Rebate Request Form Home Member Rebate Request Form To receive your rebate in a timely manner, please fill out this form and provide all necessary documentation. Failure to provide all of the required information will delay the process.Questions about rebates, equipment or qualifications for rebates (including information about submitting rebates for insulation and air sealing, please contact LMREEnergyServices@fesco-oh.org For information on commercial and industrial rebates, or questions, comments or concerns about this form, please contact KAED@fesco-oh.org Member Name First Last Account Number Contact Phone Number Email Address Member Address Address Address 2 City/Town State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP code Geothermal Rebate? Manufacturer? Manufacturer - Select -BardBryantCarrierClimate MasterComfort AirEnertechFlorida Heat PumpPhillipsTemp-MasterTetcoWaterFurnaceOther… Enter other… Model/Serial Number Size (tons)? Energy Efficiency Rating (EER)? Coefficient of Performance (COP)? Type of system replaced? Type of system replaced - Select -Dual FuelGeothermalHeat PumpNatural GasNew HomeOilOther electricPropaneOther… Enter other… Heating Backup? Heating Backup - Select -ElectricNatural GasOilPropaneOther… Enter other… Water Heating Option? - Select -Not-ApplicableOn-demandSupplemental Closed/Open Loop/DGX? - Select -Closed loop water to airDGXOpen loop air to water Loop Type? - Select -HorizontalOpen WellPondPump and DumpVertical Receipt/Proof of Purchase? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Heat Pump Rebate? System - Select -Air SourceDuctless Size (tons)? SEER/SEER2 Rating? Heating Seasonal Performance Factor (HSPF/HSPF2)? Model/Serial Number Heating Backup? Heating Backup - Select -ElectricNatural GasOilPropaneOther… Enter other… Type of system replaced? Type of system replaced - Select -Dual FuelGeothermalHeat PumpNatural GasNew HomeOilOther electricPropaneOther… Enter other… Receipt/Proof of Purchase? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Electric Water Heater? Manufacturer? Manufacturer - Select -A.O. SmithAmericanBradford WhiteCraftmasterG.E.KenmoreLowesMarathonMorfloRelianceRheemRichmondRuudStateTrue ValueVaugh SepcoWhirlpoolOther… Enter other… Tank size? - Select -45 gallons or less46-55 gallons56-65 gallons66-75 gallons76 gallons or more Type? - None -StandardHeat Pump Water Heater EF/UEF? Size of elements (watts)? Type of system replaced? - Select -ElectricFuel OilNatural GasNew HomeOther- NOT ElectricPropane Receipt/Proof of Purchase? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Fridge/Freezer/Washing Machine Rebate? Proof of purchase (receipt)? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Proof of old appliance haul away/recycling? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Proof of Energy Star rating (Energy Guide Label)? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Electric Vehicle Level 2 Charger? Manufacturer Manufacturer - Select -AeroVironmentBlinkBoschChargePointClipper CreekCoulomb TechnologiesEatonECOtalityElektromotiveeMotorWerksEvatranEVgoEvochargeFreewireGeneral ElectricGoSmartLevitonSiemensOther… Enter other… Number of charge ports - Select -1234 Model Name/Number Wall mount/Pedestal - Select -Wall MountPedestal Certified (U.L. Listed)? Receipt/Proof of Purchase? Choose file One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Smart Thermostat Rebate? Manufacturer Manufacturer - Select -AmazonEcobeeEmersonHonewellNestOther… Enter other… Model/Serial Number Proof of Purchase/Receipt Choose file Please upload proof of purchase that shows no less than, date purchased, thermostat info including model name and type, and purchase amount. One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Check to confirm thermostat is energy star certified, WIFI capable and has internet access. Check here to submit a second thermostat rebate. Manufacturer Manufacturer - Select -AmazonEcobeeEmersonHonewellNestOther… Enter other… Model/Serial Number Proof of Purchase/Receipt Choose file Please upload proof of purchase that shows no less than, date purchased, thermostat info including model name and type, and purchase amount. One file only.20 MB limit.Allowed types: jpg png tif pdf doc docx. Check to confirm thermostat is energy star certified, WIFI capable and has internet access.
