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2. Applicant Name *
3. Account Number (as shown on Utility Billing)*
5. Applicant Address*
6. Telephone Number*
8. Appliance Location Address (if different)
9. Telephone (Work)
11. Date Purchased*
12. Date Installed*
14. Appliance*
15. Brand*
16. Rating*
17. Quantity*
19. Appliance
20. Brand
21. Rating
22. Quantity
24. Attach receipt
    Please scan and attach your receipt. If you can not attach the receipt, please email it to brichardson@waukee.org.
26. Scanned Receipt Required*

    I agree to email a scanned copy of my receipt to brichardson@waukee.org. I understand my rebate will not be processed until I submit my receipt.

    1. I agree
28. Customer Certification and Agreement
    The System(s) at the above address has been selected and installation accordance with guidelines established for the utility appliance rebate program. The customer understands that prior to the issuance of any payment; the equipment may be inspected and approved by the utility. The customer shall observe and comply with all ordinances, laws, and requirements of all units of governmental agencies having jurisdiction over the work to be performed. The utility does not guarantee that the equipment funded under this program will result in energy savings. In no event shall the utility be liable for any incidental or consequential damages.
29. NOTE:
    An original sales receipt indicating date of purchase, dealer's name and address, and quantity purchased must accompany this application. Rebates are limited to no more than two per household.
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field