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updated 12.23.14 Page 1 of 2 Application From Your Utilities Bill: Customer Account Number You Live in an: 1) Apartment Condo/Town House House Mobile Home 2) You Own You Rent Name on Utility Account: First / Last Name Phone Number Contact Person: (If different than above) First / Last Name Phone Number Installation Address: Street Address / Unit Number City Zip Code Mailing Address: (If different than above) Street Address / Unit Number City Zip Code Make Check Payable to: Name on the Utility Account Contact Person Applications must be submitted within 1 year of purchase. The following Energy Star® measures are eligible: dishwashers, refrigerators, room a.c. (2 max), central a.c., windows, ceiling fans (3 max), whole house fans, attic fans, solar fans, and variable speed pool pump motors. Please note that you are eligible for one incentive per item type every 5 years. ENERGY EFFICIENT ITEM INFORMATION OFFICE USE Item Replacing Existing? Purchase Date Price Paid Brand Model Incentive Amount Energy/Water Factor Total Incentive Amount **PLEASE READ AND SIGN THE PROGRAM GUIDELINES ON THE FOLLOWING PAGE BEFORE SIGNING I certify that the information on this application is true and correct and that I have read, understand, and agree to the program guidelines on this application. Applicant’s Signature: Date: Mail the completed application, receipts, and supporting documentation to: Rebate Processing Center • 1440 S. State College Blvd., Suite 2F, Anaheim, CA 92806 OR email the scanned application, receipts, and supporting documentation to: [EMAIL REDACTED] Questions? [PHONE REDACTED] FOR OFFICE USE: Application Received: Inspected on: Inspector’s Signature: Check Mailed on: Check No: Check Dated: ANAHEIM PUBLIC UTILITIES HOME INCENTIVE PROGRAMS SIGN ---PAGE BREAK--- Page 2 of 2 ANAHEIM PUBLIC UTILITIES HOME INCENTIVES PROGRAMS GUIDELINES Please read carefully before signing: • Customer must receive electric service from Anaheim Public Utilities. • The incentive offer is limited to residential customer for residential use. The appliance must be installed in a residential dwelling within Anaheim Public Utilities service area. A residential dwelling is defined a single-family home, condominium, apartment, or mobile home permanently located within Anaheim Public Utilities service area. The dwelling must be fully constructed and occupied (no new construction). • This application and a paid sales receipt for each product must be returned to the Rebate Processing Center office listed on the bottom of the application. To expedite your application, please attach a copy of your Anaheim Public Utilities bill. • The incentive offer is on a first-come, first-service basis and is effective until funding is expended or the program is discontinued by Anaheim Public Utilities. The incentive check will be mailed within 30 days following application approval. • Applicant understands and agrees that Anaheim Public Utilities or its representative may inspect the installed product before the incentive is paid. • Applicant agrees that any incentive may be credited towards any delinquent (as currently defined in the Rates, Rules and Regulations for the City of Anaheim) utility bill(s) for which the customer is responsible whether the account(s) is open or closed. • Applicant understands Anaheim Public Utilities may withhold payment of incentive until all of the conditions listed above are met. • Anaheim Public Utilities does not warrant, endorse, or assume liability for the quality, performance, or safety of the contractor and/or retailer or wholesaler. Performance of any product and acceptance of materials used is solely the customer’s responsibility. • Customer is responsible for meeting all program requirements and for checking with state/county/city governments and homeowner’s association (if any) in the area regarding local conditions, restrictions, codes, ordinances, rules, and regulations prior to installation. • MUST SUBMIT APPLICATION WITHIN 1 YEAR OF PURCHASE. MAXIMUM OF ONE APPLIANCE PER CATEGORY UNLESS APPROVED BY ANAHEIM PUBLIC UTILTIES. Applicant’s Signature: Date: Mail this signed programs guidelines sheet, along with the completed application, receipts, and supporting documentation to: Rebate Processing Center 1440 S. State College Blvd., Suite 2F Anaheim, CA 92806 OR email the scanned application, receipts, and supporting documentation to: [EMAIL REDACTED] Questions? Call [PHONE REDACTED] or (714) 765-4250 SIGN