Name Clothes Washer Rebate Application Applicant details please print clearly Telephone number Installation address Address Zip code Address Zip code City State Your new clothes washer ID: 214271
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Water Utility account number: Name: Clothes Washer Rebate Application Applicant details: (please print clearly) Telephone number: Installation address: Address: Zip code: Address: Zip code: City: State: Your new clothes washer details: Brand: Model #: Serial #: Purchase price (individual price with no tax): $ Purchase date: Installation Date: Declaration:I have read and accept the terms and conditions of this agreement and the information contained in this application is truthful and correct to the best of my knowledge. I hereby certify that I am the customer authorized to replace the clothes washer at the address listed above, and my old clothes washer has been recycled and is no longer in service. Applicant's signature: X Date: Phone: (505) 955-4225, www.savewatersantafe.com Type of machine replaced: Your old clothes washer details: Brand: Model #: Serial #: Driver's signature: X recycling and will not be re-sold. Top-Load ($350 rebate) Front-Load ($150 rebate)Please note: All information is required to receive a rebate. You will not qualify for a rebate if this section is incomplete. The clothes washer rebate applies to new, tier 3, clothes washers purchased after May 1, 2011. Please ensure you have read the terms and conditions before you complete the application below. NOTE: Original receipt(s) are required. Photocopies will not be accepted. Checked Dta BaseCase #:Sevie ddess: Cycle: Meer osition: Dte Eteed: To qualify for a rebate: Please note: Rebate amount:Terms and Conditions http://library.cee1.org/content/qualifying-product-lists-residential-clothes-washers For more information on this program, visit www.savewatersantafe.com, or contact the Water Conservation Office at (505) 955-4225. Phone: (505) 955-4225, web site: www.savewatersantafe.com Submit to: City of Santa Fe Water Division Clothes Washer Rebate PO Box 909 Santa Fe, New Mexico 87504-0909