Draft
Example Mitigation Plan
Acme, Inc.
Firewood, ME
Wood Burning Appliance Replacement and Retrofit
Project Mitigation Plan
October, 2011

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Pursuant to Section VI and Appendix B) of the Consent Decree ("Consent
Decree") between the United States of America and Acme Inc. (collectively,
"Defendants"), this work plan describes the method by which Defendants will
implement a Supplemental Environmental Project ("SEP") or Mitigation Plan
consisting of sponsorship of a wood burning appliance replacement and
retrofit project (the "Project") in specified geographical areas in New
England. As authorized by the Consent Decree, Defendants will utilize a
third-party non-profit agency - the WE CAN HELP Association (WCHA) of
New England - to implement the Project. The Project is intended to achieve
reductions in fine particle pollution and/or hazardous air pollutants in both
indoor and outdoor air by replacing or retrofitting older non-EPA
certified/qualified wood stoves, hydronic heaters (a.k.a. outdoor wood
boilers) and fireplaces with new, cleaner burning devices (for example
Energy Star gas furnaces, EPA certified wood stoves, gas stoves, or wood
pellet stoves).
I.	IDENTIFICATION OF THIRD-PARTY NON-PROFIT SELECTED TO
IMPLEMENT THE PROJECT
Defendants have selected the WE CAN HELP Association of New England ("WCHA"), a not-
for-profit voluntary health organization whose mission is "to save lives by preventing air
pollution" to implement the Project. The WCHA works to achieve its mission through research,
education and advocacy, and has an impressive record of successfully promoting initiatives to
improve air quality throughout New England.
II.	SCHEDULE AND BUDGETARY INCREMENTS FOR FUNDING OF
WCHA
Pursuant to the Consent Decree, Defendants are required to spend no less
than $xxx,000 in Project Dollars (as such term is defined in the Consent
Decree) to perform the Project, and must limit the use of Project Dollars for
administrative costs to no greater than 10% of the Project Dollars.
The WCHA has agreed to implement the Project for the sum of $xx,000
("Administrative Fee"), meaning that $xxx,000 will be used for the retrofit or
replacement of non-EPA certified wood stoves, fireplaces, old technology
outdoor wood-fired hydronic heaters) with, cleaner burning, more energy-
efficient heating appliances (e.g., Energy Star qualified geothermal heat
pumps and natural gas furnaces, wood pellet stoves, gas stoves, EPA-
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certified energy efficient wood-stoves or EPA qualified fireplace and
hydronic heater retrofit devices).
Defendants will disburse the Administrative Fee to the WCHA according to
the following schedule:
	50% of the Administrative Fee within 30 days of the final EPA approval
of this Project work plan;
	an additional 25% of the Administrative Fee on the six-month
anniversary of the date of first payment, as set forth above; and
	the remaining 25% of the Administrative Fee upon completion of the
Project, i.e., when all Project Dollars are spent.
Funding for Rebates
WCHA will receive the funding from Defendants to pay for the voucher
rebates involved in the Project. The WCHA will issue checks or electronic
funds transfer to the qualified dealers once it receives the documentation
described elsewhere herein. WCHA will set up a restricted account and will
bill Defendants monthly. Note: this is one option there are other ways to
manage the transfer of funds.
III. SCHEDULE FOR SUBMISSION OF REPORTS BY DEFENDANTS
Pursuant to Paragraph 31 of the Consent Decree, within thirty (30) days of
the end of each calendar quarter after lodging of the Consent Decree,
Defendants are required to submit quarterly reports for the preceding
calendar quarter. Defendants shall include within each quarterly report a
summary of the following activities and information:
1. Activities Conducted During Reporting Period
	Description of educational outreach activities conducted by the
WCHA
o media spots
o web outreach
o brochure development/distribution
	Number of applications for new, cleaner burning devices received
	Number of applications for new, cleaner burning devices
accepted
o geographic location of each accepted application
	Number and type of cleaner burning appliances
	Number of older appliances retrofitted
	Number of older appliances removed
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	Method/location of disposal or recycling of older appliances
replaced
	Total project dollars spent during the quarter and cumulatively
o type/amount of reimbursement
For each older appliance removed, documentation concerning the disposal of
such device shall be appended to each quarterly report, or, if not yet
available, shall be included with the next quarterly report.
