Customer Name Customer Address (street,city, state, zip) Rebate check will be mailed in the Customer’s Name at Address unless alternate is provided below or applied to account. If rebate is for new construction, the builder or homeowner is qualified to receive the rebate. Daytime Phone Mobile Phone How did you hear about our Rebate Program? Type of gas service Residential Commercial New Construction (copy of Carrollton Utilities bill is not required) Builder Name Natural Gas Equipment Type Natural Gas Forced Air Furnace (30,000 BTU or higher) Natural Gas Boiler (30,000 BTU or higher) Natural Gas Tank Water Heater (40 gallon or higher) Natural Gas Tankless/Condensing Heater (.82 EF or greater) Natural Gas Dryer Gas Cooking Stove Commercial Fryer, Griddle,Oven and/or Steamer (Energy Star Rated) Natural Gas Forced Air Furnace-Minimum Efficiency Level 90% - 93% AFUE (rebate amount: New/Conv $250 Replace $125) 94% - 95% AFUE (rebate amount: New/Conv $325 Replace $175) 96% AFUE or greater (rebate amount: New/Conv $400 Replace $200) Natural Gas Boiler Rebate Amount: Minimum Efficiency Level 85% AFUE or greater (rebate amount: New/Conv $250 Replace $125) Natural Gas Dryer (rebate amount: New/Conv $100 Replace $50) Gas Cooking Stove (rebate amount: New/Conv $100 Replace $50) ENERGY STAR rated Commercial Cooking Equipment (rebate amount: New/Conv $500 Replace $200) Natural Gas Tankless/Condensing Heater rebate amount: New/Conv $400 Replace $200) Natural Gas Tank Water Heater-Minimum Efficiency Level .62 - .66 EF -40 gallon or higher (rebate amount: New/Conv $200 Replace $100) .67 EF or greater 40 gallon or higher (rebate amount: New/Conv $300 Replace $150) • Equipment must be installed in customer’s name at address listed on Carrollton Utilities bill (unless new construction). • Include original retail receipt or contractor’s invoice. Rebate only applies to new appliances. • Include a recent copy of Carrollton Utilities bill (under customer’s name and address listed). • Limit one rebate each type appliance per 5 years. Only one rebate per application. Submit a separate form for each rebate requested. New Equipment Information (as included on receipt or contractor's invoice) Manufacturer Serial Number AFUE or EF Rating Model Number Old Equipment Information Estimated Installation Date of Old Equipment Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 Manufacturer Serial Number AFUE or EF Rating Model Number Proof of New Equipment Installation Installer Name Installer Address Date Installed Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033 Installer Signature By signing, the installer/inspector attests this information accurately reflects the equipment has been installed in compliance with the manufacturer’s specifications for the new equipment. Any and all equipment associated with this rebate must be installed in compliance with required local, state and federal codes. Any tests or inspections that may be required for the verification of such are the responsibility of the customer or installing contractor. TERMS AND CONDITIONS Rebate payments will be issued by CU after all appropriate documentation has been received. This rebate is offered to CU customers who are served under CU’s residential and commercial rate. Funding for this program may be limited; eligible rebate applications will be processed pending available funds. CU reserves the right to conduct field inspections to verify equipment installations. CU does not guarantee the performance of the installed equipment either expressly or implicitly. Program Guidelines • Applicant must be a current or future Carrollton Utilities natural gas customer and served (or will be served) under the G1 or C1 rate classification. • Limit of one each rebate type per customer account per five year period. • Rebates apply for the purchase of qualifying natural gas equipment in a new or existing home or business served by Carrollton Utilities. • Include a copy of a recent Carrollton Utilities bill under the customer’s name and address listed with the rebate form (not required for new construction). • Include an original retail receipt or contractor’s invoice. Only new appliances are eligible. • A separate rebate form is required for each rebate requested (for example, if you purchase a qualifying water heater and furnace, submit a separate form for each.) • Incomplete rebate applications may delay or disqualify your rebate. Please keep a copy of the completed forms and all attachments for your records. Mail the rebate application to: Carrollton Utilities PO Box 269 Carrollton, KY 41008 • For questions regarding the rebate process call 800-732-7055. • Rebate checks will be issued in approximately 4 to 6 weeks after receipt of all required paperwork or may be applied to customer account. • Any and all equipment associated with this rebate must be installed in compliance with required local, state and federal codes. Any tests or inspections that may be required for the verification of such are the responsibility of the customer or installing contractor. • Funding for this program may be limited. Eligible rebate applications will be processed pending available funds. • Carrollton Utilities reserves the right to conduct field inspections to verify equipment installations. Customer Signature By signing, the customer acknowledges having read and understood the terms and conditions of Carrollton Utilities Natural Choice Program. The customer certifies that all the information provided is true and correct and that the products for which the customer is requesting a rebate meet the requirements of the program. Leave this field blank