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Sample Change Out Documents

Sample Change Out Documents

These sample change out documents and forms are provided for reference to how some programs approach gathering and verifying key information. 

Stove Disposal Forms

Northern Sonoma, CA (rebate program): This "Verification of Disposal" form requires retailers to certify that the destroyed stove was not certified by the EPA, and provides space to list the brand and model names. The form also instructs participants to attach photographs of the destroyed stove (not always required in change-out programs) and copies of the disposal receipt.

Massachusetts (voucher program): This single page "Old Stove Disposal Form" also doubles as a project completion form. It must be signed by both the stove recycling facility that disposed of the stove and the stove professional that installed the new appliance.

Placer County, CA (voucher program): This stove destruction form doubles as a confirmation that a program voucher was redeemed at a participating retailer. Applicants are instructed to present this form to the retailer when purchasing a new device. It does not require a signature from the recycler, but requires the door to be removed and kept on site for possible inspection by program administrators.  

Applications

San Luis Obispo, CA (rebate program): This program application contains a detailed checklist of required verification documents. It asks applicants to estimate their wood or pellet usage (in pounds/cords and days) and agree to a number of guidelines.

El Dorado County, CA (rebate program): This single page application asks participants to list the permit number and final inspection date for the installation of their new device. The same document is used for pre-approval and reimbursement and contains several areas for the program administrator to stamp and complete at different stages of the process. This program covers the costs of building permits and various permit prices are listed.

Marin County, CA (rebate program): This seven page application is used for both the stove bounty and replacement programs. It also contains a page for verifying the disposal of the old stove and requires that a receipt from the recycling facility and building permit be attached. Direct deposit information and W9 forms are included.

Retailer/installer participation agreements

Sacramento, CA (voucher program): This three page "Statement of Expectations" outlines all program requirements for participating retailers and appliance installers. Retailers must provide a signature at the end of the form that they agree with the conditions and deadlines of participation.

Bay Area, CA (rebate program): This "Contractor Certification Form" requires the appliance installer to certify that he or she is a licensed contractor in the state, and contains questions about the new device and the device being replaced. The form also asks if a permit was required. If so the property owner is instructed to provide it.

Colorado (voucher program): This retailer participation agreement lists all program expectations in the first two pages and asks retailer and installer information on the third. It also asks for NFI certification numbers for installers.