ENHANCED REWARDS PROGRAM INCOME ELIGIBILITY APPLICATION THIS APPLICATION IS FOR EXISTING SITES ONLY.

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1 This application expires December 31, Please complete Sections 1 through 5, then complete Section 6 OR Section 7 for review and approval of eligibility for the Enhanced Rewards Program. Applicants can either provide their most recently filed IRS Form 1040 OR supporting income documentation for the previous three months. Applicants must provide complete and accurate information regarding household income and all individuals living within the household. Retain a copy of your completed application for your records. See pages 4-5 for additional guidance on completing this form. Income approval is required for participation in the Enhanced Rewards Program. Questions? Contact us at SECTION 1: CUSTOMER INFORMATION ENHANCED REWARDS PROGRAM INCOME ELIGIBILITY APPLICATION THIS APPLICATION IS FOR EXISTING SITES ONLY. Eligibility is based on the income of the utility account holder at the installation address. If you are a property owner and not the utility account holder, please have your tenant complete, sign, and submit this application. Rewards are paid to the party billed on the final sales invoice. First Name: Last Name: Installation Site Address: City: State: WI Zip: Name of Electric Utility: (For installation site) Electric Utility Account Number: Name of Gas Utility: (For installation site) Gas Utility Account Number: If you are a tenant, please provide the name of your landlord: If you are a tenant, please indicate whether you or your landlord will purchase the equipment: Are you interested in participating in Home Performance with ENERGY STAR, a Focus on Energy program which provides home energy assessments to increase your home s energy efficiency? q Yes q No SECTION 2: APPLICANT CONTACT INFORMATION (Applicants will be notified of income eligibility by phone or , followed by letter sent via U.S. Mail) First Name: Last Name: Mailing Address: (If different from above) City: State: Zip: Phone: Preferred Method of Initial Contact: q Phone q SECTION 3: CONTRACTOR INFORMATION (Focus on Energy will send your contractor a copy of the final income eligibility letter sent to you via U.S. Mail) Company/Business Name: Phone: q I do not wish for Focus on Energy to notify my contractor of my eligibility status. Mailing Address: City: State: Zip: SECTION 4: APPLICATION SIGNATURES (Please read the entire application and sign) By signing and submitting this Income Eligibility Application, I hereby certify that I have read, agree to, and have met all Terms and Conditions and Program Qualifications as outlined in this application. I further certify that all of the information contained in this application and supporting documentation is complete, true, and correct, and all household income of the utility account holder has been fully disclosed. Furthermore, I certify that I am the property owner, or if I am not the property owner, I certify that I have or will obtain permission from the property owner before replacing equipment. Application Signature: Print Name: Date: Attach copies of the following documents to your completed and signed Income Eligibility Application: q Page 1 of IRS Form 1040 OR q Income Support Documents for previous three months (include a support document for each income item listed in Section 7) Note: Do not send originals. Black out Social Security Numbers. FORM SUBMITTAL - Return signed, completed Income Eligibility Application and all supporting documentation to: Mail: Focus on Energy Income Eligibility, 222 W. Washington Ave., Suite 470, Madison, WI wisconsinverification@focusonenergy.com Fax: Questions: MM_IncomeEligibility_ of 5

2 SECTION 5: RESIDENT INFORMATION (For additional space use page 5) List every eligible household member currently living at the installation address on page 1. A household member is any individual living in the household and sharing common spaces. This includes persons related or unrelated. See page 4, Section 5 for ineligible household members. Name: Birth Date: Name: Birth Date: SECTION 6: EXPRESS INCOME APPROVAL (If the income on your last tax return greatly differs from your current income, please skip to Section 7) If you are completing this section, do not complete section 7. If you complete both Section 6 and Section 7, Focus on Energy will use the most recent income documents to determine eligibility. Please provide a photocopy of page 1 of the 2013 IRS Form 1040, 1040A, or 1040EZ for each eligible household member s income ( Ineligible Individuals for Income Purposes are described on page 4). Do not send originals and blackout social security numbers. Applicants are required to fully disclose all eligible household income. TANF/W2, Veterans Benefits, and Workers Compensation are not represented by IRS Form 1040; If you receive income from one of those income types, please provide supporting documentation as noted below. Focus on Energy will add any nontaxable income to your total taxable income. Line 22 on IRS Form 1040, Line 15 on IRS Form 1040A, or Line 4 on IRS Form 1040EZ may not reflect total gross income. If a loss is displayed on your 1040, Focus on Energy will zero out the value upon calculation. Income Type Required Supporting Documentation Income ($) (T) TANF/W2 (V) Veterans Benefits Copies of customer s checks; OR Check stubs; OR Award letters; OR