Marketing Partner Dollar Reimbursement Request

APPLIANCE REBATE
CO-OP: PAULDING PUTNAM ELECTRIC CO-OP, INC. Installing Contractor :
(Company)

(City) (state) (Zip)

Customer Name and Address
REBATE OR PRODUCT
INCENTIVE $ AMOUNT
PAID TO MEMBER:

$ __________________
Contact Number _____________________________

Date Installation was completed ______________________________

APPLICABLE PROGRAM TYPE (please check one)

 Energy Efficiency  Appliance Rebate  Touchstone HOME  Demand Response

WATER HEATER
Water Heater Rebate $
 New home
(Manufacturer) (Model #) OR REPLACES:  Electric  Gas
 Propane  Fuel Oil
Size of tank gal. Size of elements Watts

New Radio-Controlled Switch installed?  Yes  No RCS Serial number: _____________ Tone:___________

COOL RETURNS A/C CONTROL (RCS)

A/C Control Rebate $
Ton (Eligible for 50% paid to customer up to $50 per RCS)
(Manufacturer) (Model #) (Size)
 System Type:  Central Air  Heat Pump  Geothermal RCS Serial number: ________ Tone:_____
 Approximate Size of Home:  under 800 sq. ft.  801-1500 sq. ft.  1501-2500 sq. ft.  >2500 sq. ft.
 Approximate Age of Home:  5 years or less  6 to 10 years  11 to 20 years  over 20 years
 Home Type:  2 story  1½ story  Ranch  Mobile Home  Manufactured Home
 Office/Business  Other

Installing Contractors Signature: ______________________________________ Date: ______________________

Certification
This is to certify that we have provided an appliance rebate or product incentive for the installed system as designated
above and are requesting reimbursement from the Marketing Partner Dollars program.

Signed: Date:
(Cooperative Representative)

PLEASE RETURN TO: Paulding Putnam Electric Cooperative, Inc. 910 N. Williams Paulding, Oh 45879