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Mail-in
What was the main reason you purchased a select
ENERGY STAR® Qualified Refrigerator or Freezer?
Please check one:
N energy savings N larger capacity
Rebate
N available rebate N quieter operation
N like to buy the best N concerns with global
warming/climate change
N takes up less space
N other
50
Did you know about the rebate before you purchased
$
your refrigerator or freezer?
N yes N no
If so, did the rebate influence your purchase decision?
N yes N no
Why did you purchase a refrigerator or freezer at this time?
Check all that apply:
N old machine broke N remodeling
N wanted upgrade N new home
N energy savings N better performance ENERGY STAR® Qualified
N new purchase (does not replace old unit) Refrigerators or Freezers
Have you purchased other ENERGY STAR qualified products?
N yes N no
How did you hear about ENERGY STAR Qualified
Refrigerators or Freezers? Check all that apply:
N newspaper ad N TV ad
N web site N utility bill insert
N retailer/salesperson N friend/relative/co-worker
N news report/article N other
N magazine ad
Email Address
N Yes! Sign me up to receive energy saving and incentive
information from myenergystar.com.
Printed on 100%
myenergystar.com recycled paper. A-9 12-09
The ENERGY STAR® $50 Mail-in Rebate.
Get cash back from us. Get $50 back from participating utility or energy
With a new ENERGY STAR qualified efficiency service provider on your purchase of an
refrigerator, you can start saving right away. eligible ENERGY STAR Qualified Refrigerator or Freezer.
For a limited time, receive a mail-in rebate This rebate is good for purchases made January 1, 2010
through December 31, 2010.
of $50! Some restrictions may apply. Just ask
your local participating retailer for details. To receive your rebate:
A fridge made before 1993 could be costing 1) Fill out this form completely.
you approximately $300 each year to operate, 2) Enclose a copy of your dated sales receipt
depending on the size and model year. Replace and a recent copy of your electric bill.
it with a new ENERGY STAR qualified model 3) Mail it to the address below.
and cut your related energy costs in half. See Incomplete information will delay or disqualify your rebate. All
the chart below for comparisons of sample rebate requests must be postmarked no later than January 31, 2011.
Work Phone
150
Mailing Address (if different)
100 City State Zip
50 House type (check one in each row):
$0
Top Freezer Bottom Side-by-Side Chest
N own N rent
Refrigerator Freezer
Refrigerator
Refrigerator Freezer N primary residence N vacation home
N single family N condo/ N multifamily
townhouse ___ # of units
Appliance Type
Year of Purchase
For installation address: