Address Account # Member # Equipment Specifications Quantity Rebate. ENERGY STAR Appliances

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1 Rebate not to exceed cost of high efficiency equipment. Equipment must be purchased or recycled in Installed equipment must be on cooperative's lines. Submit the documentation listed below no later than 6 months after purchase or recycle date, or by January 4, 2016, whichever date comes first. ENERGY STAR label for each item purchased For recycled appliances, include receipt for each item showing unit is in working order City State Zip Code Date Phone # Clothes Washer Refrigerator Dishwasher Dehumidifier Equipment Specifications Quantity Rebate Room Air Conditioner Recycling Freezer Recycling - Refrigerator Recycling - Window Air Conditioner ENERGY STAR Appliances Must be ENERGY STAR appliance (visit to verify) Must be ENERGY STAR appliance (visit to verify) Must be ENERGY STAR appliance (visit to verify) Must be ENERGY STAR appliance (visit to verify) $100 $100 Must be ENERGY STAR appliance (visit to verify) $25 Appliance Recycling Freezer must be in working order. Freezer must be removed from service and fully disposed of following federal, state, and local laws. $25 Refrigerator must be in working order. Refrigerator must be removed from service and fully disposed of following federal, state, and local laws. $25 Window air conditioner must be in working order. Window air conditioner must be removed from service and fully disposed of following federal, state, and local laws. $25 $50 $25 Quantity x Rebate Not approved Reason: Total Rebate Amount Requested I certify the rebates requested are for equipment purchased in 2015 and that the rebate request was made within 6 months of purchase and/or recycle. Cooperative Representative: Date: Total rebate issued: $

2 Rebate not to exceed cost of bulb, fixture, or unit. Equipment must be purchased in Installed equipment must be on cooperative's lines. Submit the documentation listed below no later than 6 months after purchase date, or by January 4, 2016, whichever date comes first. Equipment Specifications and Required Information CFL s & LED s Quantit y Rebate CFL Lamp Less than 60 watt (not 60 watt incandescent equivalent) $1/lamp CFL Lamp CFL or LED Fixture (Energy Star, hardwired) LED Exit Sign LED Lamp LED Linear Fixture LED Outdoor Lighting Fixture Occupancy Sensor Pulse Start Metal Halide T5 Fixture T8 Fixture (Replacement only) Greater than or equal to 60 watt (not 60 watt incandescent equivalent) Enter wattage: NOTE: Cannot apply for both CFL or LED fixture AND CFL or LED Lamp rebates. Enter wattage: Enter nbr of fixtures: Enter total lumens of all new fixtures: Incentive is based on the quantity of T5 lamps needed to provide the equivalent lumen output. To determine that quantity, divide the total lumens of all new fixtures by 2,500 and round to the nearest whole number. Enter the equivalent number of lamps in the Quantity field to the right. Replacement only Enter nbr of fixtures: Other Enter nbr of bulbs per fixture: Multiply nbr of fixtures x nbr of bulbs/fixture & enter in quantity field to the right Enter nbr of fixtures: Enter nbr of bulbs per fixture: $3/lamp $5/fixture $5/sign $3/lamp $6 / equivalent lamp $15/fixture $5/each $15/fixture $6/lamp/ fixture $4/bulb/ fixture Multiply nbr of fixtures x nbr of bulbs/fixture & enter in quantity field to the right Not -Reason: I certify the rebates requested are for equipment purchased in 2015 and that the rebate request was made within 6 months of purchase. Quantity x Rebate

3 Rebate not to exceed cost of high efficiency equipment. Equipment must be purchased and/or installed in Installed equipment must be on cooperative's lines. Submit the documentation listed below no later than 6 months after installation date, or by January 4, 2016, whichever date comes first. Equipment Specifications Size: If under 1 ton, round to nearest ¼ ton; If over 1 ton, round to nearest ½ ton Air Conditioners Quantity Rebate Central AC & Ductless MiniSplit SEER 14 or greater or EER 11.5 or greater $40/ton Size x Quantity x Rebate Central AC & Ductless MiniSplit SEER 15 or greater or EER 12.5 or greater $60/ton Central AC & Ductless MiniSplit SEER 16 or greater or EER 13.5 or greater $80/ton Commercial AC & PTACs Heat Pump - Air Source & MiniSplit Heat Pump - Commercial Air Source & PTHPs Heat Pump - Geothermal Variable Speed Blower Motor Under 20 ton: EER 11.5 or greater 20 to under 60 ton: EER 10.5 or greater 60 ton and over: EER 10 or greater SEER 14 or greater, HSPF 8.2 or greater, or EER 11.5 or greater Under 20 ton: EER 11.5 or greater 20 to under 60 ton: EER 10.5 or greater 60 ton and over: EER 10 or greater New furnace with variable speed blower motor Heat Pumps Other Enter the following required information for Air Conditioners & Heat Pumps: Manufacturer or brand name: Model Number: AHRI certificate number: Enter the following required information for Variable Speed Blower Motors: SEER or EER value (not required for Geothermal Heat Pumps): $40/ton $150/ton $150/ton $300/ton AFUE of new furnace: Is central air conditioning present?: Yes No Not - Reason: I certify the rebates requested are for equipment purchased and/or installed in 2015 and that the rebate request was made within 6 months of install. $35/unit