2.	Anticipated Activities for the Next Reporting Period
3.	Project Percentage Completion (Approximate)
IV.	ACTIONS TO ENSURE THE WCHA WILL IMPLEMENT THE
PROJECT IN ACCORDANCE WITH CONSENT DECREE
Defendants and the WCHA have extensively discussed the Project
requirements imposed by the Consent Decree, including the requirements in
Appendix B thereto. As a result of these discussions, Defendants and the
WCHA have agreed that this work plan will serve as the agreement between
the two parties with respect to the Project.
V.	ELEMENTS OF PROJECT TO BE IMPLEMENTED BY WCHA
The objective of the Project is to achieve maximum air quality benefits
through the use of $XXX,000 in project dollars for the retrofit or replacement
of non-EPA certified stoves, old technology hydronic heaters and open
fireplaces with new, cleaner burning heating appliances and retrofit devices.
The geographical area of Project implementation is limited to Money,
Hopscotch and Rockfish counties in NE (the "Geographic Area").
1. General Approach to Project Implementation
The WCHA plans to implement the Project using a staff coordinator who will
work with WCHA State Director of Health Promotion and Public Policy for
New England to oversee the Project in the Geographic Area. The WCHA's
Project outreach will rely heavily on earned media (news articles, letters to
the editor, op-ed submissions, radio/television interviews, etc.). The WCHA
will use its Leadership Board members in NE as spokespersons for the
Project and to attract key partners, volunteers and customers.
Potential Partners:
The WCHA will promote the Project in the (Name geographic area) by
focusing on participating heating appliance retailers, chimney sweeps, pellet
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suppliers, major businesses, health and medical care organizations, fire
departments, media representatives, social service groups and others who
can reach large numbers of people and may share its goal of improved air
quality and public health. (See section 2b for more detail). Co-marketing
the Project with these key organizations will be a key strategy for public
education and participant recruitment. As an example, the WCHA is an
active member of the Asthma Health Improvement-Asthma Educator
Network in Snow Fall Valley Asthma Coalition. Due to the potential for
significant reduction in indoor and outdoor pollution from the Project, the
asthma coalition is likely to be very helpful in promoting the Project among
the asthma educators in New England.
Website:
The WCHA's website will be updated to feature the Project and serve as the
key point of entry for information for participants as well as participating
retailers. The WCHA will also ask its partners to use their websites and email
lists to promote the Project and to link to the WCHA site.
Toll-free Line:
The WCHA's toll-free telephone Helpline will enable interested participants
and potential partners and sponsors to get information and become
involved.
Posters and Brochures:
Posters and brochures used in the previous projects and provided by EPA will
be modified for this Project and distributed through the retailers and in other
community locations. These posters and brochures will be forwarded to the
EPA for review and comment prior to distribution.
Media Outreach:
Given the funding level available for administration and advertising for the
Project, the WCHA will implement a project marketing plan that will rely
largely on "earned" media (e.g. news stories, letters to the editor, op-ed
submissions, talk radio, company newsletters and email blasts, etc) as a way
of educating the public about the advantages of cleaner burning stoves,
proper operation and publicizing the Project. There are a number of media
outlets servicing the Geographic Area and the WCHA's Project Coordinator
will reach out to those listed in Appendix A.
Retailer Information:
The WCHA will work with the Hearth Patio and Barbeque Association whose
New England office can help recruit retailers. The WCHA will supply its
participating retailers with EPA "Burn Wise" materials (e.g., Wet Wood is a
Waster brochure) to be distributed with each new wood burning appliance to
stress the need to burn wood properly. Whenever possible, the WCHA will
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also take advantage of opportunities from any of its participating retailers to
obtain sponsored advertising.
2. Specific Program Components
a. Partnership Development
Heating Appliance Retailers:
The most essential partnership is with retailers that sell and install wood-
burning appliances, retrofit devices and other heating appliances in the
Geographic Area. The WCHA will identify heating appliance retailers who are
interested in participating. The WCHA will formally enlist them through a
written agreement that will identify the retailer as a participant.
The agreement will stipulate:
a)	that they will accept the Project vouchers as an instant rebate;
b)	follow best practices in appliance installation procedures, and
c)	attest that they will remove and properly recycle or dispose of older
stoves.
Only qualified retailers with signed agreements will be used by the Project
(see Appendix B). Retrofit or replacement of new, cleaner burning appliances
will be done by professionals in conformity with all applicable state and local
codes and/or be installed by certified by professionals, (e.g., National
Fireplace Institute, the Chimney Safety Institute of America, or an
equivalent organization). This is noted on the voucher application form (see
Appendix C).
Business Community:
Another key partner will be the business community in the Geographic Area.
The WCHA will contact the local Chambers and other traditional community
service organizations, such as the local Rotary Clubs, Lions Clubs, etc.
These organizations are a good point of entry into the local business
community and are often looking for educational programs for their
membership. The WCHA will seek the assistance of these groups and their
members to promote the Project among their employees, customers, family
and friends.
Some businesses may want to supplement the "rebate" being provided as a
way of helping their employees purchase retrofit or replace non-EPA certified
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stoves with new, cleaner burning technologies. Pellet manufacturers will be
approached directly and/or through the stove retailers and asked to consider
giving away a supply of pellets or providing some other incentive to Project
participants who purchase pellet stoves. This same approach will be taken
with gas suppliers.
Health Care Providers:
The WCHA has relationships with many health care providers and institutions
in the Geographic Area. The WCHA intends to work closely with its health
care system colleagues who will be asked to have their institutions or
companies promote the Project among staff and the communities they serve
by stressing the health improvement aspect of the Project.
The improvements in indoor air quality from the Project are potentially
substantial (over 70% reductions in particulates). This information will be
especially useful to anyone with a chronic illness who is currently burning
wood using an older stove and to those health care providers, like home
oxygen companies or home health aides, who provide services to those with
chronic illnesses.
b. Education and Outreach
As stated above, the WCHA will use its relationships in the Geographic Area
as key distribution channels for education and for promoting Project
participation. While this is one venue for education and outreach, the WCHA
is also very skilled in educating the public on a variety of health issues
through "earned media." WCHA will use its existing clipping service and
other means of tracking media impressions. Project staff will make personal
contact with the key media in the Geographic Area.
Kick-off Event:
The WCHA believes the media will find the Project to be newsworthy and can
be persuaded to report on it periodically. The WCHA plans to conduct a
Project kick-off press conference, to not only publicize the Project, but to
identify media contacts who seem especially interested in the Project.
The WCHA will invite an EPA spokesperson to this event to highlight the
Project's national, regional and local significance. Participating retailers will
also be invited, as will a representative of Acme Inc. The WCHA will
consider doing a "soft launch" of the Project where a limited number of
vouchers would be issued and redeemed prior to the Project kick-off to allow
it to have some "real life" stories shared at the press event. The Project has
many interesting angles for the media to highlight from its air quality
impacts to the human interest story appeal of replacing an older stove for a
low-income family, possibly even one with a child suffering from asthma.
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Communicating the Benefits: The WCHA will provide educational outreach
about: the Project and the benefits of retrofitting or replacing non-EPA
certified stoves with new, cleaner burning appliances; proper operation and
installation of the cleaner burning appliances and a description of the
financial incentives of the Project. The WCHA will use the tools outlined in
the Section V 1. above and work with the partners previously identified to
raise awareness about the program and its benefits.
