Water Heater Rebate Application

Complete the form below, or print and return: Water Heater Rebate Application (PDF)

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This field is for validation purposes and should be left unchanged.

(Not valid for gas or tankless water heaters)

Member Name(Required)

First Last

Account #

Phone(Required)

Email(Required)

Address(Required)

Physical address where insulation was installed

Street Address Address Line 2 City State ZIP Code

Water Heater Replacement Type

New/Additional Water Heater Installation

NG/LP Gas to Electric Conversion

New Construction/Manufactured Home

Note: Old electric water heater replaced with new electric water heater does not qualify.

Water Heater Information:

Serial #

Make/Brand

Model

Capacity in Gallons

Water Heater Cost ($)

Installation Date (MM/DD/YYYY)

Up to a $300 rebate on qualifying products

Please include a valid invoice/receipt of purchase for the water heater which was installed.

Max. file size: 100 MB.

Member Signature (Full Name)(Required)

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