4 NOTE: Commercial and agricultural customers that install certain types of energy saving equipment and/or incorporate energy efficient measures may qualify for custom rebates. New and existing facilities are eligible. Please contact us for details. Rebate not to exceed cost of high efficiency equipment. Equipment must be purchased and/or installed in Installed equipment must be on cooperative s lines. Rebates are in place through December 31, 2015, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as Submit the documentation listed below no later than 6 months after installation date, or by January 4, 2016, whichever date comes first. Exhaust Fan Circulation Fan Equipment High Volume Low Speed (HVLS) Fan Dairy Plate Cooler/ Well Water Pre-Cooler Dairy Refrigeration Heat Recovery with electric backup Specifications and Required Information Fans under 36 must be greater or equal 18 cfm/watt Fans 36 & over must be greater or equal 21 cfm/watt Fans must be AMCA or University of Illinois BESS Lab rated Enter efficiency rating in cfm/watt: Fans under 36 must be greater or equal 18 ft-lbs/kw Fans 36 & over must be greater or equal 21 ft-lbs/kw Fans must be AMCA or University of Illinois BESS Lab rated Enter thrust rating in ft-lbs/kw: Fans must be greater or equal 12 ft diameter, greater or equal 1 HP, and must have a motor with a variable speed controller Size / Rating: Enter nbr inches or HP if applicable Enter rating for fans as applicable Quantity Rebate $1/inch diameter $1/inch diameter $1/inch diameter $500/unit $300/unit Low/Zero Energy Livestock Waterer 500 watts or less, insulated tank $50/unit Scroll Refrigerator Compressor Maximum rebate is $1,000/compressor $30/HP Variable Frequency Drive (VFD) Maximum rebate is $1,000/drive; Minimum is 1 HP to qualify $30/HP Enter the following information for Variable Frequency Drives: Manufacturer and model number: Cost (not including installation/labor): Intended use of Motor/VFD (grain drying, pumping, etc ): Estimated annual hours of operation: Not - Reason: I certify the rebates requested are for equipment purchased and/or installed in 2015 and that the rebate request was made within 6 months of install. Size x Quantity x Rebate

5 Rebate not to exceed cost of high efficiency equipment. Equipment must be purchased in Installed equipment must be on cooperative's lines. Submit the documentation listed below no later than 6 months after purchase date, or by January 4, 2016, whichever date comes first. Equipment Specifications Quantity Rebate Conservation Flow Restrictors - Faucet 1.5 gallons per minute or less $1 Quantity x Rebate Flow Restrictors - Shower 2.5 gallons per minute or less $5 Not -Reason: I certify the rebates requested are for equipment purchased in 2015 and that the rebate request was made within 6 months of purchase.

6 Member may qualify for up $500 for implementing measures recommended during an audit or assessment. Rebates cannot exceed 50% of the cost of the implemented measures. Professional labor costs can be included in the cost. Recommended measures must be implemented in Audit must be arranged by your cooperative or a cooperative approved partner. Building undergoing audit must be on cooperative s lines. Each Account qualifies for only 1 audit or assessment rebate per calendar year. Submit the documentation listed below no later than 6 months after date measures are implemented, which must be within 1 year of the audit date, or by January 4, 2016, whichever date comes first. A copy of your receipt or invoice for each implemented measure Copy of the Audit Documentation Address Account Member # Rebate for: Residential Farm Commercial Industrial Institution/Government Other: AUDIT OR ASSESSMENT INFORMATION (Please fill out entire section) Service Performed: Audit Assessment Date of Service: Cost of Service: Service Performed by: Home Auditor Certified Energy Manager Cooperative or Dairyland Staff Service Provider Name: Service Provider Phone: Service Provider : Water heater fuel type: Electric LP Other: Home heating fuel type: Electric LP Fuel Oil Other: Measures implemented to qualify for the audit or assessment rebate (50% of the cost up to $500): Other Energy Efficiency Steps Taken (whether receiving a rebate or not): Cost Not -Reason I certify the rebates requested are for measures recommended in the audit, measures were installed in 2015, and rebate request was made within 6 months of install.