The WCHA will use the existing educational resources on the EPA website at
http://www.epa.gov/burnwise on how to burn wood properly and adapt
program promotional material from other change-out projects. In addition,
there are excellent consultative resources available at the EPA, the Hearth,
Patio and Barbecue Association and the Chimney Safety Institute of America
that will be helpful. The WCHA will also prepare a simple presentation about
the Project that is localized to the Geographic Area and can be used by the
Project coordinator, the ALA in New England Leadership Board members,
volunteers, and others for public talks.
c. Project Operation
The WCHA will assume sole responsibility for the operation and management
of the Project (see draft timeline Appendix D). This will include, but not be
limited to, the following:
	Recruitment, hiring and supervision of Project staff;
	Preparation, distribution and processing of applications for wood-
stove replacement vouchers from homeowners using a form from
our Massachusetts project (see Appendix C );
	Administration of the financial incentive program:
o The WCHA will issue vouchers to homeowners based upon
receipt of a completed application form that includes a
certification section in which the applicant agrees to a number
of requirements for participation (see Appendix E).
o This voucher will be redeemed only at participating retailers
with whom the WCHA has signed agreements and who are
using its Voucher Tracking Form (see Appendix F) to get
reimbursed. Among those requirements are the following:
 attesting that an operating older stove will be
retrofitted or replaced with a new, cleaner burning
device;
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	that the older device will be removed and properly
recycled by the retailer;
	that the replacement device will be purchased prior to
the voucher expiration date (usually 3-4 weeks) and,
	a picture before and after installation will be submitted
to WCHA.
	Voucher Tracking:
o Participating retailers will submit the Voucher Tracking Form
to redeem each voucher.
o The tracking form will be sent to the WCHA, along with the
before and after photos, the original voucher, an invoice for
the purchase, validation that the older stove was recycled, as
required.
o The Voucher Tracking Form and accompanying documentation
will be scanned and emailed to the WCHA's contact at
Defendant's office for review and approval.
o Upon approval, the WCHA project coordinator will submit the
paperwork to the WCHA business office for payment.
	Proper Operation and Education:
o Retailer must ensure the recipient of the new
appliance/retrofit purchased through this incentive program
reviews/demonstrates proper operation of the new appliance.
o Retailer must provide educational materials (e.g., Burn Wise
fact sheet, brochures) and explain the benefits (e.g., lower
emissions, better efficiency) of proper wood burning
techniques, including the use of dry seasoned wood for wood
burning appliances.
	Wood Burning Replacement Options
o Non-EPA certified wood burning appliances stoves must be
replaced by a new cleaner burning appliance/retrofit devices
(e.g., gas stove or furnace, pellet stove, EPA certified wood
stove, EPA qualified hydronic heater)
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o The plan is to allocate the resources available to retrofit or
replace stoves, as follows (this is subject to modification as
the Project moves forward):
Vouchers for wood burning appliance replacement options include the following:
Wood-stove, Fireplace/Boiler Replacement Options
Incentive
1
Energy Star qualified geothermal heat pumps, EPA
Phase 2 hydronic heaters (Biomass wood pellets;
continuous feed fuel only)
Up to $6,000
2
Hydronic heater retrofit kit (heaters must be less than 7
years old)
Up to $2,000
3
Energy Star natural gas boilers and gas furnaces
Up to $2,500
4
EPA certified wood-stoves (4.5 gram/hour or less)
Up to $1,000
5
Gas or wood pellet energy efficient hearth appliances
Up to $1,750
6
EPA Qualified retrofit device or gas appliance for open
fireplace
Up to $500
* Program may want to include EPA Phase 2 qualified hydronic heaters.
