Form 920C

Incentive Application ENERGY STAR®

Refrigerators, Freezers & Clothes Washers
Energy Trust Products Program
To be completed by Participant
Portland Energy Conservation, Inc. (PECI) is a Program Management Contractor for Energy Trust of Oregon, Inc.
i
This offer is valid for residential clothes washers with a modified energy factor (MEF) of 2.0 or higher and FastTrack ID (program use only)
®
residential ENERGY STAR refrigerators and freezers installed in Oregon for customers of Portland General
Electric (PGE), Pacific Power, NW Natural, and Cascade Natural Gas (refrigerator incentives are only for
Oregon customers of PGE and Pacific Power). To qualify for the clothes washer incentive, Participants with Project ID (program use only)
an electric water heater must be customers of PGE or Pacific Power and Participants with a gas water heater
must be customers of NW Natural or Cascade Natural Gas.
How to get your Energy Trust incentive ii :
n Purchase an ENERGY STAR qualified residential refrigerator or freezer or a clothes washer with a modified energy factor
(MEF) of 2.0 or higher between January 1, 2009 and December 31, 2009.
o Complete and sign this incentive application or visit https://forms.energytrust.org/920c/ for web form. Application must be
received by January 31, 2010.
p Mail the incentive application, and a copy of the itemized sales receipt, to:
ENERGY STAR Products Incentive
th
1400 SW 5 Avenue, Suite 700
Portland, OR 97201-5542
q Your incentive check will be mailed to you 4 to 6 weeks after your application is received.

Participant Information
First Last Daytime personal work
Name Name Telephone
Installation
City State Zip
Address
Mailing
City State Zip
Address

Clothes Washer Information (Must complete all information to process $75 or $100 incentive.)
Residential Serial
Brand Model
Clothes Washer Number
Incentive Levels: $75 for a CW with MEF 2.0 to 2.19 and $100 for a CW with a MEF of Serial number is located on the inside of the
2.2 or higher door or on the back left corner of the washer.

Refrigerator or Freezer Information (Must complete all information to process $50 incentive.)
Residential
Serial
Refrigerator or Brand Model
Number
Freezer
Qualifying refrigerators must be 20% or greater more efficient than Serial number is located on the inside of the
Incentive Level: $50 federal standards; freezers must be 10% or greater more efficient. door or on the back left corner of the machine.

Utility Information (Must complete all information to process any incentive.)

Electric Utility Account Number Gas Utility Account Number
Pacific Power – Cascade –
PGE – NW Natural –
Other Other
Water Heater electric gas Clothes Dryer electric gas

Signature
By signing below, I certify that all information on this form is true and correct to the best of my knowledge. I also represent that I have
read, understood and agreed to the terms and conditions herein.
Participant
Date
Signature

Form 920C v12 090528 Return completed form to: Page 1 of 2

Energy Trust Products Program
1400 SW 5th Avenue, Suite 700 ♦ Portland, Oregon 97201-5542
1-877-283-0702 ♦ fax 1-877-501-9629
energytrust.org
 Form 920C
Incentive Application ENERGY STAR®
Refrigerators, Freezers & Clothes Washers
Energy Trust Products Program
To be completed by Participant
Portland Energy Conservation, Inc. (PECI) is a Program Management Contractor for Energy Trust of Oregon, Inc.

Additional Terms and Conditions

ELIGIBILITY: Incentives are available to Oregon residential electric service customers of Portland General Electric (PGE) and
Pacific Power and Oregon residential natural gas service customers of NW Natural and Cascade Natural Gas. To qualify for
the clothes washer incentive, Participants with an electric water heater must be customers of PGE or Pacific Power and
Participants with a gas water heater must be customers of NW Natural or Cascade Natural Gas. Incentives for refrigerators or
freezers must be installed in homes within the PGE or Pacific Power service territory. Sales receipt must be dated between
January 1, 2009 and December 31, 2009. Incentives are available for applications submitted within 90 days from the date of
purchase. Limited to one incentive per clothes washer, refrigerator or freezer. Regardless of date of purchase, no incentive
applications will be accepted after January 31, 2010. Neither Energy Trust nor Portland Energy Conservation, Inc. (PECI)
shall be responsible for lost or misdirected mail.
NO ENDORSEMENT: In promoting ENERGY STAR Products, Energy Trust does not endorse any particular manufacturer. The fact
that the names of particular manufacturers, equipment or systems may appear on this Application does not constitute an
endorsement. Manufacturers, contractors, equipment, or systems not mentioned are not implied to be unsuitable or defective in any
way.
TAX LIABILITY: Energy Trust is not responsible for any tax liability, which may be imposed on the Participant as a result of
payment of any incentives. Energy Trust is not providing tax advice, and any communication by Energy Trust is not intended or
written to be used, and cannot be used, for the purpose of avoiding penalties under the Internal Revenue Code.
ENERGY INFORMATION RELEASE: Participant authorizes Energy Trust to access energy usage data relating to the property at
which the energy efficient product is installed by accessing the electric and natural gas accounts at the physical address of the
project. Participant agrees to provide other reasonable assistance to Energy Trust to obtain such information.
DISCLAIMER / NO LIABILITY: Participant understands that, while Energy Trust is providing funding for the incentives payment,
Energy Trust is not supervising work performed for Participant nor is Energy Trust responsible in any way for proper product
installation, completion of that work or proper performance of any product purchased. Energy Trust is simply providing funding to
assist Participant in implementing energy efficient measures. Energy Trust does not guarantee any particular energy savings results
by its approval of the Application or by any other of its actions.

i
Modified Energy Factor (MEF) measures the energy used during the washing process, including machine energy, water heating energy, and dryer
energy. The most efficient clothes washers have the highest MEF ratings.
ii
Many premium efficiency refrigerators and clothes washers also qualify for an Oregon Residential Energy Tax Credit. For information, visit
http://egov.oregon.gov/ENERGY/CONS/RES/tax/appliances.shtml.

Form 920C v12 090528 Return completed form to: Page 2 of 2

Energy Trust Products Program
1400 SW 5th Avenue, Suite 700 ♦ Portland, Oregon 97201-5542
1-877-283-0702 ♦ fax 1-877-501-9629
energytrust.org