Multi-Family Building Appliance Rebate Claim Form
1. Applicant Information
Applicant Name
Organization/Property Management
Email
Phone Number
2. Property Information
Property Name
Property Address
Number of Units
City
State
ZIP Code
3. Appliance Information
Please enter all qualifying appliances below:
Unit #
Appliance Type
Brand
Model #
Serial #
Date Installed
Refrigerator
Washer
Dishwasher
Dryer
Other
Refrigerator
Washer
Dishwasher
Dryer
Other
Refrigerator
Washer
Dishwasher
Dryer
Other
4. Supporting Documents
Attach Invoice(s)
Additional Documents
5. Certification & Signature
I certify that all information provided above is true and complete to the best of my knowledge.
Name
Date