 Reporting
o WCHA shall ensure that the report includes materials and/ or
verification of compliance with the Consent Decree and spells
out the public benefits.
o With respect to Acme Inc.'s quarterly reports due under the
Consent Decree, WCHA shall complete and submit such
reports not later than the 10th calendar day of the month in
which the report is due.
Compilation and reporting on a participant satisfaction survey (see Appendix
F)
Appendices
A.	Geographic Area Media Outlets
B.	Retailer Application Form
C.	Voucher Application Form
D.	Project Timeline
E.	Voucher Tracking Form
F.	Participant Satisfaction Survey
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APPENDIX A
Project's Geographic Area Media Outlets
Location: Grand County
Name of Print	Contact Information
Daily Times	doe.iohn@dailytimes.com
Weekly Herald	smith.iohn@weeklyherald.com
TV
List of TV networks
Radio
List of Radio stations
Location: Lincoln County
Name of Print
Daily Times
Weekly Herald
TV
List of TV networks
Radio
stations
Contact Information
doe.iohn@dailytimes.com
smith.iohn@weeklyherald.com
Contact Information
Contact Information List of Radio

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Appendix B - Retailer Application Form
Pa rties: This Retailer Agreement ("Agreement") is for services between the WE CAN
HELP Association of New England (""WCHA"). 45 Ash St. Hartford CT 06108, and
	, of	(hereinafter
called ""Subrccipient"). effective as of the last date indicated below.
Subject Matter: The subject matter of this Agreement is a wood stove change-out
program. Detailed services to be provided by the Subrecipient pursuant to this Agreement
are described in Attachment A, which is incorporated by reference herein.
Maximum Amount: In consideration of the services to be performed, the WCHA
agrees to pay Subrecipient, in accordance with the payment provisions specified in
Attachment A, a sum not to exceed $1,000 per new EPA certified wood stove replacement
voucher; $1,750 for a new pellet or gas stove voucher; $6,000 for a new cleaner burning gas
furnace, geothermal, EPA Phase II hydronic heater voucher and up to $2,000 for a retrofit
voucher Agreement Term: The period of Subrccipient's performance shall begin
upon date of execution, signified by the date of signature by the WCHA, and end on or
before June 30, 2013 or, if earlier, the date on which all Project Dollars are spent.
Amendment: No changes, modifications, or amendments in the terms and conditions
of this Agreement shall be effective unless reduced to writing, numbered, and signed by the
duly authorized representative of WCHA and Subrecipient. Any request for an amendment
to this Agreement must be made in writing at least 30 days prior to the end date of this
Agreement or the request may be denied.
Cancellation: This Agreement may be cancelled by either party by giving written
notice to the other at least_30days in advance; provided , however, that WCHA may
terminate this Agreement immediately for reasons stated in Attachment A, incorporated by
SubreciDient Proaram Contact:
Name:
Phone:
E-mail:
SubreciDient Fiscal Contact:
Name:
Phone:
E-mail:

WCHA's Proaram Contact:
Name: Jane Doe
Phone: (207)624-0000
E-mail:
WCHA's Fiscal Contact:
Name: John Doe
Phone:(860)838-0000
E-mail:
Attachments: This agreement also consists of the following attachment(s) that
are incorporated herein: Attachment A - Standard WCHA Provisions
 Attachment B - Voucher Tracking Form
WE CAN HELP Association of New England:
Date:
John Smith, President and CEO

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APPENDIX C
VOUCHER APPLICATION FORM
1. Entire
How the Rebate Program Works
1.	WCHA is offering rebate vouchers valued between $1,000 and $4,000 to homeowners in
Hopscotch, Rockfish and Money Counties in New England for retrofit or replacement of
non-EPA certified wood stoves or hydronic heaters (a.k.a. outdoor wood boilers) and
with new, cleaner burning devices.
To qualify for a rebate voucher, the homeowner must first complete the application
below. Applications for rebate vouchers will be accepted until March 31, 2013 or Project
Dollars are depleted. Please include a photo of the currently installed older stove.