7 Rebate is limited to ½ the cost of the audit, not to exceed $500. Audit must be performed in Audit must be performed by a Professional Engineer, Certified Energy Manager, or a cooperative approved partner. Building undergoing audit must be on cooperative s lines. Submit the documentation listed below no later than 6 months after audit date, or by January 4, 2016, whichever date comes first. Copy of the Audit Documentation AUDIT INFORMATION (Please fill out entire section and INCLUDE COPY OF AUDIT with this form) Date of audit: Cost of Audit: Performed by: Professional Engineer Certified Energy Manager Other: Auditor Name: Auditor Phone: Auditor Address: Other Energy Efficiency Steps Taken: Not -Reason I certify the audit was performed in 2015 and rebate request was made within 6 months of audit.

8 Rebate not to exceed cost of high efficiency equipment. Equipment must be purchased and/or installed in Installed equipment must be on cooperative's lines. Rebates are in place through December 31, 2015, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as Submit the documentation listed below no later than 6 months after install date, or by January 4, 2016, whichever date comes first. High Efficiency Water Heater High Efficiency Water Heater Heat Pump Water Heater Equipment Specifications Quantity Rebate Solar Storage Water Heater with Electric Backup gallons, Energy Factor.90 or greater, must be controlled by cooperative s load control program 100 gallons or greater, Energy Factor.85 or greater, must be controlled by cooperative s load control program Energy Factor 2.00 or greater, minimum of 80 gallons, must be controlled by cooperative s load control program $125/unit $200/unit $300/unit $300/unit Size x Quantity x Rebate Not - Reason: I certify the rebates requested are for equipment purchased and/or installed in 2015 and that the rebate request was made within 6 months of purchase or install.

9 (Dairyland Power Cooperative System Only) NOTE: The rebate amount for this program is $500. To qualify for the rebate, ONE of the following program/code requirements must be met: Touchstone Energy Home Program: Meeting all the requirements of the Touchstone Energy Home Program, as defined in the attached checklist, will qualify for this rebate. A qualified rater or inspector* must verify and fill out the attached checklist. (Complete Sections 1, 2, and the Checklist on attached page) Touchstone Energy Home Program with air infiltration control requirements bypassed: Meeting all the requirements of the Touchstone Energy Home Program except the air infiltration control requirements, as defined in the attached checklist, will qualify for this rebate. A qualified rater or inspector* must verify and fill out the attached checklist. A blower door test is required in place of the air infiltration control requirements. Less than 3 air exchanges/hour at -50 Pascal is considered passing. (Complete Sections 1, 2, 3, and the Checklist on attached page) 2012 International Energy Conservation Code: Meeting the requirements of the 2012 IECC will qualify for this rebate. REScheck software can be used to verify compliance with IECC REScheck software does not verify air infiltration so a blower door test must be performed. Less than 3 air exchanges/hour at -50 Pascal is considered passing. (Complete Sections 1, 3, and submit documentation showing compliance with 2012 IECC) Focus on Energy New Homes Program: A home built in Wisconsin meeting Focus On Energy s New Homes Program energy efficiency level 2 requirements will meet the requirements for this rebate. (Complete Section 1 and submit documentation showing compliance with Focus On Energy New Homes Program) *A qualified rater or inspector refers to a person who is knowledgeable in building standards, has experience in using blower door test equipment, if blower door test is performed, and is approved by your electric cooperative. One of the above rebate qualifying actions must have been completed in New home must be on cooperative s lines. Rebates are in place through December 31, 2015, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as Submit the documentation listed below no later than 6 months after certification, or by January 4, 2016, whichever date comes first. Documentation as explained above, depending on which program/code was followed Section 1: MEMBER INFORMATION (Please fill out entire section) Which program/code requirement has been met to qualify you for this rebate (program/code requirements are listed above): Touchstone Energy Home Program Touchstone Energy Home Program with air infiltration control requirements bypassed 2012 International Energy Conservation Code Focus on Energy New Homes Program (level 2 requirements) Section 2: RATER / INSPECTOR VERIFICATION (Please fill out entire section) I certify the home has met 1) All requirements in the attached checklist if member is qualifying with option 1 (Touchstone Energy Home Program) 2) All requirements in the attached checklist if member is qualifying with option 2 (Touchstone Energy Home Program less the air infiltration control requirements) Rater or Inspector Name Rater or Inspector Signature Date of Final Inspection Section 3: BLOWER DOOR TEST VERIFICATION (Please fill out entire section) I certify that the home has met the requirement of less than 3 air exchanges per hour at -50 Pascal. Air Exchanges Per Hour Date of Blower Door Test Name of Person Performing Blower Door Test Signature of Person Performing Blower Door Test Not -Reason I certify the home for which the rebate is requested has met the requirements of the above program/code requirements.

