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Section 1 – Applicant Information (System Owner)
First Name (As shown on your Income Tax Return)	Middle Initial (If used on Tax Return)	Last Name (As shown on your Income Tax Return)
Click or tap here to enter text.	Click/tap	Click or tap here to enter text.
Email Address	Phone Number
Click or tap here to enter text.	Click or tap here to enter text.
Installation Address	City	State	Zip Code
Click or tap here to enter text.	Click or tap here to enter text.	MD	Click/tap
County	Congressional District*	MD Legislative District*
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*Find Maryland Congressional and Legislative Districts at https://www.mdelect.net
Mailing Address (If different from Installation Address)	City	State	Zip Code
Click or tap here to enter text.	Click or tap here.	Choose	Click/tap
Primary Point of Contact	☐ Applicant ☐ Contractor
Section 2 – Clean Burning Stove Information (One stove per application)
Clean Burning Stove Type	System Capacity (Btu/hr)	Total System Cost	Rebate Amount**
☐ Pellet Burning Stove	Click/tap	Btu/hr	Click/tap	Choose
☐ Wood Burning Stove	Click/tap	Btu/hr	Click/tap	Choose
Stove Manufacturer	Click or tap here to enter text.	Gram/hr***	Click/tap
Model	Click or tap here to enter text.	EPA Efficiency Rating	Click/tap %
**Stoves with an EPA-published efficiency rating will receive the higher award. ***Grams of particulate matter emitted per hour. Pellet stoves cannot emit more than 3.0 Grams/hr, and wood stoves cannot emit more than 2.0 Grams/hr.
Survey Questions (Required)
Are you replacing an existing wood-burning stove?	☐ Yes ☐ No
What type of heating fuel will you be displacing?	Click or tap here to enter text.
How are you disposing of the old stove (if applicable)?	Click or tap here to enter text.
Section 3 – Applicant Signature – CAREFULLY READ THE STATEMENTS BELOW BEFORE SIGNING
I affirm under penalties of law that: 1. A qualified clean energy system has been installed on the installation property specified in Section 1 of this Residential Clean Energy Rebate Application. 2. I am a legal resident of the State of Maryland. 3. I own the property for which I am applying and it is my primary residence. 4. If the property is held in a trust: I attest that the trust is revocable and I have the right to remove the property from the trust. 5. I have complied with all state laws, local ordinances and other legally-binding requirements. 6. The contents of this Application are true to the best of my knowledge, information and belief. 7. I have read and agree to the terms and conditions outlined in the Residential Clean Rebate Terms and Conditions.
Print Full Name (As shown on your Income Tax Return)	OFFICIAL USE ONLY
D13	03	512SA	1299
Click or tap here to enter text.	AGENCY	FUND	PCA	SUB-OBJ	FY
Social Security Number (REQUIRED to issue payment)
Click or tap here to enter text.	SSN	AMOUNT
MEA-
Handwritten Signature	PM INIT	MEA INVOICE NUMBER	DATE RECEIVED
X
MEA APPROVAL	FINANCIAL ADM APPROVAL
PLEASE NOTE: Your application is not valid unless signed.	DATE:
POSTED:

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Section 4 – Permitting & Installation Information
State the Permitting Authority (County or Municipality having jurisdiction) and applicable permit numbers and dates of final inspections below:
Circle Y or N:	Final Inspections:
Required?	Permitting Authority	Building Permit Number	Date Passed
Y / N	Click or tap here to enter text.	Click/tap to enter text.	Click/tap to enter text.
Required?	Permitting Authority	Electrical Permit Number	Date Passed
Y / N	Click or tap here to enter text.	Click/tap to enter text.	Click/tap to enter text.
Required?	Permitting Authority	HVAC/Mech Permit Number	Date Passed
Y / N	Click or tap here to enter text.	Click/tap to enter text.	Click/tap to enter text.
Required?	Permitting Authority	Plumbing Permit Number	Date Passed
Y / N	Click or tap here to enter text.	Click/tap to enter text.	Click/tap to enter text.
Project Installation Information
Project Start Date	Project Completion Date	Total Person Hours Worked
Click/tap to enter text.	Click/tap to enter text.	Click/tap to enter text.
Section 5 – Installation Contractor Information (to be obtained from Contractor)
MEA strongly encourages the Applicant to use a contractor who is National Fireplace Institute (NFI) certified. Installers must have a Maryland Home Improvement Commission (“MHIC”) license. Please enter the information for the installation contracting company which installed the clean energy system in the section below. Contractors must be incorporated or registered to do business in the State of Maryland, possess all licenses and certifications required by all applicable Federal, State, and local laws, regulations, and other legally-binding requirements and be in Good Standing with the Maryland State Department of Assessments and Taxation. By signing the Application in Section 3, you are attesting that the following information about the installation contractor is true and correct to the best of your knowledge, information, and belief. If the stove was self-installed, write “Self” under the Company Name and leave remaining areas blank.
Company Name	License Type	MHIC License Number
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Name of Contact Person	Title of Contact Person
Click/tap to enter text.	Click/tap to enter text.
Company Phone Number	Contact Person’s Email Address
Click/tap to enter text.	Click/tap to enter text.
Company Street Address	City	State	Zip Code
Click/tap to enter text.	Click/tap to enter text.	Choose	Click/tap