Completed applications must be signed by the homeowner and mailed to the program
coordinator at the address below.
2.	The Southern New England Wood Burning Change-out Project Coordinator will review
the applications to determine if the preliminary qualification requirements have been
met. Qualified applicants will receive a rebate voucher worth $1,000 for a new EPA
certified wood stove, $1,500 towards a new pellet or gas stove, $6,000 towards a new
EPA Phase II hydronic heater (see modification on page 9), or up to $2,000 for a retrofit
device. Rebate vouchers will be valid for four (4) weeks. Special low income vouchers of
up to $3,000 are available to those who can show proof of participation in the Low
Income Heating Assistance Program, Women Infants and Children Supplemental Food
Program, or state Medicaid and the time of application.
3.	The homeowner may use the rebate voucher to retrofit or replace a non-EPA certified
stove with a new, cleaner burning device from a participating retailer only, provided the
voucher has not expired. Vouchers will be applied as an instant rebate off the total price
of the stove. No retroactive rebates are allowed. Voucher expiration date may be
extended at the discretion of WCHA.
4.	New, cleaner burning devices must be professionally installed in accordance with local
fire and building codes. The EPA recommends that installers be National Fireplace
Institute or Chimney Safety Institute of America certified (or an equivalent organization).
The installation must be coordinated and certified by the participating retailer. No do-it-
yourself installations are allowed under this program.

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5. Older stoves that were replaced through the program must be permanently removed
from service and surrendered to the participating retailer, who will render them
inoperable and coordinate their disposal and recycling.
6. The participating retailer will take a photo of the older stove prior to removing it and
will also take a photo of the replacement stove after it is installed.
VOUCHER APPLICATION FORM
All sections of this application must be completed. A copy should be retained by the
homeowner for his or her records. The rebate program is not responsible for materials lost by
mail. Please review the program terms prior to signing below and submit your completed
application with attachments by mail, or hand delivery to:
Jane DoeChange-out Project Coordinator
WE CAN HELP Association
122 State St
Firewood, IN, 47035
Applicant Information:
Name:	
Physical Home Address (where older stove is
located):	
Mailing Address (if different):	
Phone Number:	 Email (if available):	
Current Wood Burning Stove:
Make/Model:	Est. Year Stove Manufactured:	
~	I have included a picture of my older stove
~	I am applying for the following voucher: ~ Wood stove $1,000 ~ Pellet or Gas $1,750
~ Gas heater, $2,500
~	Geo thermal, Phase II OWB $6,000 ~ Retrofit - up to $2000

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Additional Information:
1. How did you hear about the Change-out Program?.
2.	Why are you applying? (Please check all that apply.)
~	Not satisfied with current device;
~	To reduce pollution;
~	To save money
~	Other:	
3.	Was the rebate a significant factor in replacing your stove?	~ Yes ~ No
4.	In a typical heating season, how many cords of wood do you typically burn?	
5.	Is your wood stove used as a primary source of heat?	~ Yes ~ No
6.	Do you know how old your stove is? If yes, how old:	years
CERTIFICATION:
I certify the following:
a.	I understand that only currently installed and operating non-EPA certified wood stoves are
eligible to be replaced under this program.
b.	I understand that participants are limited to receiving one rebate voucher per address.
c.	I understand that applications are processed in the order they are received. Rebates will be
distributed on a first-come, first-served basis. Funding is limited; rebates are not
guaranteed. The voucher will only be valid for four weeks from the date of its issuance. No
retroactive rebates are available. Voucher expiration date may be extended by at the
discretion of the WCHA.
d.	I understand that applications may only be accepted for residences in Rock, Mack and
Hillsborough Counties.
e.	I understand that if I qualify, I will receive a voucher and a current list of participating
retailers who will honor the voucher if it is submitted by the expiration date written on the
voucher.
f.	I will be retrofitting or replacing an operable non-EPA certified wood stove that is currently
in use in my residence. The participating retailer who installs the new device is responsible
for properly dismantling and disposing of the old device.
g.	If I choose to retrofit or replace a device with funds from this program, I will make a
commitment to purchase a device from a participating retailer within the four (4) week
period and authorize the retailer to forward to the WCHA a notification of the purchase
agreement, with verification that my existing wood stove is not EPA-certified.

