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Clothes Washer and Dishwasher Rebate Application.

Fort Collins Utilities Customers


Application #:

Fort Collins Utilities offers bill credits on ENERGY STAR qualified clothes washers and dishwashers.

Clothes Washer Rebates $50 Bill Credit.


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Dishwasher Rebates $25 Bill Credit.


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Retailer Manufacturer Model # Serial #

Manufacturer Model # Serial # Retail Store

Customer Information.
Customer name Installation address Fort Collins Utilities account # for installation address __ __ __ __ __ __ - __ __ __ __ __ Mailing address
street city state zip

Home phone Daytime phone E-mail address Customer type: Homeowner Renter Landlord Business
By signing this form, I certify that I purchased the above clothes washer or dishwasher and plan to install it for use at the address indicated above within the Fort Collins Utilities service area.

Get Started.
1. Purchase and install a qualified clothes washer or dishwasher according to the program rules. 2. Return a completed application form and a copy of your sales receipt to: Fort Collins Utilities Customer Service Division ENERGY STAR Rebate Program P.O. Box 580 Fort Collins, CO 80522 For more information, call (970) 221-6700 or e-mail fortcollinsconserves@fcgov.com.
Fort Collins Utilities use below this line

Program Rules.
Clothes washer or dishwasher must be a 2011

ENERGY STAR qualified appliance.

Appliance must be for use at an address that receives electric or water service from Fort Collins Utilities. Allow 46 weeks for bill credit processing. Fort Collins Utilities reserves the right to verify the purchase and installation location of any appliance for which a rebate is requested. Rebate program is subject to available funds. A copy of the receipt must include model number, purchase price and date of purchase.

Approved

Not Approved Date

Employee Initials

Comments

Where Did You Hear about the Rebate?

Bill insert Newsletter Retailer Web Media (newspaper, radio) Friend, family member Other
Fort Collins Conserves. A Year-Round Activity.
Utilities

Utilities Programs.
Home Energy and Water Audits
Reduce costs and increase the comfort of your home. Sign up for an affordable home efficiency audit. See details at fcgov.com/HomeEfficiency.

Appliance Recycling.
Many local appliance stores will pick up old appliances as part of their delivery service for new machines. These machines are typically recycled by independent companies.

Toilet Rebates and Recycling


Save thousands of gallons of water by installing a WaterSense labeled toilet. Receive a $35 rebate when you purchase a WaterSense labeled toilet and another $15 for having your old toilet recycled. See details at fcgov.com/ toilet-rebates.

Other Options
Habitat Home Supply 4001 S. Taft Hill Rd. (970) 223-9909 Will pick up machines in good working condition. Larimer County Landfill 5887 S. Taft Hill Rd. (970) 498-5760 Drop off only (fee applies). Appliances are recycled by a salvage company. Aragon Iron & Metal 516 U.S. Hwy. 287 (970) 484-2577 Drop off only. Machines scrapped (not recycled). Colorado Iron & Metal 1400 E. Mulberry St. (970) 482-7707 Drop off only. Machines scrapped (not recycled).

Green Energy
Sign up for our renewable energy program at your home and business. Learn more at fcgov. com/GreenEnergy.

Refrigerator & Freezer Rebates and Recycling


Well pick up your old refrigerator or freezer (in working condition), recycle it and give you a $35 bill credit.

Learn about more Fort Collins Utilities energy and water conservation programs at fcgov.com/FortCollinsConserves.

Affidavit - Restrictions on Public Benefits


I , swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen. I am not a United States citizen but I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Signature Date

Utilities