A letter from the county TANF/ W2 agency stating the amount of customer s assistance The most recent letter from the Veteran s Affairs stating customer s monthly benefits (WK) Workers Compensation Stubs or statements from the checks Annual Income (do not use adjusted gross income) If you do not receive income from the above, please only provide page 1 of the , 1040A, or 1040EZ (Focus on Energy will add any non-taxable income to the total taxable income displayed) TOTAL TAXABLE HOUSEHOLD INCOME (Non-taxable income will be added into calculations as appropriate) $ SECTION 7: INCOME INFORMATION (For additional space, use page 5) If you complete this section, do not complete Section 6. List all gross income for each eligible household member. Applicants are required to fully disclose all eligible household income. Applicants must provide the previous three months gross income from date of application submittal (i.e. if applicant is submitting in June, applicant must provide gross income for March, April, and May). Annual gross income is accepted only for asterisked Income Types. Income Support Documents: Documentation, including but not limited to paycheck stubs, employer letter of income, Social Security award letter, letter from the Social Security office with information on benefits, most recently filed tax record and/or an IRS Form 1099, must be submitted for each income item listed in the table below. Provide a brief description of the documentation being attached to this application in the column Support Document for each income item listed. Bank statements are only accepted as proof of income for Dividends/Interest and/or Social Security Supplemental Income. For more information on these Income Types and completing this section, please see pages 4-5. (A) Alimony Received (D) Dividends/Interest* (DL) Disability Long-Term (DS) Disability Short-Term (G) Gambling/Lottery/ Bingo (LC) Land Contract Payment** (P) Pensions, Annuities, and IRA s* (R) Rental Income* (SE) Self-Employment* (SS) Social Security (T) TANF/W2 (V) Veterans Benefits (SSDI) Social Security Disability Income (SSI) Social Security Supplemental Income (TR) Tribal per Capita* (UC) Unemployment Compensation*** (W) Wages & Tips*** (WK) Workers Compensation * This income type is based on the average of the prior 12 months of income. A copy of tax records and/or IRS Form 1099 must be provided. ** Only the interest income received is counted. A copy of the amortization schedule or the IRS Form 1099 issued for tax purposes must be provided. *** If the household member is a seasonal employee (a person whose main source of income is earned in less than 12 months of a calendar year), the annual income must be provided for both wages and unemployment compensation received in the prior tax year. Copies of IRS Form W2 and IRS Form 1099 must be provided. Household Member s Name: Income Type: Income Source: Previous Three Months of Income (Gross) Month 1 Month 2 Month 3 Total 3 Month Household Income: 3 Month Total: Income Support Document: 2 of 5

3 OFFER AVAILABILITY The Enhanced Rewards Program is valid for equipment purchased and installed between July 1, 2014 and December 31, If an applicant receives income eligibility approval following submittal of this application, the approval is valid for participation in the Enhanced Rewards Program for purchases and installations completed by December 31, Any applicant who fails to submit an Enhanced Rewards Application for qualifying equipment purchased and installed within that period will be required to submit a 2015 Income Eligibility Application. Income approval does not guarantee payment of Cash-Back Reward. Applicants are eligible for the Cash-Back Reward amounts available at the time of installation. Submittal of an Enhanced Rewards Application does not guarantee payment of a Cash-Back Reward. All requirements listed on the Enhanced Rewards Application must be met to be eligible for Cash-Back Rewards. Applicants who do not obtain pre-approval of income eligibility assume all liability if he/she is deemed ineligible for the Enhanced Rewards Program. All applications must contain current, complete, and accurate information based on the date of application. Income Eligibility Applications will be processed within one business day from receipt if all necessary documentation is included. Applicants will be notified of income eligibility or denial by phone or , followed by a letter of income eligibility notification sent via U.S. Mail. Only single family dwellings and multifamily dwellings of three or fewer units are eligible for Cash-Back Rewards from the Enhanced Rewards Program. Cash-Back Rewards may be available for other customer or property types. Please visit focusonenergy.com for other offerings and applications. Applicants who are not eligible for the Enhanced Rewards Program will be denied the Cash-Back Rewards listed on the Enhanced Rewards Application. Applicants who do not qualify for the Enhanced Rewards Program may be eligible for the Residential Rewards Program. Ineligible applicants will be contacted following review of the Enhanced Rewards and Income Eligibility Applications to determine eligibility for other rewards. Incomplete applications cannot be processed. Failure to complete the Income Eligibility Application in full and provide the required supporting documentation will either delay the income eligibility process or result in your