Equipment Specifications and Required Information Quantity Rebate

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1 Rebate not to exceed 50% of the cost of equipment. Recycling rebates qualify for the entire rebate, regardless of the recycling cost. Equipment must be purchased or recycled in Installed equipment must be on cooperative's lines. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after purchase or recycle date, or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each item purchased ENERGY STAR label for each item purchased if applicable For recycled appliances, include receipt for each item showing unit is in working order City State Zip Code Date Phone Equipment Specifications and Required Information Quantity Rebate Total: Quantity x Rebate Clothes Washer Must be ENERGY STAR appliance (visit to verify) $100 Refrigerator Must be ENERGY STAR appliance (visit to verify) Enter size of refrigerator (must be minimum of 10 cubic feet): Dishwasher Must be ENERGY STAR appliance (visit to verify) $50 Dehumidifier Must be ENERGY STAR appliance (visit to verify) $25 Room Air Conditioner Must be ENERGY STAR appliance (visit to verify) $25 Recycling Freezer Freezer must be in working order. Freezer must be removed from service and fully disposed of following federal, state, and local laws. $25 Recycling - Refrigerator Refrigerator must be in working order. Refrigerator must be removed from service and fully disposed of following federal, state, and local laws. $25 Recycling Room Air Conditioner Room air conditioner must be in working order. Room air conditioner must be removed from service and fully disposed of following federal, state, and local laws. $25 Not approved Reason: $100 Total Rebate Amount Requested Cooperative Representative: Date: Total rebate issued: $

2 Rebate not to exceed 50% of the cost of equipment. Equipment must be purchased in Installed equipment must be on cooperative's lines. Rebates are not allowed for a measure and a component of that measure. For example, if a CFL or LED fixture comes with a bulb, the fixture qualifies for a rebate but not the bulb. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after purchase date, or by January 4, 2017, whichever date comes first. This Rebate Form Documentation showing number of lumens or number of bulbs per fixture if applicable A copy of your receipt or invoice for each item purchased Equipment Specifications and Required Information Quantity Rebate Total: Quantity x Rebate CFL Lamp Capped at 50% of cost $1 LED Lamp Capped at 50% of cost $3 LED Outdoor Fixture Capped at 50% of cost; Minimum 15 watts $15 LED Exit Sign Capped at 50% of cost $5 Occupancy Sensor Capped at 50% of cost $5 Pulse Start Metal Halide (Replacement only) CFL or LED Indoor Fixture Capped at 50% of cost $15 Multiply Fixtures x Lumens and enter result in the Quantity column. Rebate is $1 per 400 lumens so divide Quantity by 400 and enter result in the Total column (result can be rounded up to the next whole number & is capped at 50% of cost). Attach another rebate form for fixtures with a different number of lumens. Example: 5 LED Fixtures, each with 1,200 Lumens. 5 Fixtures x 1,200 Lumens = 6,000 Quantity 6,000 6,000/400 lumens=$15 $15 Enter number of Fixtures: Enter number of Lumens per fixture: $1 per 400 lumens T5 Fixture Multiply Fixtures x Bulbs and enter result in the Quantity column. Rebate is $6 per bulb so multiply Quantity x $6 and enter result in the Total column (capped at 50% of cost). Attach another rebate form for fixtures with a different number of bulbs. Example: 4 T5 Fixtures, each with 3 Bulbs. 4 Fixtures x 3 Bulbs = 12 Quantity x $6 = $72 $72 Enter number of Fixtures: Enter number of Bulbs per fixture: $6 T8 Fixture (Replacement only) Multiply Fixtures x Bulbs and enter result in the Quantity column. Rebate is $4 per bulb so multiply Quantity x $4 and enter result in the Total column (capped at 50% of cost). Attach another rebate form for fixtures with a different number of bulbs. Example: 4 T8 Fixtures, each with 3 Bulbs. 4 Fixtures x 3 Bulbs = 12 Quantity x $4 = $48 $48 Enter number of Fixtures: Enter number of Bulbs per fixture: $4 Not -Reason:

