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Buyers Name: Address: Phone: Date of Purchase:

Please attach copy of your sales receipt and complete the following information to receive rebate for the purchase of an energy efficient appliance(s). Mail to: City of Lodi Electric Utility, Attn.: Customer Program; 1331 S. Ham Lane, Lodi CA 95242.

NOTE: All rebates less than $300. are applied as a credit on customers City of Lodi utility account.

** If removing/replacing an existing, older appliance, please note approximate

AGE of the older appliance here: ___________

Energy efficient refrigerator $50. rebate (EnergyStar-rated)

Make______________ Model______________ (Freezer: Bottom_____ Top____ Side_____) Front-loading or EnergyStar-rated clothes washer $50. rebate

Make______________ Model______________ (Gas Hot Water____ Electric Hot Water____)

I CERTIFY that the information as shown above is true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand and agree false statements and/or omissions of material fact will cause forfeiture of requested rebate and/or other appropriate action as deemed necessary by the City of Lodi. I also certify that the above noted appliance(s) will be housed and utilized by a City of Lodi Electric Utility customer.

Buyers Signature: ________________________________

Date Signed: _______________