum rebate is
$500. If your application is incomplete, it will be returned to you for completion. Keep a copy of
the completed forms and invoices/receipts for your records.
Web site: [Link]/energy
05/14 ODOE -203
State Home Oil
Weatherization
Energy Audit Checklist
Make your home more comfortable and affordable
Walk through your home and answer the questions (Column 2) before you make any
improvements. You (or ask a contractor to help you) decide which areas should have the
recommended conservation measures (Column 3) installed. You (or your contractor) can then
proceed to do the work. This Energy Audit Checklist must be filled out to qualify for SHOW rebates.
Applicant Name:
Area
BEFORE
AFTER
Condition of your home prior to
work being done
Recommended
conservation measures
Attics and Ceilings
Insulated?
Yes
No
Insulate to R-38*
Walls Outside walls
Attic exposed wall
Insulated?
Insulated?
Yes
Yes
No
No
Insulate to achieve R-13*
Insulate to R-21*
Floors (crawl spaces)
Insulated?
Yes
No
Insulate to R-30*
Ducts (in unheated areas)
Insulated?
Sealed?
Yes
Yes
No
No
Insulate with R-8
Seal duct leaks
Exterior Doors
Insulated?
Yes
No
Install insulated exterior door
(U-0.20)
Windows
Double-pane vinyl
U-0.35 or better?
Yes
No
Whole House
Well-sealed?
Yes
No
Water Heater
(unheated areas)
Insulated?
Yes
No
More than 20 years old or less than
70% steady state efficiency?
Furnace
Yes
Programmable Thermostat
No
Is your thermostat programmable?
Yes
No
*Refer to Insulation Fact Sheet in your SHOW packet or on the Web site.
Install energy efficient
double-pane vinyl windows
(U-0.35 or better)
Weatherstrip and caulk
Do blower door test and
duct sealing
Insulate to minimum R-3
Replace oil burner or furnace
with new burner (at least 80%
tested, steady state efficiency)
or new furnace (at least 81%
tested, steady state efficiency)
Install a programmable
thermostat
For Office Use:
Audit No.
Mail this completed form with the Energy Rebate form and receipt(s) to:
Oregon Department of Energy
625 Marion St. NE, Salem, OR 97301-3737
Toll-Free: 1-800-221-8035, Fax: 503-373-7806
Web site: [Link]/energy
ODOE 08/07 CF-023
Energy Rebate
Make your home more comfortable and affordable
I. APPLICANT INFORMATION
Name:
Home Phone:
Mailing Address:
Work Phone:
City:
County:
State:
Zip:
State:
Zip:
E-mail address:
Site Address (if different from mailing address):
City:
Dwelling Type:
County:
Single Family Home
Primary space heating fuel:
Oil
Manuf. Home
Duplex/Triplex
Propane, butane, or kerosene
Apt.
No. of Units:
Wood
II. ENERGY CONSERVATION MEASURE REBATES
If you did the work yourself, the cost should be for the products or materials only. No labor costs may be included.
Duct testing and sealing must be conducted by a Performance Tested Comfort Systems (PTCS) technician.
The rebate amount may not exceed 25% of the cost of the measure. The only exception is the blower door test and
duct leakage test rebates, which are 100% of the cost not to exceed $100.
You MUST attach copies of itemized invoice(s) or receipt(s) marked paid-in-full.
(For duct sealing, please attach a copy of the PTCS worksheet provided by your technician.)
The Department of Energy must receive the request within one year of when the work was completed.
Insulation in
Measure(s) Installed
Attic/ceiling
Floor
Wall
Cost
Ducts
X=
Rebate
.25
Weather-stripping and caulking
.25
Duct sealing (attach copy of PTCS worksheet from technician)
.25
Air Sealing
.25
Programmable thermostat
.25
Oil burner 80% or more efficiency Maximum rebate $150
.25
Oil furnace 81% or more efficiency Maximum rebate $150
.25
Above-ground oil tank (must install qualifying furnace at the same time)
Maximum rebate $150
.25
Replacement windows Maximum rebate $150
.25
Insulated exterior door Maximum rebate $150
.25
Blower-door test to assess whole house air leakage (duct leakage test)
Maximum rebate $100
1.00
Total costs and rebates
Final rebate amount Maximum rebate for all measures is $500
Water Heater (in unheated areas)
To complete application please turn page
For Office Use:
Audit No.
III. CONTRACTOR CERTIFICATION (If you used a contractor)
I certify that:
I installed the measures in compliance with the SHOW Program Energy Conservation Measure
Specifications and if a burner or furnace was installed, the tested steady state efficiency is at
least 80% for a burner or 81% for a furnace.
I am licensed and in good standing with the Oregon Construction Contractors Board.
Any defect in materials, manufacture, design or installation found in measures installed in this
job within two years of completion shall be remedied without charge and within a reasonable
period of time.
Name of Contractor:
Date:
(Please print)
Contractor
Signature:
CCB#:
Company Name:
PTCS
Tech ID:
Mailing Address:
Phone:
City:
State:
Zip:
Fax:
IV. APPLICANT CERTIFICATION
I certify that:
I installed the listed measures
by myself
Contractor Certification Section III above).
All of the information on this form is true to the best of my knowledge.
The work has been completed and I have paid in full the actual costs shown on the receipt(s) or
contractors invoice.
I will grant permission for the Oregon Department of Energy inspector to perform an inspection
on request. (We select a random number of rebate recipient jobs to inspect. You will be notified
if you are selected.)
I understand that the Oregon Department of Energy does not sell information from this
application for a mailing list. However, the Oregon Department of Energy may be required to
disclose the name, address, phone number and e-mail address from the application under the
Oregon Public Records law ORS 192.410 et seq. We can withhold the address, phone number
and e-mail address following a written request explaining personal safety concerns, such as a
temporary restraining order. The Oregon Department of Energy does not endorse any company
that requests the information.
by a contractor (have contractor complete the
Applicant
Signature :
Date:
Mail this completed form with the Energy Audit Checklist and copies of receipt(s) to:
Oregon Department of Energy
625 Marion St. NE, Salem, OR 97301-3737
Toll-Free: 1-800-221-8035, Fax: 503-373-7806
Web site: [Link]/energy
06/10 ODOE-CF-061