Appliance Rebate Form

Marketing Partner Dollar Reimbursement Request APPLIANCE REBATE CO-OP: PAULDING PUTNAM ELECTRIC CO-OP, INC.

Installing Contractor : (Company) (City)

(state)

(Zip)

Customer Name and Address REBATE OR PRODUCT INCENTIVE $ AMOUNT PAID TO MEMBER:

Contact Number

_____________________________

Date Installation was completed

$ __________________

______________________________

APPLICABLE PROGRAM TYPE (please check one)  Energy Efficiency

 Appliance Rebate

 Touchstone HOME

 Demand Response

WATER HEATER (Manufacturer)

Size of tank

Water Heater Rebate $  New home OR REPLACES:  Electric  Propane

(Model #)

gal.

Size of elements

New Radio-Controlled Switch installed?

 Gas  Fuel Oil

Watts

 Yes  No

RCS Serial number: _____________ Tone:___________

COOL RETURNS A/C CONTROL (RCS) A/C Control Rebate $ Ton (Manufacturer)

   

(Model #)

(Eligible for 50% paid to customer up to $50 per RCS)

(Size)

System Type:  Central Air  Heat Pump  Geothermal RCS Serial number: ________ Tone:_____ Approximate Size of Home:  under 800 sq. ft.  801-1500 sq. ft.  1501-2500 sq. ft.  >2500 sq. ft. Approximate Age of Home:  5 years or less  6 to 10 years  11 to 20 years  over 20 years Home Type:  2 story  1½ story  Ranch  Mobile Home  Manufactured Home  Office/Business  Other

Installing Contractors Signature:

______________________________________

Date: ______________________

Certification This is to certify that we have provided an appliance rebate or product incentive for the installed system as designated above and are requesting reimbursement from the Marketing Partner Dollars program.

Signed:

Date: (Cooperative Representative)

PLEASE RETURN TO: Paulding Putnam Electric Cooperative, Inc. 910 N. Williams Paulding, Oh 45879