Safe Water Heater Rebate Application

Safe Water Heater Rebate Application

Applicants submit this completed form with the required documentation to the Western Propane Education and Research Foundation (WPERC) at the address at the bottom of this page. To apply for this rebate:

(1)Complete the entire application as inaccuracies could delay or disqualify this application;

(2)Applicants and propane marketers must sign the application;

(3)Attach the required document, including a safety inspection record dated not more than 30 days

prior to sending this application;

(4)Keep a copy of the completed application and all necessary documentation for your records.

WATER HEATER INFORMATION

REPLACE EXISTING ELECTRIC - $300 Rebate

Old (electric) Brand Serial No.

New (propane) Brand Serial No. Install date

Information that must be submitted with application (failure to submit both will disqualify application)

(____)Copy of paid invoice for purchase of water heater.

(____)Copy of safety inspection records (must be dated within 30 days of application postmark).

APPLICANT INFORMATION (where the rebate check will be mailed.)

Name Company

Address City/State/Zip

Phone Fax

Installation location if different from above

I hereby agree not to remove the Eligible Water Heater from service for five years, I understand that this rebate is available only through authorized Propane Marketers in California, that it is not a government program, and that the Program may end at any time. I acknowledge that I have received a copy, read, and understand the Safe Water Heater Rebate Program terms and conditions and I agree to be bound by the terms and conditions and this Application.

Applicant signatureDate

PROPANE MARKETER INFORMATION

Name Company

Address City/State/Zip

Phone Fax

I understand and agree to all rules and conditions for participation in this Program. I acknowledge that the installation at this location is eligible for a rebate and that the installation meets all Program terms and conditions. I hereby declare that I am authorized to sign this application and that the information stated herein is true, correct and complete to the best of my knowledge. By signing this application, I affirm that this installation passed the safety inspection defined in the Program and certified by the attached inspection record.

Company representative signatureDate

WPERC - 2131 Capitol Avenue, Suite 206, Sacramento, CA 95816-5755

Phone: (916) 447-9742 / Fax: (916) 447-9740

Return original to WPERC and keep a copy for your records.