Legal Business Name / Bank Council / Tribal Council / First Nations Business incorporation no
Federal Provincial Territorial
Last Name First Name Middle Name Telephone no. (including area code) Email Street name and no. City Province Postal code
Street name and no. City Province ON Postal code Municipal tax roll no. House file no.
Street name and no. City Province Postal code
Quoted Price of my Home Energy Audit is $ − Less any discounts $ =$ , the eligible cost of the Home Energy Audit
If the Eligible cost is greater than/equal to $300: Home Energy Audit Grant = $150.00
If the Eligible cost is less than $300: Home Energy Audit Grant = Eligible cost $ × 50% = $
Authorized Agent’s Name Signature Date
On behalf of the Service Organization, I performed the Home Energy Audit on the residence referenced in this application, and I confirm that the information contained in this form is accurate and identical to the information in the electronic file being transferred to NRCan and the Government of Ontario.
Service Organization Name Service Organization Telephone Number Energy Advisor’s Name Signature Date of Audit
Please mail this completed form to the Ontario Home Energy Audit Program Office, Ministry of Energy, 880 Bay Street, 3rd Floor, Toronto, ON M7A 2C1. Service Organization and Homeowner are to retain a copy of this completed form.