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Office Use Only Rebate

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ENERGY STAR® Qualified Residential Appliance Rebate Application
Please complete form and sign/date below. All information is required to process rebate(s). Incomplete forms will be returned to the applicant. This will delay rebate processing. Customer Information
Customer No. Applicant Name Relationship to CLPUD Customer (if not account holder) Installation Address City Mailing Address City State BRAND MODEL NUMBER QTY Zip Account No.
(Required)

Month/Year:

Date Are you the account holder? Yes No

Family Member

Landlord

Tenant

Other (please specify) _______________ Phone State Zip

PRODUCT INFORMATION REFRIGERATOR
Must be ENERGY STAR qualified

REBATE AMOUNT $25 7.75 Cu Ft or greater $25 7.75 Cu Ft or greater

STAND-ALONE FREEZER
Must be ENERGY STAR qualified

CLOTHES WASHER
Must be ENERGY STAR qualified and have a minimum 2.0 MEF Water heater type: Electric Gas Water heater must be electric to qualify. Dryer type: Electric Gas No rebate available for clothes dryers.

$70 MEF 2.0 or greater

TOTAL
APPLIANCE PURCHASE TIPS  ENERGY STAR qualified appliances use 10% to 50% less energy than other appliances  Go to http://www.energystar.gov/ for a list of qualifying appliances
Upon signing this agreement, customer acknowledges the following: This rebate offer may be discontinued at any time by Central Lincoln PUD (CLPUD). CLPUD disclaims any warranty, whether expressed or implied, regarding the product(s) listed above for any materials or labor associated with installation, maintenance, repair, or any energy savings associated with its use. Rebate offer applies to new product(s) only. CLPUD reserves the right to inspect all installed product(s). Product(s) must meet all program criteria to qualify for rebate(s). Rebate(s) under $100 will be issued in the form of a credit on the customer’s utility bill. I understand the above and certify that I am a customer of CLPUD and the above mentioned product(s) are installed and operating at the location indicated above.

SIGNATURE

DATE

Mail or fax completed application, legible copy of purchase receipt(s) and copy of Energy Guide label to: Central Lincoln PUD Attn: Energy Efficiency Rebates 4120 SE International Way #A211 Milwaukie, OR 97222 FAX: 1-503-344-6942
Participation in this energy efficiency program allows Central Lincoln PUD to use your electrical energy consumption history for energy savings research. Your consumption history may be shared anonymously with Bonneville Power Administration for energy savings verification and research.

Rebate Applications are due within six (6) months of purchase to qualify. Allow 8-10 weeks for processing.

Call 1-888-883-9879 to learn about additional energy efficiency programs.
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