Contractor Invoice Template - Free Download
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This form, subject to change, is effective from October 1, 2015. www.goingductless.com
Return completed form to:
100 SW Main St, Suite 1500 Portland, OR 97204
Phone 888.958.7472 E-mail: DHPServices@clearesult.com
Contractor Invoice Form
To be completed and signed by the General Contractor. All applicable fields are required for approval.
Incomplete forms or incorrect reporting will delay approval.
Official Use Only: Project ID
Site City / State / ZIP code:
General Contractor Company Name:
Date of Installation:
Distributor branch location (City, State):
Retail Partnership: Yes No If yes, please specify retailer and provide Retail Invoice (Home Depot, etc.) _____________________________________
TOTAL installed cost, including: equipment, labor, electrical, tax, permit and other (prior to rebate/discounts): $___________________________________
Equipment cost: $__________ Labor cost: $__________ Electrical cost: $__________ Tax cost: $__________ Permit cost: $__________ Other cost: $__________
Total # of all outdoor units installed: __________
Total # of all indoor units installed: __________
Which method was used to ensure the DHP functions as the
primary heating system
Thermostat(s) set back, DHP as primary
Furnace / zonal heater(s) off at breaker
Furnace / zonal heater(s) off at thermostat(s)
Other (please explain):__________________
Detailed Description of Outdoor Unit #1 Installed to Serve Main Living Area
Outdoor Unit #1 Model No.:
AHRI Certified Ref#:
HSPF# (Min: 9.0 single-zone & 8.0
Additional refrigerant added to
Outdoor unit #1: (over manufacturer’s
Indoor unit(s) for
Outdoor unit #1
Indoor unit model number(s)
for OUTDOOR UNIT #1 ONLY
Installed line set length
Indoor Unit 1
(in main living area)
Description of Additional Outdoor Units (if installed, do not include Outdoor Unit #1 data):
Outdoor Unit #2 or 3
AHRI Certified Ref#
Number of indoor units
Outdoor unit 2
Outdoor unit 3
General Contractor Signature Release
By signing below, the General Contractor/ installer certifies that this invoice form and all accompanying documents are complete and accurate. The signature certifies that the
General Contractor/Installer is licensed, bonded, insured, has been trained by the manufacturer of the installed product and has received NW Ductless Heat Pump Project
installer orientation. By signing this, the General Contractor/installer has read and understood the terms and conditions printed on the back of this form and/or Project
information on the NW Ductless Heat Pump Project website (www.goingductless.com).
Who is the best person to contact
Signature: By checking this box you are providing
a signature and agreeing to the above terms.
Employee Name (Installer) & Installing Company/Sub-Contractor:
Phone: ( ) - Work Cell
Alternative phone: ( ) - Work Cell
Yes, I have obtained a completed Homeowner Participation Form for this installation.
Yes, I have included a copy of the job sales invoice for proof of installation.
Yes, I have installed line hide (and UV tape as needed) on the entire length of exterior, insulated refrigerant lines (For details, see page 2.).
Yes, I have installed the system in accordance with Manufacturer specifications, and the NW Ductless Heat Pump Project Best Practices, including adherence to proper
Yes, I have all required licenses, registrations, certifications and permits for the work performed at the site address on this form.