section 6 REBATE PRODUCT INFORMATION Refer to: • Applicable rebate catalog at focusonenergy.com/catalogs for rebate codes, rebate per unit, and product eligibility requirements. • focusonenergy.com/products for qualified products lists. • Your itemized invoice(s) that include Manufacturer and Model Number(s). • Rebate Product Information Sheet at focusonenergy.com/catalogs if additional lines are needed.
/ /
PROJECT COMPLETION DATE:
REQUESTED REBATE (A X B)
# OF UNITS (A)
REBATE PER UNIT (B)
UNIT MEASURE
CODE
MANUFACTURER NAME
MODEL #
(Example) L3111
STARK LIGHTING
LED5VZP
Fixture
10
$ 25
$ 250
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Manufacturer Specifications Attached
Subtotal from Rebate Product Information Sheet (if applicable) $
(if applicable): Yes
m
Itemized Invoice(s) Attached: Yes m
REBATE TOTAL* $
section 7 CUSTOMER SIGNATURE
I, the undersigned Customer, agree the stated energy efficiency measure(s) was (were) installed at the job site address listed above as part of the Focus on Energy Program. I have read and agreed to the provisions set forth herein and to the Terms and Conditions posted at focusonenergy.com/terms . I understand Focus on Energy may revise these Terms and Conditions at any time, and I will not be notified in the event changes are made. To the best of my knowledge, the statements made on this application are complete, true, and correct, and I have submitted the appropriate supporting documentation to receive a rebate. If the Customer is identified as the Payee in Section 5, the following certifications are required for this form to substitute for the Internal Revenue Service (IRS) form W-9. Under penalty of perjury, I certify that: • The number shown on this form is the correct taxpayer identification number. • I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. • I am a U.S. person. The IRS does not require my consent to any provision of this document other than the certifications required to avoid backup withholding.
SIGN HERE
___________________________________________________________________________________________________________ CUSTOMER SIGNATURE NAME (PRINT) DATE
Submit applications and supporting documentation to: MAIL: Focus on Energy 3113 West Beltline Highway, Suite 201 Madison, WI 53713 EMAIL: multifamily@focusonenergy.com
*Rebate may be adjusted based on project caps. See measure requirements and Terms and Conditions for more information.
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