application being denied. PROGRAM QUALIFICATIONS You are only eligible to participate in the Focus on Energy Enhanced Rewards Program if you are: A current residential customer of a participating utility in Wisconsin at the time of equipment purchase and installation and meet the income requirements set forth below. Installing qualifying energy efficient equipment in an existing residential dwelling. New construction does not qualify. Your installation of high efficiency equipment is only eligible for a Cash-Back Reward if you meet the program qualifications outlined in the Enhanced Rewards Application. Call if your situation differs from the requirements listed above. Customers will be reviewed for eligibility on a case-by-case basis. Please note: Approval of income eligibility is required for the Cash-Back Rewards included in the Enhanced Rewards Application and applicants are strongly encouraged to complete the income eligibility process prior to submitting a reward application. Income Eligibility Requirements: Applicants must have documented income of less than 80 percent of the State Median Income (SMI), as listed in the table below, to participate in the Enhanced Rewards Program. Review and verification of income eligibility is required prior to payment of a Cash-Back Reward. Applicants with documented income greater than the 80 percent SMI value listed in the table below for his/her household size may be eligible to participate in the Residential Rewards Program. Applicants with income less than the 60 percent SMI value listed for his/her household size may participate, but are encouraged to contact a local weatherization agency for information on other available assistance programs. Please call 211 for more information on eligibility and the assistance programs available. Income eligibility is determined by the 2013 IRS Form 1040 OR the previous three month income values (gross) for all household members (unless otherwise noted on page 2 as an income type that requires 12 months of gross income, verified by an IRS Form 1099 or other Income Support Documents). Applicant must report the names of all eligible household members (as defined on page 4) living at the installation address at the time of application submittal. Applicant must fully disclose all income for each household member on page 2, unless the individual is considered ineligible for income purposes (as noted on page 4). If replacing a shared system in a two unit dwelling, at least one utility account holder must be income qualified. If replacing a shared system in a three unit dwelling, at least two utility account holders must be income-qualified and a separate Income Eligibility Application must be submitted for each utility account holder. If replacing dedicated unit in a two to three unit dwelling, the utility account holder(s) of unit dwelling(s) where unit(s) is/are being replaced must be income-qualified. Please note: Applicants must black out all Social Security Numbers on documentation submitted with applications. Handling and storage of personal information, applications, and all supporting documentation follow strict security and data handling measures similar in scope to the requirements of Wisconsin Home Energy Assistance Program (WHEAP) and Low Income Home Energy Assistance Program (LIHEAP). GROSS SMI LIMITS BY HOUSEHOLD SIZE (2014) Annual Income 3 Month Income Household Size Lower Limit: 60% SMI Upper Limit: 80% SMI Lower Limit: 60% SMI Upper Limit: 80% SMI $24,692 $32,290 $39,887 $47,485 $55,083 $62,680 $64,105 $65,529 $66,954 $68,378 $69,803 $71,228 $32,923 $43,053 $53,183 $63,313 $73,443 $83,574 $85,473 $87,372 $89,272 $91,171 $93,071 $94,970 $6,173 $8,073 $9,972 $11,871 $13,771 $15,670 $16,026 $16,382 $16,739 $17,095 $17,451 $17,807 $8,231 $10,763 $13,296 $15,828 $18,361 $20,894 $21,368 $21,843 $22,318 $22,793 $23,268 $23,743 How to use this chart: Income eligibility is determined using applicants 2013 IRS Form 1040 or the documented income of the previous three full months. Certain income types require 12 months, which will be used to calculate a monthly average to determine the three month income value. Applicants must have a three month income of no more than the Upper limit: 80 percent SMI listed for his/her household size in the table above. 3 of 5

4 TERMS AND CONDITIONS By submitting this application, the signatory(ies) and applicant(s) agree to all of the following terms and conditions. Applicant certifies that the information contained in the application and all supporting documentation provided is true and complete statement of facts. The Applicant may be required to provide proof of any information on this application and that giving false information will invalidate this application, require the return of any Cash- Back Rewards received and could possibly subject the Applicant to criminal prosecution. Applicants submitting a reward application who have not been pre-approved for Income Eligibility assume all risk, as he/she may not be approved for participation in the Enhanced Rewards Program and therefore ineligible for the rewards listed on the Enhanced Rewards Application. Income Eligibility approval does not guarantee payment of a Cash-Back Reward. Applicants must meet all other requirements to be eligible for a Cash-Back Reward. All equipment installations are subject to verification inspection by the program to ensure the equipment is properly installed