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h.	I understand that devices purchased with funds from this program will be professionally
installed and that there will be additional costs for installation and a permit from my
community if required for installation. Installations must comply with all local fire and
building codes. The installers must be certified (e.g., National Fireplace Institute, the
Chimney Safety Institute of America, or an equivalent organization). The installation must
be coordinated and certified by the participating retailer.
i.	I understand that I am responsible to pay the retailer for the purchase price and
professional installation costs of my new device, less the rebate amount.
j. I understand that I will forfeit my voucher if I provide the WCHA with false information or
fail to obtain any required permit or if the required information is not submitted to the
WCHA prior to the expiration date listed on the voucher.
k. The WCHA does not warranty any devices purchased under this rebate program, including,
but not limited to, the quality, functionality or satisfaction of the device.
I. I understand that proper wood burning practices (e.g., burning only dry seasoned wood)
and proper stove installation and operation (e.g., maintaining a hot fire) are critical to the
effectiveness of my new device.
Applicant Signature:	
Date:	
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APPENDIX D
Project Timeline
DRAFT*
October 2011- November 2011
	Hire part time staff and recruit specific New England volunteers from
the board
	Recruit participating retailers
	Establish voucher rebate application process; tracking protocols and
retailer rebate procedures and educate retailers
	Create website as part of WCHA site
	Create and distribute posters/brochures
	Plan for official "kick-off" media event
	Peak promotion and installation period
	Earned media priority
	Presentations throughout the Geographic Area
December 2011- March 2012
	Continue to build awareness about the Project
	Business group presentations
	Focus on "Burnwise" education
	Human interest stories on satisfied participants
	Prepare for Spring "kick-off"

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April 2012- November 2012
	New season "kick-off"
	Emphasis on earned media and co-sponsored ads
	Heavy Project promotion period
	Assess Project success to date and modify, as needed
December 2012- August 2013
	Implement any necessary Project changes
	Continue project operations
	Compile final report and financials
	Close out Project

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APPENDIX E
VOUCHER TRACKING FORM
This form is to be completed by participating retailers * and sent to: Michelle Edwards, NH Wood
Burning Appliance Change-out Program, The WE CAN HELP Association, 122 State Street, Augusta,
Maine 04330. See "Checklist" on page 2.
Date:		Voucher #:	
Consumer's Name:	Phone:
Address:	City:	
County:	State:	 Zip:	
New Cleaner Burning Device
Manufacturer:	
Model:	
New Appliance Type:	Wood ~ Pellet ~ Gas ~	Other:
~	
Retrofit Description (if applicable):
Retailer Name:	 Phone	
Retailer Address:	
City:	State:	 Zip:	
Installation
Name of Certified Installer**:	
Old Non-EPA Certified Wood Stove
Manufacturer:	
Model:	
I certify that the old stove was not EPA-certified (NOTE You will ONLY be reimbursed for
replacing stoves that are NOT EPA certified:		Yes ~
I certify that the old stove was in-use prior to replacement: 	Yes ~
I certify that the installed device was new:	Yes ~
Page 2 of 2
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Recycling (for Replacement Projects):
I certify that the old wood stove has been removed from the residence:	Yes ~
I certify that the old wood stove's doors have been removed and hinges destroyed prior to
the stove's release to a recycling facility:	Yes ~
I certify that the old wood stove has been released to a recycling facility, with its doors
removed, and that the stove is to be destroyed:	Yes ~
Name of Recycling Facility:	
Signature (recycling facility):	
Date:	
I certify that the information contained on this tracking form is accurate and the form is
completely filled-out. I also agree that I must meet the program requirements and be a
participating retailer in order to receive reimbursement from the WE CAN HELP Association
in New England. This form must be submitted with ALL sections completed especially the
recycling section, along with the rebate voucher, a copy of the invoice, photograph of stove
prior to removing it AND of newly installed stove in order to receive reimbursement.
