Cash-Back Rewards on

ENERGY STAR® Qualified

Refrigerators and Freezers
Focus on Energy, through the American Recovery and Reinvestment Act, is offering an exciting
new program to help you reduce energy costs. The program encourages the replacement of
old, inefficient appliances to help you save on future energy costs. Best of all, you can receive
Cash-Back Rewards for upgrading your existing appliances to energy-efficient models. By
making an upgrade before your equipment fails, you will not only save money on the new
equipment, you will save money each month on your energy bills.

To claim your Cash-Back Reward, please complete both Step 1 and Step 2 Cash-Back Rewards are available for ENERGY
STAR® qualified refrigerators and/or freezers
(required for processing) (please print) installed in Wisconsin residences—for replacement
STEP 1: of existing appliances only. Rewards are available to
residential customers only, businesses (including
Store Name landlords) are not eligible. This offer is available on a
first-come, first-served basis for completed and
qualified applications while funds last. Step 2 (see
Store Salesperson Phone back page) must be completed to provide proof that
existing unit was turned in.

Customer Name Phone Mail this completed form and a legible copy of your
sales receipt showing model number and purchase
date to:
Install Address City ZIP
,WI Focus Appliance Reward
c/o EFI Fulfillment Center
Mailing Address ( same as install) City PO BOX 1210
Westborough, MA 01581-1210

State/ZIP E-mail Address Reward applications must be postmarked within

30 days of purchase date.

Electric Utility Company Name Appliance must be purchased on or after January

1, 2010 to be eligible. If you do not receive your
reward within eight weeks of mailing, please call
Purchase Date 888.465.2070, between 7:00 a.m. and 7:00 p.m.
CT, Monday through Friday and between 7:00 a.m.
and 4:00 p.m. CT, on Saturday.
Removal Date Age of Old Appliance
Focus is not responsible for lost, late or undelivered
applications. Fraudulent submissions could result
in federal prosecution under U.S. Mail Fraud Statute
Cash-Back Rewards for ENERGY STAR qualified refrigerators or freezers (18 U.S. code, section 1241 and 1242). This form
has no cash value. Please retain a copy for your
 For a current list of ENERGY STAR qualified refrigerators and freezers ask a salesperson records. Facsimile or photocopy submissions of this
partnering with Focus on Energy or visit focusonenergy.com/recovery. form are not acceptable.

Qualifying appliances must be installed within the

Please check one box  Refrigerator–$75 Reward
State of Wisconsin. Neither Focus on Energy or
(required for processing)  Freezer–$50 Reward Wisconsin Energy Conservation Corporation warrant
the performance of installed equipment expressly
Brand of New Unit Model Number of New Unit or implicitly. Offer may be subject to change without
prior notice. If you have questions regarding this
form, call 888.509.3247, ext. 284.
Serial Number of New Unit
Visit focusonenergy.com/recovery for updates on
funding availability or to learn about programs
outside of Wisconsin.
Customer Signature
I certify that the information provided in this application is accurate and truthful. I certify that a
similar appliance was replaced at the home and that the recycling requirement was met through
the method checked under Step 2 (on back page).

_______________________________________________________________________________________________
Sign or initial here
Cash-Back Rewards on
ENERGY STAR® Qualified
Refrigerators and Freezers
STEP 2: To be completed by customer (required for processing)

In order to receive a reward for the purchase of a new ENERGY STAR qualified refrigerator or freezer, you must
provide proof that the existing unit has been taken out of service and recycled. Please indicate the recycling
method used by checking the appropriate box below and submit any required documentation with your reward
application. One box must be checked and documentation provided in order to qualify for Cash-Back Rewards.

A list of all program-approved retailers is available at focusonenergy.com/recovery. Only retailers on this list are
eligible to provide proof of recycling. If you purchase a refrigerator and/or freezer from a retailer that is not on
this list, you must use a recycling service to recycle your old unit.

 Program-approved retailer—the retailer picked up the old refrigerator or freezer at the time of delivery of
the new appliance. Sales receipt must indicate the old appliance will be picked up, or a separate delivery
receipt showing the pick-up of the old appliance must be submitted with this form. The retailer or pick-up
representative must sign below.

I have picked up the old refrigerator or freezer from the customer. The refrigerator or freezer will be taken out
of service and recycled, and will not be resold or reused.

______________________________________________________________ _______________________________
Pick-up representative signature Date of pick-up

OR

 Recycling service—a recycling program or service was used to recycle the old refrigerator or freezer. A
copy of your documentation or receipt from the service verifying the refrigerator or freezer was turned in,
must be submitted with this form in addition to your sales receipt.

Eligible services
Local municipality program (through counties, cities, towns, or villages)
Local utility programs
Private recycling services

If you have additional questions on energy efficiency or renewable energy for your home, call 800.762.7077
or visit focusonenergy.com.

This program is funded in part by the Wisconsin Department of

Administration, Office of Energy Independance.

© 2010 Focus on Energy RES-2470-1209-ARRA