Mh Rebate Application

Residential Energy Efficiency Program ENERGY STAR® Manufactured Home Rebate Application Offer through September 30, 2009 or until funding expires

APPLICATION INSTRUCTIONS 1. Complete Application 2. Attach a copy of your Certificate of Compliance 3. Return to Benton PUD within 30 days of purchase Applicant Name (please print)

Site Address

City

Payable To

Mailing Address

Zip

Unit/Apt.

Benton PUD Account ID

City

Zip

Phone Number

*Rebate available on electrically heated homes only *All rebates are subject to change

ENERGY STAR® Manufactured Home Rebate: $750 Manufacturer Heating & Cooling System Heat Pump

REN00074

Furnace with Central Air Conditioning REN00072

Furnace without Central Air Conditioning REN00084

Serial No. Floor Area (sq. ft.)

Energy Efficient Label ID No.

Date of Purchase

Manufactured Home Dealer

*ENERGY STAR® Manufactured Homes must meet NEEM specifications to qualify for rebate.

By signing below, I certify that all information listed above is true and correct and the installation address is in the Benton PUD service territory. I attest that I have not previously applied for or received a rebate for the ENERGY STAR® Manufactured Home listed above. I understand that Benton PUD reserves the right to verify ENERGY STAR® Manufactured Home certification through inspection and that completion of this form does not guarantee my rebate. I acknowledge that Benton PUD’s ENERGY STAR® Manufactured Home Rebate Program is subject to change and funding availability. Applicant Signature__________________________________ Date___________________________

FOR BENTON PUD USE ONLY Premise/Invoice Number Approved? Y N

GL DEP 908.30 45

Energy Services Vendor ID RESOURCE 112

Amount

Verified By/Date Manager Approval / Date

PTR# Insert PTR# from above form

Remit completed form to: Benton PUD, 2721 W. 10th Ave., P.O. Box 6270, Kennewick, WA 99336 (509) 582-1234 6/2/2009