and operating. Participants must allow, if requested, the program or a program representative reasonable access to their home to verify the installed equipment. The program will only pay one Cash-Back Reward for each piece of equipment. Cash-Back Rewards paid on this application cannot be claimed on another Focus on Energy application. Similarly, Cash-Back Rewards can only be paid to one person or entity (i.e., either the resident or contractor, not both). All natural gas utility customers should verify with their gas utility to ensure that their natural gas pressure is adequate for any natural gas equipment being installed. The program is not responsible for items (i.e. income eligibility applications, supporting documentation, reward applications, reward checks) lost or damaged in the mail. APPLICATION GUIDANCE Section 1: Customer Information The Customer on this application should be the household member who is the utility account holder of the home where equipment will be installed. The Customer Information section should be completed using the account holder s utility information, the installation address, and other information regarding the property and utility account holder. If you are the property owner but another household member is the utility account holder, please have the utility account holder complete this application. Section 2: Applicant Information Enter the contact information of the individual submitting this application. If an applicant who is not the customer listed in Section 1 is submitting this application, he/ she will be signing on behalf of the customer and all requirements apply. Select your preferred method of contact, phone or , so that we may easily reach you to notify you of eligibility determination, or for additional information if required. Section 3: Contractor Information If known, enter the contact information of the contractor you plan to have install your qualifying equipment. Section 4: Application Signatures Prior to signing the application, please ensure the application has been completed in full, all information is correct, and you have read through all requirements and Terms and Conditions. Section 5: Resident Information Household Members: All individuals living in the household at the time of application submittal (related, unrelated or living together in the dwelling unit) are household members. Persons living in a housing arrangement with their own room who share common spaces are part of the household for this application. The following individuals are not eligible household members and should not be included on page 2, nor should their income be included on page 2. q Roomers/Boarders/Renters who do not provide for the necessities of life for other household members (i.e. an individual who pays rent for their portion of the living space only, and does not otherwise provide financial support for other eligible household members). q Temporary Residents/Household Members: Individuals who are not permanent residents of the household but will be living in the household for less than 30 days after application submission. Temporary Residents include individuals who lived in the household during a portion of the preceding three months but are not living in the household at the time of application submittal. q Foreign Exchange Student from another country attending school on an exchange program. q College students, unless they live in the household full-time and do not have another residence (i.e. dorm room or apartment). q Foster children of applicant who are orphaned, neglected, or delinquent and are not living in the household. q Medical attendant who does not live in the household. q Military on Active Duty: A household member who is currently in active duty, or has been called into active duty and is to be out of the household for at least 60 days. The base income of this individual should not be listed on page 2, but any household support provided to maintain the household (i.e. housing allowances, allotments sent directly to the household for support) should be listed on page 2. Section 6: Express Income Approval Provide photocopies of each eligible household member s 2013 IRS Form Add each member s total income and place the combined value in the Total Taxable Household Income field. Section 7: Income Information How to complete the Income Information Section: Income of all members of the household, as defined on page 2, must be included in Section 7: Income Information q Household Member s Name: Enter the name of the household member for the income item you are listing in that row. q Income Type: Enter the Income Type, selecting a code from the Income Type table on page 2. q Income Source: Enter the name of the employer, pension payer, self-employment, or the source of other types of income. q Months: Please write which months you are submitting income information for at the top of these columns in the spaces provided. Enter the monthly income for each income type for the previous three full months. (For example, if you are submitting your application in the month of May, you must provide income for the months of February, March, and April). If you are submitting an income type that requires 12 full months of income information, as noted on page 2, please leave the Month fields blank. Monthly income estimates will be determined by using the income support documents to calculate the average monthly income. q