2025 Residential Midstream Program: Incentive Application Form
Distributor Information
Please complete all required fields *
Distributor Company Name
*
Distributor's Name
*
Distributor's First Name
Distributor's Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NIPSCO Account Holder Information
NIPSCO Account Number
*
First 9 Digits only, no dashes or spaces. Please call the NIPSCO Hotline at 1-800-721-7385 option 4 to verify eligibility if needed.
Account Holder
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Installation Address for Equipment
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Installation Contractor Information
Contracting Company Name
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contractor's Name
Contractor's First Name
Contractor's Last Name
Product Information
Complete one piece of equipment per submission. Additional equipment can be added after this submission.
EQUIPMENT TYPE
*
Natural Gas Furnace 95%+ AFUE
Air Conditioner 15.2 - 16.1 SEER2
Air Conditioner 16.2+ SEER2
ENERGY STAR Heat Pump Water Heater 2.0+ UEF
Air-Source Heat Pump 15.2 - 16.1 SEER2
Air-Source Heat Pump 16.2 - 17.0 SEER2
Air-Source Heat Pump 17.1+ SEER2
Total incentive
Date of Sale
*
-
Month
-
Day
Year
Date
Manufacturer
*
Model Number
*
Estimated Date of Installation
*
-
Month
-
Day
Year
Date
Serial Number
*
AHRI Certification #
*
File Upload - please attach all invoices and/or AHRI certificates
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Additional Notes
Terms & Conditions
Distributor Signature
*
Date
*
-
Month
-
Day
Year
Date
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