100110 Roseville Energ Rebate 6/28/10 12:30 PM Page 1

Rebate
2010/2011 Application No.
Energy Efficiency Rebate Program
Residential Rebate Request Form
& Eligibility Requirements
QUALIFICATIONS: PLEASE NOTE:
• All energy efficient equipment must be installed in a residential dwelling receiving • Customers may be eligible for additional rebates if there is a change in residence.
electricity from Roseville Electric and must be purchased new at retail price. • Roseville Electric has partnered with the Electric & Gas Industries Association
• OFFER IS VALID ON PURCHASES FROM JULY 1, 2010 – JUNE 30, (EGIA) for the administration of this program.
2011, OR UNTIL FUNDS ARE DEPLETED, WHICHEVER COMES • Do not include rebate application with your utility bill.
FIRST. ALL APPLICATIONS MUST BE POSTMARKED NO LATER • Customer must fill out and sign the application below or apply online at
THAN 60 DAYS AFTER INSTALLATION. www.conservationrebates.com.
• To receive the $100 rebate for the refrigerator (one rebate per household), • Roseville Electric and EGIA reserve the right to verify both the efficiency and
customer must provide documentation that the new unit is ENERGY STAR® installation of equipment before rebate is issued. If installation can not be verified,
rated and that the old unit has been hauled away and recycled properly by the the customer may be expected to return some or all of the rebate received.
retailer or disposal company. See the list of qualified models at the program • Roseville Electric and EGIA are not responsible for items lost or delayed in the
website listed below. See the list of retailers that recycle refrigerators on the mail, nor any remittance delayed due to incorrect rebate applications.
Roseville Electric website. Without proof of recycle, the rebate will be $25 for the • Roseville Electric and EGIA disclaim any and all liability, loss or damage that may
purchase of an ENERGY STAR® refrigerator. Maximum of one rebate per arise as a result of the applicant’s or contractor’s participation in this program.
household for an ENERGY STAR® refrigerator. Customer may recycle a • Roseville Electric and EGIA are not responsible for any taxes that may be
maximum of two refrigerators per household. imposed as a result of your receipt of any financial rebates from Roseville Electric.
• A Roseville Electric customer can receive the $75 rebate for just recycling an • Rebates may not exceed the cost of the energy efficient equipment.
old-working refrigerator without purchasing a new Energy Star refrigerator. • By accepting a rebate from the City of Roseville, I understand that the city or it's
Take the old refrigerator to the Placer County Materials Recovery Facility
assignee, may conduct an on-site pre and post project inspection and
(MRF) or have it taken away by a company that is certified by the State of
measurement and verification analysis. This may require sharing my name,
California as a “Certified Appliance Recycler.” To receive the rebate a receipt
address, electricity usage, or other needed information with a consultant for these
from the MRF or from the recycler is required with the application. Check our
website for a list of Certified Appliance Recyclers (two rebates per household). purposes.
• Not all ENERGY STAR® clothes washers qualify for a rebate. Only high-efficiency • For more program information, to verify eligibility, or to see qualifying product
models with a Water Factor (WF) of 6.0 or less are eligible. Ask your participating lists, please visit www.conservationrebates.com or contact the program
dealer for qualified models or visit the program website listed below. administrator, EGIA, at 877-419-7271.
Visit www.conservationrebates.com to enter your rebate online and to see qualified appliance models.
Please remember to mail a copy of your receipt and your confirmation page to the address indicated.
Tear here and retain the above section for your records. Return completed portion below with a copy of your sales receipt.

Mail Form To: Roseville Electric Rebate Program, 3800 Watt Ave., Ste. 105, Sacramento, CA 95821
Be sure to include a legible copy of sales receipt that clearly identifies store name, product, make and model, purchase price and date.
Rebate
How did you hear about this program? ■ Website ■ Newspaper/Magazine Application No.
■ Called RE ■ Outreach Event ■ Friend/Relative ■ RE Newsletter ■ Other _____________________
■ Check this box to be enrolled in the Power Partners AC cycling program and receive $10 for joining and $10 each summer you participate – see www.roseville.ca.us/PowerPartners for details.
Please complete the required information below:
Would you have purchased and installed this energy efficient measure if Roseville Electric didn’t offer a rebate? ■ Yes ■ No

PURCHASER PAYEE
Roseville Utility Account Number
■ Landlord ■ Purchaser
—
Name Name

Installation address Mailing Address

City State Zip Telephone City State Zip Telephone

The amounts below supersede all rebate values previously stated on any preceding application.

APPLIANCES
Date Date P u rc h a s e
Measure P u rc h a s e d Installed R e q u i r e d E f f i c i e n cy Brand Model Price Rebate
$25 w/o proof
■ Refrigerator ENERGY STAR® – See qualifications
of recycle
ENERGY STAR® – See qualifications $100 with proof
■ Refrigerator (with proof of recycle) of recycle
$75 with proof
■ Refrigerator Recycle Only (without purchase)
of recycle
■ Clothes Washer High-efficiency WF 6.0 or less Up to $75*

■ Pool Pumps//Variable Not Two Speed $200

*$25 for City of Roseville wastewater customers and $50 for City of Roseville water customers. Ask your participating dealer for qualified models or visit the program website.

X
Purchaser Signature (REQUIRED) Date Explanation (if needed)
100110 Roseville Energ Rebate 6/28/10 12:30 PM Page 2

Visit www.conservationrebates.com to:

• Apply For Your Rebate Online

• Print Out An Application
• View and Print Qualifying Product Lists
• See Participating Retailers
• Get Additional Program Details

Have you enclosed a copy

of your sales receipt
or invoice?

Thank you for participating in the

Roseville Electric
Energy Efficiency Rebate Program

Valid on purchases from July 1, 2010 through June 30, 2011, or until available funds are depleted.

REMINDER:
All rebate requests must include a paid receipt and verification of efficiency level installed. Rebate will not
exceed the cost of the measure. Program is subject to funding availability. Rebate levels can change or end
at any time.

Qualifying rebate amounts will be credited to customer’s account. If the rebate is by check, allow four (4)
to six (6) weeks from the time we receive your rebate request form to process your check. If an inspection
is required, your rebate check will be processed within four weeks of the inspection. Your rebate
application must be postmarked no later than 60 days after installation.

— SAVE THIS PORTION FOR YOUR RECORDS —

RECYCLED PAPER
Return Address
PLACE
___________________________________________________
STAMP
___________________________________________________ HERE
___________________________________________________
ROSEVILLE ELECTRIC
ENERGY EFFICIENCY REBATE PROGRAM
3800 Watt Ave. Ste. 105
Sacramento, CA 95821
Page 3 12:30 PM 6/28/10 100110 Roseville Energ Rebate