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Refer to page 2 of this form for instructions SMUD TRANSACTION NO. RATE WATER HEAT CODE
CITY / STATE / ZIP CODE (Check To Be Mailed To) CITY / STATE / ZIP CODE
HOME PHONE WORK PHONE TENANT HOME PHONE TENANT WORK PHONE
( ) ( ) ( ) ( )
Complete all information requested below and attach sales receipt for all products purchased and installed.
Rebate Eligibility Requirements Rebate Amount Total
Subject to modification or termination due to available funds Purchase Product Information Rebate
NOTE: Rebate checks will be mailed 8-10 weeks subsequent to receiving all required documentation. Applications are processed
on a first-come, first-served basis.
© SMUD-1918c (2 of 2) 12/09 Forms Management