2009 CASH REWARD CLAIM FORM— IOWA

INDOOR LIGHT FIXTURE, CEILING FAN AND OCCUPANCY SENSORS

You must complete all information to avoid claim denial or processing delays. (Cut from
product box) "
CUSTOMER INFORMATION
Person or Company Receiving Cash Reward Mailing Address (if different than installation address)

Installation Address City State Zip

City State Zip Name on IPL Account

IPL Account No. (at installation address) Contact Person Phone No.
_ _ _ _
( )
Residential Building Type Approximate Year Building Was Constructed (required)
❒ Single-Family ❒ Manufactured Home ❒ Apt./Condo (3+ Units)
Non-Residential Building Type (check only one)
❒ Type #1 ❒ Type #2 ❒ Type #3 ❒ Type #4 ❒ Type #5 ❒ Type #6
Convenience Store Apt./Condo (3+ Units) Church Education Industrial Agriculture
Grocery Hospital Health Clinic Office Farm Building
Warehouse
Restaurant Lodging Other Commercial Retail

Tax Status
❒ Residential ❒ Sole-Proprietor* ❒ Partnership* ❒ Government ❒ Non-Profit ❒ Corporation ❒ Religious
*If sole-proprietor or partnership, you must provide a Social Security or Federal Tax ID number and the associated legal name listed on the document.
SSN or Fed. Tax ID: Legal Name:

ENERGY STAR® INDOOR LIGHT FIXTURE INFORMATION

Complete for each fixture. Maximum of 5 fixtures per residential customer. For non-residential replacement projects >8 fixtures, call 1-866-255-4268 for cash rewarad
details and alternative claim form. Bulb only purchases do not apply.
Lamp Type
(Choose from the # of Lamp Equipment
Manufacturer Model# list below) Lamp Wattage Units Purchase Price
________________________ ________________________ _________________ ________________ _____________ $____________________
________________________ ________________________ _________________ ________________ _____________ $____________________
________________________ ________________________ _________________ ________________ _____________ $____________________
________________________ ________________________ _________________ ________________ _____________ $____________________
________________________ ________________________ _________________ ________________ _____________ $____________________
Cash Reward: $20.00 x ________________ = $____________ Cash reward amount will not exceed 50
Lamp Type: Linear, square, circular, CFL, fan kit Total # of fixtures percent of equipment purchase price.

OCCUPANCY SENSOR INFORMATION

Manufacturer Model# Purchase Price # of Units
_____________________________ _____________________________ $_________________________ __________________
Cash reward amount will not exceed 50
Total # of units x $20 per unit = $_________________________
percent of equipment purchase price.
Cash Reward

ENERGY STAR CEILING FAN ENERGY STAR CEILING FAN

ENERGY STAR CEILING FAN WITH LIGHT KIT LIGHT KIT (Light Only)
Complete for each fan *. Complete for each fan *.
Complete for each fan *.
Manufacturer Purchase Manufacturer Purchase
Manufacturer Purchase Equipment Model# Price
Equipment Model# Price Equipment Model# Price
____________ ____________ $____________ ____________ ____________ $____________
____________ ____________ $____________
Bulb wattage No. of Bulbs Bulb wattage No. of Bulbs
____________ ____________ $____________
____________ ____________ ____________ ____________
Cash Reward: $20.00 x number of ceiling fans Cash Reward: $40.00 x number of ceiling fans Cash reward: $20.00 x number of light kits

* Maximum of 5 ceiling fans per customer account, per year. Cash reward amount will not exceed 50 percent of equipment purchase price.

CUSTOMER AGREEMENT
I certify that this lighting equipment was purchased between January 1, 2009 and December 31, 2009, and installed by February 28, 2010. All statements made in this application
are correct. I agree to the terms and conditions in the 2009 Cash Rewards booklet.
Customer Signature Date Donate your cash reward to IPL’s Hometown Care Energy Fund and help
local families in need (tax deductible). ❒ Yes ❒ No
Cut out the UPC code(s) and ENERGY STAR logo(s) from each product box (light fixture and ceiling fan only), include model number(s) and copy of itemized sales receipt, along with
completed claim form and mail within 90 days of installation to: IPL • Energy-Efficiency Programs • P.O. Box 351 • Cedar Rapids, IA 52406-0351
FM-0623 REV. 2 LTNG IA 01/09