LOW INCOME

Household Information

Retailer Information (Optional)

Applicants may visit any retailer participating in the Fireplace & Woodstove Change-Out program and are not required to choose a retailer at the time of application. If you are working with a retailer, please provide their information below. The District may contact the retailer you listed below regarding your application.

Certifications

By submitting this application, I certify that I have read, understand and will adhere to the Fireplace & Woodstove Change-Out Program Voucher Guidelines and agree to all the following:

• I understand that the installation of a new device must be conducted by the contracted Retailer, where new device was purchased, or a third-party contractor affiliated with that Retailer and under their direct supervision. Self-installation, installation by non-licensed contractor or a third-party contractor not affiliated with that Retailer is not eligible under this program.
• I understand that submission of this voucher application does not guarantee incentive funding for the new device.
• I understand that it is my responsibility to verify that the new device is eligible under the program guidelines. New wood or pellet devices must be on the current list of EPA Certified Wood Heaters and new gas fireplaces must meet ANSI z21.88/CSA2.33.
• I will be removing an operable old device or modifying an open hearth fireplace/wood burning firebox at the device address specified on this voucher application.
• If applicable, I agree to surrender my old device to a licensed recycling/dismantling facility or to the participating retailer to dispose of at a licensed recycling/dismantling facility within 90 days of installation of the new device. If I undertake the responsibility of disposing my old device, I agree to submit a dated receipt and certification from the dismantler/recycler that my old device will be permanently destroyed.
• I understand that if I install the new device in a location other than what is identified in the pre-installation photos at the device address, I must first contact District staff to receive approval and I must still render the old device permanently inoperable. At the time of claim, where I will be seeking reimbursement for the completion of my project, I will be required to provide additional documentation, such as an additional photos, to confirm that the location of the old device can no longer service a wood-burning device.
• I understand that the selection of a Fireplace & Woodstove Change-Out retailer is completely my choice and the District does not endorse, or is not in partnership with any Fireplace & Woodstove Change-Out program retailers or installers and any such issues arising from the purchase or installation of the new device is between the applicant and the retailer or installer. The District will not be held liable for any circumstances or events that occur between the applicant and retailer or installer. Participating retailers are independent contractors; they are not officers, representatives, agents, servants, employees, partners, associates, etc. of the District.
• I understand that this is a reimbursement program and I will not be reimbursed until the new unit is paid in full, completely installed, and a complete Claim for Payment packet is submitted to the District. Applicants eligible for Instant Reduction, please see page 2 of the Voucher Guidelines for payment processing.
• I have not made any non-refundable payments towards the purchase of the new device or disassembled my old device, and will not install the new device until I have received an approved voucher from the District.

• I understand that the installation of a new device must be conducted by the contracted Retailer, where new device was purchased, or a third-party contractor affiliated with that Retailer and under their direct supervision. Self-installation, installation by non-licensed contractor or a third-party contractor not affiliated with that Retailer is not eligible under this program.
• I understand that submission of this voucher application does not guarantee incentive funding for the new device.
• I understand that it is my responsibility to verify that the new device is eligible under the program guidelines. New wood or pellet devices must be on the current list of EPA Certified Wood Heaters and new gas fireplaces must meet ANSI z21.88/CSA2.33.
• I will be removing an operable old device or modifying an open hearth fireplace/wood burning firebox at the device address specified on this voucher application.
• If applicable, I agree to surrender my old device to a licensed recycling/dismantling facility or to the participating retailer to dispose of at a licensed recycling/dismantling facility within 90 days of installation of the new device. If I undertake the responsibility of disposing my old device, I agree to submit a dated receipt and certification from the dismantler/recycler that my old device will be permanently destroyed.
• I understand that if I install the new device in a location other than what is identified in the pre-installation photos at the device address, I must first contact District staff to receive approval and I must still render the old device permanently inoperable. At the time of claim, where I will be seeking reimbursement for the completion of my project, I will be required to provide additional documentation, such as an additional photos, to confirm that the location of the old device can no longer service a wood-burning device.
• I understand that the selection of a Fireplace & Woodstove Change-Out retailer is completely my choice and the District does not endorse, or is not in partnership with any Fireplace & Woodstove Change-Out program retailers or installers and any such issues arising from the purchase or installation of the new device is between the applicant and the retailer or installer. The District will not be held liable for any circumstances or events that occur between the applicant and retailer or installer. Participating retailers are independent contractors; they are not officers, representatives, agents, servants, employees, partners, associates, etc. of the District.
• For low-income verification, I acknowledge that the income information provided, includes all sources of income for household members receiving income, and will be used to assess and verify my low-income eligibility for the Fireplace & Woodstove Change-Out Program. My signature gives consent for this information to be shared with other government agencies. I declare, under penalty of perjury under the laws of the State of California, that to the best of my knowledge the information on this application is true and correct. I understand that submitting false information may result in criminal conviction or in a civil penalty of not less than $150 and not more than $1000, and that I will not be eligible to receive future assistance.
• I understand that this is a reimbursement program and I will not be reimbursed until the new unit is paid in full, completely installed, and a complete Claim for Payment packet is submitted to the District. Applicants eligible for Instant Reduction, please see page 2 of the Voucher Guidelines for payment processing.
• I have not made any non-refundable payments towards the purchase of the new device or disassembled my old device, and will not install the new device until I have received an approved voucher from the District.

• I will be decommissioning an operable old device or open hearth fireplace at the device address specified on this voucher application.
• I understand that submission of this voucher application does not guarantee incentive funding for the decommissioning of my existing device.
• I understand that I will not be reimbursed for this project until the San Joaquin Valley Air Pollution Control District (District) deems my wood-burning fireplace fully decommissioned.
• The District requires the use of a state licensed contractor when doing work related to the decommissioning of the wood-burning fireplace. The contractor must complete a Fireplace Decommissioning Contractor Certification Form (will be included with the voucher packet). I understand that I will not be reimbursed for any work performed by an unlicensed contractor.
• I assume all the risk and outcome of the fireplace decommissioning work completed for this project. I understand that I am responsible for obtaining all necessary permits and completing required inspections to ensure the project meets federal, state and local requirements.
• I understand that I will need to provide photographic proof throughout the wood-burning fireplace decommissioning process, from start to finish. The photos must clearly shows all steps taken and I agree to submit these photos with the claim for payment packet.
• I understand that if I currently have a freestanding stove or fireplace insert, I agree to surrender my old device to a licensed recycling/dismantling facility or to the participating retailer to dispose of at a licensed recycling/ dismantling facility within 90 days of decommissioning and I am responsible for obtaining a dated receipt from a dismantling/recycling facility as proof of destruction. Freestanding stove and fireplace insert projects are not eligible for reimbursement without a dated receipt from a dismantling/recycling facility.
• I understand that the selection of a licensed contractor is completely my choice and the District does not endorse, or is not in partnership with any licensed contractors and any such issues arising from the decommissioning of my existing device is between the applicant and the licensed contractor. The District will not be held liable for any circumstances or events that occur between the applicant and rlicensed contractor. Licensed contractors are independent contractors; they are not officers, representatives, agents, servants, employees, partners, associates, etc. of the District.
• I understand that this is a reimbursement program and I will not be reimbursed until the decommissioning of my existing device is complete, the licensed contractor is paid in full, and a complete Claim for Payment packet is submitted to the District.
• I have not made any non-refundable payments towards the decommissioning of my old device, and will not start any decommissioning work until I have received an approved voucher from the District.