Electric Vehicle Charging Station

Member Name*

Account No.*

Phone No.*

Email Address*

Site Installation Address

Street Address*

City*

State*

Washington

Zip Code*

Mailing Address (if different than Site Installation address)

Street Address

City

State

Select

Zip Code

Type of Charging Station (model)*

Vehicle Type (year/make/model)

Installation Date*

L&I Permit No.

Contractor Name

Contractor Phone No.

Primary Electric Heat Source *

Select or enter value

Other Electric Heat Source

Own or Rent?

Select

Do you live at this residence full-time? (Yes/ No)

Select

If yes, how many permanent occupants in the home?

Low-Income Energy Efficiency Measures*

Does your household fall below 200% of the 2024 Federal Poverty Level?

1 Person: $30,120

2 People: $40,880

3 People: $51,640

4 People: $62,400

5 People: $73,160

6 People: $94,680

7 People: $94,680

8 People: $105,440

9 or more: Add $10,760 each

Yes

Self-Attestation of Income*

I am a Homeowner or Tenant of the single-family home, manufactured home, or multi-family unit that will receive or have received energy efficient upgrades.

I am a customer of Orcas Power & Light Cooperative. I am aware that this utility and Community Action Agencies in my area can provide energy efficient upgrades at a high-level of assistance, but it requires I prove I meet certain income qualification guidelines.

I do hereby declare that my gross annual household income does not exceed the maximum income for my household size as indicated in the eligible income threshold above or as stated by my state or tribe.

I benefit from any of the Eligible Income-Qualified Programs listed below.

• Section 8 eligibility

• LIHEAP certification

• HUD Housing

• Supplemental Social Security Income

• TANF

• NAHASDA

I certify that the information presented is true and accurate. I further understand false, misleading or incomplete information may render me (the Applicant) ineligible to receive my utility's higher income-qualified incentive. If my utility finds that any information provided in connection with this application is false, then my utility reserves the right to require reimbursement of any incentives provided to which I am not entitled. My utility reserves the right to request additional documentation or proof of income to verify income qualification and to verify benefits.

By selecting "Yes" I agree that the above statement is true.

By selecting "No" I agree that the above statement is NOT true.

Yes

File Attachments*

Please include a copy of an invoice (receipt) showing model number & specifications of Charging Station, as well as an invoice from contractor showing date of installation. Please also include a picture of installed EV charger.

Drag and drop files here or

Terms & Conditions

Complete application must be received within 6 months of the installation date to be considered for incentive. Homeowners must comply with all applicable codes and regulations. Available to all active OPALCO members in good standing (no arrears balance). OPALCO reserves the right to inspect installation and will coordinate inspection as applicable. Rebate is cost reimbursement of charges and fees directly related to the purchase and installation of any Level 2 240 V AC Charging station up to $500.00. OPALCO is not responsible for any part of the charging station maintenance, power consumption, and any and all implied warranties (including but not limited to implied warranties or merchantability or fitness for a particular purpose) and shall not be responsible for any necessary service repair or upgrades, or representation or promise with respect to the equipment, materials, or labor required for the installation of the appliance on the premises, or the cost of such equipment, materials and labor. Cannot be combined with other OPALCO rebate offerings. Additional conditions may apply. By signing below, the member implies that all information provided is true and accurate to the best of their knowledge.

Member Signature

Signature of Applicant*

Signature Date (Applicant)*

Check the box if you would like to donate any part of your rebate to the PAL Program.

VOLUNTARY Demographic Information

Why do we ask? This information helps us access grants and other funding opportunities to better serve you!

Veteran?

YES

Disabled?

YES

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Site Installation Address

Mailing Address (if different than Site Installation address)

Terms & Conditions

Member Signature

**VOLUNTARY** Demographic Information

VOLUNTARY Demographic Information