3 Rebate not to exceed 50% of the cost of equipment. Equipment must be installed in Installed equipment must be on cooperative's lines. Rebates not allowed for a measure and a component of that measure. For example, if an air source heat pump has a variable speed blower motor, the air source heat pump qualifies for a rebate but not the variable speed blower motor. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after installation date, or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each item purchased AHRI certificate number Documentation showing the equipment has been installed Equipment Specifications Size: If under 1 ton, round up to nearest ¼ ton; If over 1 ton, round up to nearest ½ ton (Size of unit is based on 12,000 Btuh/ton) Quantity Rebate Central AC & Ductless MiniSplit SEER 14 or greater or EER 11.5 or greater $40/ton Total: 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 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 $40/ton $150/ton $150/ton $300/ton New Furnace with Efficient ECM Blower Motor Required Information Enter the AHRI certificate number: Enter the manufacturer or brand name: The ECM blower motor on the new furnace must be variable speed OR Efficiency (AFUE) >= 95% AND kwh/yr (Eae) <= 670 as listed on the AHRI certificate Enter the SEER or EER value: Not required for Geothermal Heat Pump or New Furnace with Efficient Blower Motor Is Air Conditioning Present?: Only required for new furnace with efficient blower motor $35/unit Yes No Not - Reason:

4 NOTE: Agricultural, Commercial and Industrial members that incorporate certain energy efficient equipment not listed below may qualify for a custom rebate. New and existing facilities are eligible. Please contact us for details. Rebate not to exceed 50% of the cost of equipment. Equipment must be installed in Installed equipment must be on cooperative s lines. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after installation date, or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each item purchased Documentation showing the equipment has been installed Equipment Specifications and Required Information Size Quantity Rebate Commercial Vending Machine Controls $25 Dairy Plate Cooler/Well Water Pre-Cooler $500 Dairy Refrigeration Heat Recovery w/electric backup Used with controlled electric water heater $300 Low/Zero Energy Livestock Waterer 500 watts or less, insulated tank $50 Exhaust Fan Circulation Fan Scroll Refrigerator Compressor 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: Maximum rebate is $1,000/compressor Enter inches of each fan below Enter inches of each fan below Enter HP of each compressor below $1/inch $1/inch $30/HP Total: Size x Quantity x Rebate Variable Frequency Drive (VFD) Maximum rebate is $1,000/drive; Minimum is 1 HP to qualify Enter HP of each VFD below $30/HP Enter the following information for Variable Frequency Drives: Enter the manufacturer and model number: Enter the intended use of VFD: Grain drying, pumping, etc. Not - Reason:

5 Rebate not to exceed 50% of the cost of equipment. Equipment must be purchased in Installed equipment must be on cooperative's lines. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after purchase date, or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each item purchased Equipment Specifications Quantity Rebate Flow Restrictors - Faucet 1.5 gallons per minute or less; Capped at 50% of cost $1 Flow Restrictors - Shower 2.5 gallons per minute or less; Capped at 50% of cost $5 Not -Reason: Total: Quantity x Rebate

6 Rebate not to exceed 50% of the cost of energy efficiency improvements up to $500. Cost can include material and professional labor. The cost of the audit cannot be included. Energy Efficiency improvements must be recommendations from an audit arranged by your cooperative or a cooperative approved partner. Home or farm being improved must be on cooperative s lines. Improvements must be completed within 24 months of the audit date. If member has multiple audits performed in a calendar year, only improvements from one of the audits will qualify for this rebate. Each audit qualifies for only one rebate (additional improvements completed in a later year do not qualify for another rebate). Apply for rebate in the calendar year the improvements are completed, regardless of the date of the audit. Applying for other rebates is encouraged. For example, audit recommended lighting improvements also qualify for the lighting rebate. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after improvements are completed or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each improvement Copy of the audit documentation Documentation showing improvements have been completed Rebate for: Home Farm AUDIT INFORMATION (Please fill out entire section) Date of Service: Service Performed by: Home Auditor Certified Energy Manager Service Provider Name: Service Provider Phone: Service Provider : Water heater fuel type: Electric LP Other: Home heating fuel type: Electric LP Fuel Oil Other: Energy Efficiency Improvements Total Cost of Improvements (Sum of lines 1 thru 8): 50% of Total Cost of Improvements (Enter 50% of the amount entered on the previous line): Total Rebate Amount Requested (Enter the amount entered on the previous line, or $500, whichever is less): Not -Reason I certify the requested rebate meets the eligibility criteria listed above. Cost

7 Rebate not to exceed 50% of 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 pre-approved partner. Building undergoing audit must be on cooperative s lines. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after the audit, or by January 4, 2017, whichever date comes first. This Rebate Form Copy of the Audit Documentation Rebate for: Commercial Industrial Institution/Government Other: AUDIT INFORMATION Date of audit: Cost of Audit: Performed by: Professional Engineer Certified Energy Manager Other: Auditor Name: Auditor Phone: Auditor Address: Recommended Energy Efficiency Steps Taken: Not -Reason I certify the audit meets the eligibility criteria listed above.

