Home Energy Evaluation Form

Name*

DMEA account number*

Email*

Phone*

Address*

Apartment, suite, etc.

City*

Zip*

Monthly kilowatt hour (kWh) use*

Coffee maker

Convection oven

Electric oven

Refrigerator (apartment size or under counter)

Refrigerator (standard size)

Please list any other important information about how you use electricity in your kitchen, such as under sink water heaters or additional large appliances.

Air conditioner

Air conditioner - central air (tons if known)

Air source heat pump - system size (tons if known)

Electric baseboard heat - total length of baseboards (feet)

Electric ceiling heat - house square footage (sq. feet)

Fan(s)

Fireplace - electric - 1500 Watt

Furnace - electric - size (kW) or circuit breaker amps

GeoExchange heating cooling system - system size (tons)

Heat tape (number of feet)

Humidifier

Space heater - portable - 1500 Watt

Stove (space heating) - electric (watts)

Swamp cooler

Please list any other important information about how you use electricity to heat or cool your home.

Clothes dryer

Electric water heater - list number of people

Freezer

Hot water recirculation pump

Sewage ejector or lift pump

Sump pump - to remove water from under house

Water pump - domestic water for whole house

Computer

Oxygen concentrator

Television

Whirlpool bathtub

Waterbed

Lighting - total number of standard incandescents

Lighting - total number of compact fluorescent bulbs

Lighting - total number of LEDs

Fish tank (list number of gallons)

Please list any other important information about your home's indoor energy use.

Hot tub

Air compressor - floor mounted

Engine heater - truck, car, tractor or utility

Battery charger - 6 volt or 24 volt for deep cycle batteries for golf cart, etc. (list quantity of each)

Battery charger - electric vehicle - Chevrolet Volt, Tesla, etc.

Welder / welder type

Christmas / outdoor lights

RV plugged into house

Stock tank heater

Well pump irrigation

Yard lights

Please list any other important information about your outdoor energy use.

Other: Do you have any unique circumstances we should know about, such as a home business that requires equipment or additional medical equipment?

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