Proof of Work Order for Heating Device

Instructions for Retailers/Installers

1. Before submitting this Proof of Work Order, retailers/contractors or installers are responsible for verifying that the old device to be removed qualifies for the wood smoke reduction program by ensuring that the home is located within the program area, that the device is installed in the home, and that the device is an uncertified wood stove or an uncertified wood-burning fireplace insert, or one manufactured before 1995. Pellet devices and open-hearth fireplaces are not eligible under this program.
   
   
2. Retailers/contractors or installers are responsible for verifying that the funds are available by contacting the Clean Air Agency.
   
   
3. In order to secure funds, a copy of the Proof of Work Order must be submitted to the Clean Air Agency when the customer orders the new device, and no later than April 30, 2011. Funds are limited and are available on a first-come, first-served basis after October 7, 2010.
   
   
4. Installations must be completed by June 30, 2011, unless an extension is received from the Clean Air Agency.
   
   
5. Reimbursement to the retailer/installer requires the following completed forms: (a) Coupon, (b) Proof of Work Order, (c) Certificate of Destruction, (d) Recycling Report; three photos: (1) existing installed uncertified device, (2) uncertified device rendered inoperable and (3) professionally installed replacement device; and a copy of an itemized sales invoice.
   
   

Household Occupant Information
Coupon number:
First Name:
Last Name:
Street:
City:	, WA
ZIP:
New Device/Fuel
Natural gas stove Natural gas fireplace insert Natural gas furnace Electric whole-house heat pump with natural gas back-up furnace Electric whole-house heat pump with electric back-up furnace Electric ductless heat pump
Retailer Information
Retailer/Contractor Claiming Coupon:
Retailer Contact:
Retailer E-mail:
Retailer Phone:
Installer Name:
New Device Make/Model:
By submitting this form on-line, the retailer/installer agrees to remove an uncertified or pre-1995 wood stove, wood-burning fireplace insert, wood furnace or coal-burning device; render it inoperable; recycle it; and replace it with a professionally installed new program-approved device.