1050 Attc

PON 1050 Incentive Application Form Attachment C
INCENTIVE APPLICATION FORM

Name of Eligible Installer:________________________________________ NYSERDA Installer Number: ________________
Name of Company: ____________________________________________
Owner Name: _________________________________________________ Owner Phone Number: _______________________
Installation Address: ______________________________________________________________________________________
City: ______________________________________ State: ______________ Zip: _______________________
Mailing Address (if different from Installation address): __________________________________________________________
___________________________ City: _________________________________ State: ________________ Zip:____________
Owner Email: _________________________________________ Utility Service Territory: ______________________________
Expected Date of Installation ____________________________ Expected Date of Interconnection: _____________________
Please attach proof of payment by customer into Renewable Portfolio Standard (as shown on utility bill or letter from utility)
Building or Customer type Check all that apply:
___New Construction ___Existing Home –––Commercial ___Single Family Res.

___2-4 Family
___Mutifamily ___Agricultural ___Industrial
Residential
___Educational ___Not-for-Profit ___Municipality/Government ___Other________________
Required System Documentation - Each Incentive Application must include as attachments: site map, shading analysis, three-line
electrical drawing, and utility bill.
PV Panel Manufacturer: Model: Number of Panels:
PV Panel Manufacturer: Model: Number of Panels:
Inverter Manufacturer: Model: Number of Inverters:
Inverter Manufacturer: Model: Number of Inverters:
Inverter Efficiency: __________________ Orientation:_____________________ Tilt: _______________________

Total System Production kW (DC at STC): _______________________ Total System Production AC: __________________
Customer’s Annual Electric usage (kWh): _________________
Expected Annual kWh Produced by system: __________Annual Electrical Offset Associated with the PV System:_______ %
(Must not be greater than 110%)
Total Cost Before Incentive: ________________ Incentive Total: _________________
Incentive Calculation: __________________________________________________________
Estimated Annual losses from shading: ___________ kWh: ______________%
Estimated Annual losses from orientation, tilt, etc: ____________ kWh ___________ %
Estimated Annual losses from shading & orientation: _______________ kWh ______________ %
Does total square footage of PV array exceed 4,000 square feet: ___Yes ___No ______________square ft.
If Batteries are Part of this System, What is their Capacity: ______________________________________
PON 1050 Incentive Application Form Attachment C
CHECKLIST: (This form will be returned if the following are not included)
___Site map
___Three-line electrical drawing
___Photo(s) of installation site
___ Shading Analysis Results
___ Signed copy of Installer-Customer Purchase Agreement
___ Copies of any Permits and Approvals from all jurisdictions having authority for non-residential systems. Residential systems
can submit permits with Application or with initial invoice.
___ Copy of utility bill
___ Other proof of payment by customer into RPS/SBC
CERTIFICATION STATEMENT
Review and sign PRIOR to submitting Incentive Application Forms for NYSERDA review.
I certify that all information provided in this application, including worksheets and analysis and permits and approvals, is true and
correct to the best of my knowledge.
Installer Signature: __________________________________________________ Date: ______________________________
Company Signature: _________________________________________________ Date: _______________________________
Customer Signature: _________________________________________________ Date: ______________________________
All forms and attachments should be sent to:

NYSERDA New York State Energy Research and Development Authority
ALS-Solar Incentive App.
17 Columbia Circle Albany, NY 12203-6399

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PON 1050 Incentive Application Form Attachment C

INCENTIVE APPLICATION FORM

_New Construction _Existing Home –––Commercial ___Single Family Res.

PV Panel Manufacturer: Model: Number of Panels:

PV Panel Manufacturer: Model: Number of Panels:

Inverter Manufacturer: Model: Number of Inverters:

Inverter Manufacturer: Model: Number of Inverters:

Inverter Efficiency: ________ Orientation:_ Tilt: _____________

Installer Signature: ____________________ Date:

Company Signature: ___________________ Date: _

Customer Signature: ___________________ Date:

All forms and attachments should be sent to:

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