Name of Participating Retailer:	
Signature:	
* Participating retailers must be registered with the WE CAN HELP Association in New
England.
** EPA recommends that installers be professionally certified (e.g., Chimney Safety
Institute of America or National Fireplace Institute)
To assure quick processing, please make sure you send all items listed.
Checklist:
~	Rebate Voucher enclosed
~	Pre and post installation photos
~	Copy of invoice
~	Signature of recycler (on form)
~	Your signature (on form)
Mail all to: Jane Doe
NH Wood stove Change-out Program
WE CAN HELP Association
122 Main Street
Snow Valley,, Maine 04330
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APPENDIX F
Change-out Customer Satisfaction Survey
As a participant in the recent Wood stove Change-out Program with WCHA, please
take a few moments to reflect on your experience with the program. This survey is
designed to gather input regarding your satisfaction with the program and the
process.
1.	On a scale of 1-10 (with 10 being "most satisfied"), how satisfied were you
with the Wood stove Change-out Program as a whole?
~	1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10
2.	How did you hear about the program? (check all that apply)
~	A poster at a local business
~	A radio announcement
~	A newspaper ad
~	From participating dealer
~	Word of mouth
~	Other (please specify):	
3.	Do you think your rebate was too much, too little, or just right?
~	Too much	~ Too little	~ Just right
4.	What was your experience with the application process?
~	It was easy
~	It was confusing and/or difficult
~	It was difficult but I was able to easily get answers to any questions I had.
~	01 h e r (please specify):	
5.	If you have any suggestion(s) on how the application process could be
improved, please indicate
below:	
6. Where did you purchase your new appliance?
~ Name of local store #1 ~ Name of local store #2 ~ Name of local Store #3

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7. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you
with the participating dealer?
~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10
Comments:		
8. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you
with the INSTALLATION of your new heating appliacne?
~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10
Comments:	
9. On a scale of 1 - 10 (with 10 being "most satisfied"), how satisfied were you
with your new heating appliance?
~ 1 ~ 2 ~ 3 D4 ~ 5 ~ 6 ~ 7 ~ 8 D9 D10
Comments:	
10. After installing your new heating appliance, during this past heating season
did you notice any difference in heat output?
~	Yes, I noticed greater heat output
~	Yes, but the heat output seemed to be less
~	No, I did not notice a difference
~	Not applicable, due to timing of installation
~	O t h e r (please specify):	

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11.	After installing your new heating appliance, did you notice any difference in
the amount of fuel used?
~	Yes, I used less fuel
~	Yes, I used more fuel
~	No, I didn't notice any difference
~	Fueltype changed, so I was not able to compare
~	Not applicable because of timing of installation
~	01 h e r (please specify):	
12.	If still burning with wood, after the change-out, did you notice more or less
smoke coming from the chimney?
~	More	~ Less	~ About the same	~ Not sure I didn't notice
13.	After the change-out, did you notice more or less smoke INSIDE your home?
~	More	~ Less ~ About the same	~ Not sure I didn't notice
14.	Aside from the voucher, what was your main motivation for participating in
the program? If you choose more than one answer, indicate your 1st, 2nd,
3rd, etc. choice.
	Improved energy efficiency
	Improved indoor air quality
	Improved outdoor air quality
	Improved safety
	Less time and energy handling wood
	Other	
15. What suggestions would you make to improve the
program?	
Thank you for taking the time to complete this survey. Your answers
will help improve future wood stove change-out programs, should
funding become available.

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