8 Rebate not to exceed 50% of the cost of equipment. Equipment must be installed in Installed equipment must be on cooperative's lines. Rebates are in place through December 31, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after install date, or by January 4, 2017, whichever date comes first. This Rebate Form A copy of your receipt or invoice for each item purchased Documentation showing the equipment has been installed Equipment Specifications Quantity Rebate Residential High Efficiency Water Heater Residential High Efficiency Water Heater Commercial Water heater Commercial Water Heater 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 gallons, must be controlled by cooperative s load control program 100 gallons or greater, must be controlled by cooperative s load control program Heat Pump Water Heater Integrated (all-in-one) units, Energy Factor 2.00 or greater $300 $125 $200 $125 $200 Total: Size x Quantity x Rebate Solar Storage Water Heater with Electric Back-up $300 Not - Reason:

9 AND INSTRUCTIONS FOR COMPLETING THIS FORM (Dairyland Power Cooperative System Only) To qualify for this program s $500 rebate, ONE of the following four program/code requirements must be met: 1. Touchstone Energy Home Program To qualify for the rebate under this Program/Code, the following is required: a. A qualified rater or inspector* must verify ALL the requirements on the attached checklist have been met. b. Submit the completed checklist and this rebate form with Section 1 and Section 2 completed. 2. Touchstone Energy Home Program with blower door test in place of Ductwork & Air Infiltration Control requirements To qualify for the rebate under this Program/Code, the following is required: a. A qualified rater or inspector* must verify all requirements on the attached checklist have been met, except for the requirements in the Ductwork & Air Infiltration Control category. b. A blower door test is required in place of the Ductwork & Air Infiltration Control requirements. Less than 3 air exchanges/hour at -50 Pascal is considered passing. Person performing the test must complete Section 3 of this rebate form. c. Submit completed checklist and this rebate form with Section 1, Section 2, and Section 3 completed International Energy Conservation Code To qualify for the rebate under this Program/Code, the following is required: a. A qualified rater or inspector* must provide documentation showing compliance with IECC 2012 using REScheck software. b. A blower door test is required. Less than 3 air exchanges/hour at -50 Pascal is considered passing. Person performing the test must complete Section 3 of this rebate form. c. Submit documentation showing compliance with IECC 2012 and this rebate form with Section 1 and Section 3 completed. 4. Focus On Energy New Homes Program To qualify for the rebate under this Program/Code, the following is required: a. A Wisconsin built home must meet the energy efficiency level 2 requirements of Focus On Energy New Homes Program. b. Submit documentation showing compliance with Focus On Energy New Homes Program and this rebate form with Section 1 completed. *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, 2016, or until funds are depleted. Funds are limited so members are encouraged to submit as soon as possible. All documentation listed below must be submitted no later than 6 months after certification, or by January 4, 2017, whichever date comes first. This Rebate Form Documentation as explained above, depending on which program/code was followed Section 1: MEMBER INOFRMATION (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 Ductwork & 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 Ductwork & 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. Name of Person Performing Blower Door Test Not -Reason Air Exchanges Per Hour Signature of Person Performing Blower Door Test Date of Blower Door Test

10 2016 TOUCHSTONE ENERGY HOME PROGRAM CHECKLIST Dairyland Power Cooperative System Only Check one checkbox for each requirement below Requirement Category Requirement Detail Requirement 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 Exhaust Ductwork & Air Infiltration Control Circulating hot water pipes Mechanical system piping Fenestration Glazed fenestration Window/Glass Skylight Doors HVAC Water heating Appliances Can lights Exhaust systems Attic ventilation Kitchen & bath ventilation Duct work House wrap 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 Outdoor air intakes and exhaust shall have automatic or gravity dampers that close when system is not operating. Sump pump basins should be sealed. Vented with aperture = 1 sq ft per 300 sq ft ceiling area. Conditioned attics allowed. Per local or state codes 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 insulation materials. Building cavities cannot be used as supply ducts. Ducts shall be sealed with mastic and mesh or U1-181a aluminum tape. Required and must be installed per manufacturer's recommendation. Limit air leakage by sealing: 1) 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