section 6 BUSINESS PROPERTY TYPE Select one only. If applying for both existing and new construction equipment rebates please complete two separate applications. q Equipment Upgrades & Retrofits q New Construction & Major Renovations Select one (1) property type that best describes your business: q Agriculture Producer q Dairy - Traditional q Dairy - Robotic q Other: q Financial Institution q Government q Grocery/Convenience Store
q Manufacturing (product): ___________________ q Multifamily q Office q Religious & Spiritual Organization
q Restaurant q Retail q Vehicles Sales/Service q Water/Wastewater q Other: __________________
q If Dairy, what is the average number of cows being milked daily? ____________
q Health Services q Hotels & Lodging q Information, Technical & Scientific Services
________________
q Education
q With K+ Daily Education q No K+ Daily Education
section 7 REBATE PRODUCT INFORMATION Refer to: • Applicable rebate catalog at focusonenergy.com/catalogs for rebate codes, rebate per unit, and product eligibility requirements. • Your itemized invoice(s) that include Manufacturer and Model Number(s). • Business Rebate Product Information Sheet at focusonenergy.com/catalogs if additional lines are needed.
/ /
PROJECT COMPLETION DATE:
# OF UNITS (A)
UNIT MEASURE
REBATE PER UNIT (B)
REQUESTED REBATE (A X B)
CODE
MANUFACTURER NAME
MODEL #
(Example) L3111
STARK LIGHTING
LED5VZP
Fixture
10
$ 25.00
$ 250.00
$ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $
Subtotal from Rebate Product Information Sheet (if applicable) $ REBATE TOTAL* $
section 8 CUSTOMER SIGNATURE
I, the undersigned Customer, agree the stated energy efficiency measure(s) was (were) installed and are functional 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:
*Rebate may be adjusted based on project caps. See measure requirements and Terms and Conditions for more information.
Focus on Energy 725 W. Park Avenue Chippewa Falls, WI 54729 business@focusonenergy.com
MAIL:
EMAIL:
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