Three Month Total: Sum the three month total income for each income item you have listed. q Income Support Document: List the supporting document you are submitting as an attachment to the application (i.e. paycheck stub or an IRS Form 1099). You must submit a supporting document for each income item for verification purposes. Ineligible Individuals for Income Purposes: The income of the following individuals should not be included in Section 7: Income Information. q All individuals who are considered ineligible household members in the list above, under Section 5: Resident Information. q The earned income of minors under the age of 18 (or full-time high school students). Income Types: The following provides explanation for each Income Type listed on page 2 (Section 7: Income Information). q (A) Alimony Received: Payment(s) received from a former spouse. q (DL) Disability Long-Term: Payments made by an employer or insurance company for a permanent disability or medical condition. q (DS) Disability Short-Term: Payments made by an employer or insurance company for a temporary disability or medical condition. q (D) Dividends/Interest: Money that is received/earned in any of the twelve months prior to application and a household member has access to withdraw the money without penalty. (Examples of interest that might not be accessible: IRAs, CDs, etc.) q (G) Gambling/Lottery/Bingo: All income received from gambling, lottery, or bingo activities. Do not deduct losses. Continued on page 5 4 of 5

5 APPLICATION GUIDANCE, CONTINUED q (LC) Land Contract Payment: Provide only the interest received from the land contract payment. Use the amortization chart from the agreement, or the amount from the 1099 listed on the most recent tax form divided by 12. q (P) Pensions, Annuities, and IRA s: These payments are scheduled and paid on a regular basis. For pension or annuities paid on a monthly basis enter the amount paid each month. For those paid on a quarterly or other basis, enter the average monthly amount. Please provide most recent tax forms or 1099 form for verification. For railroad pensions or other federal pensions that have a medical premium deduction, subtract the amount up to the current Medicare Part B premium amount. q (R) Rental Income: Income received from rental purposes. This is a form of self-employment and must be reported as the net income received from the last 12 months, or prior tax year, divided by 12 for a monthly income amount. q (SE) Self-Employment: The annual income from self-employment reported on the self-owned business s tax forms. The net annual amount is divided by 12 to get a monthly amount. If the business s recent taxes have not yet been filed, contact the local energy assistance agency for the appropriate forms q (SS) Social Security: Income received from Social Security because you or your spouse is retired. Report the awarded amount minus the Medicare Part B premium. Do not subtract any other deductions or premiums. q (SSDI) Social Security Disability: Income received from Social Security for long-term disability. This amount includes the social security survivor s benefits and ancillary benefits paid to children because of a deceased or disabled parent. q (SSI) Social Security Supplemental Income: Income paid by Federal Social Security (U.S. Treasury) and the State of Wisconsin for the elderly/disabled. The Federal amount and State amount should be entered on separate income lines as two different incomes. q (T) TANF/W2: Cash payments received from Wisconsin s Temporary Assistance for Needy Families program - Wisconsin Works. q (TR) Tribal per Capita: Tribal per capita gross amounts received in the 12 months prior to application or during the previous tax year, less the first $2,000 received by the applicant in the same 12 months or the same tax year. q (UC) Unemployment Compensation: Payments received as part of unemployment benefits. An individual who is considered seasonal will need to report the UC income received in the prior tax year. The prior year amount is then divided by 12 to get a monthly income amount. q (V) Veterans Benefits: Income from VA Compensation, VA Pension (do not list as pension income), Retired Military Compensation, or Dependency and Indemnity Compensation (DIC). q (W) Wages & Tips: All gross wages and tip income received in the three months prior to the application month for all adults 18 and over living in the household. Include all commissions, bonuses, and profit sharing received in the last 12 months in the wage total. If the primary source of income for that individual is considered seasonal, you will need to provide copies of the W-2 s of all employment and the 1099 for the Unemployment received from the prior tax year. Seasonal employees are individuals whose primary employment is normally less than 12 months per year. The annual amount from each source will be divided by 12 to arrive at a monthly income amount. Please note: Wage income for individuals under the age of 18 and those that are 18 and older currently enrolled in high school is not counted as household income. If a household member is under the age of 18 and has wage income, or is 18 or older and enrolled in high school, please explain in the case notes. q (WK) Workers Compensation: Money received as an insurance benefit paid to an employee to replace wage income lost due to an injury in a work related incident. ADDITIONAL NOTES 5 of 5