10 2015 TOUCHSTONE ENERGY HOME PROGRAM CHECKLIST Dairyland Power Cooperative System Only Requirement Category Requirement Detail Requirement Check one checkbox for each requirement below Meets Requirement Does Not Meet Requirement Cannot Determine if Requirement Met Not Applicable Foundation Basement wall R-15. R-20 if more than half the insulation is on the interior of the mass wall. Crawlspace wall R-15. R-20 if more than half the insulation is on the interior of the mass wall. Ground cover 6-Mil vapor barrier taped at all joints with 6" overlap Slab R-10 to depth of 4 ft Insulation Floor over crawlspace R-30 Ceilings without attic spaces Ceilings with attic spaces Wood frame wall Knee walls Mass wall (poured concrete or log) R-49. If insufficient space for R-49, then R-30, but is limited to 500 sq ft or 20% of insulated ceiling, whichever is less. R-49. Wherever full height of uncompressed insulation extends over the wall top plate at the eaves, R-38. R-20 cavity insulation + R-5 exterior insulation, or R-13 cavity insulation + R-10 exterior insulation If 6" wall: R-20 in cavity, R-5 outside of knee wall. If 3 1/2" wall, R-13 in cavity, R-10 outside of knee wall. R-15. R-20 if more than half the insulation is on the interior of the mass wall. Windows / Doors Equipment Ductwork Exhaust / Air Infiltration Circulating hot water pipes Mechanical system piping Fenestration Glazed fenestration Window/Glass Skylight Doors HVAC Water heating Appliances Can lights Duct work Exhaust systems House wrap Attic ventilation Kitchen & bath ventilation Sealing R-3 with manual off switch R-3 if piping over 105 degrees Fahrenheit or under 55 degrees Fahrenheit U-Factor 0.32 maximum or ENERGY STAR labeled No requirement U-Factor 0.32 maximum or ENERGY STAR labeled U-Factor 0.55 maximum Metal insulated (exception for entry). Performance same as 2004 IECC: insulated metal U-0.6, wood U-0.5, insulated nonmetal edge, max 45% glazing, any glazing double pane U-0.35 Heat pump recommended & must be properly sized in accordance with ACCA Manual S, based on building loads calculated in accordance with ACCA Manual J or other approved methodologies. Dual Fuel gas furnace must be closed combustion, 90+ AFUE, & have ducted intake & exhaust. Temperature controls must be installed, including a programmable thermostat where required. Electric or heat pump recommended, or else closed combustion. Efficiency for electric: 50 gallon=0.93 EF; > 50 gallon=0.89 EF Recommend ENERGY STAR where applicable Insulation contact rated and air tight Strongly recommended to be located in conditioned area. If supply and return outside of thermal envelope: R-12 - ducts in floor trusses outside of thermal envelope; R-10 - insulation can be in form of duct wrap or equivalent coverage with building materials. Building cavities cannot be used as supply ducts. Ducts shall be sealed with mastic and mesh or U1-181a aluminum tape. Outdoor air intakes and exhaust shall have automatic or gravity dampers that close when system is not operating. Sump pump basins should be sealed. Required and must be installed per manufacturer's recommendation. Vented with aperture = 1 sq ft per 300 sq ft ceiling area. Conditioned attics allowed. Per local or state codes Limit air leakage by sealing: 1) All joints, seams & penetrations 2) Site-built windows, doors & skylights 3) Openings between window & door assemblies & respective jambs & framing 4) Utility penetrations 5) Dropped ceilings or chases adjacent to thermal envelope 6) Knee walls 7) Walls & ceilings separating a garage from conditioned spaces 8) Behind tubs & showers on exterior walls 9) Can lights & bath fan housings 10) Common walls between dwellings 11) Ducts, air handlers, filter boxes, & building cavities used as ducts 12) Other sources of infiltration

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