This form is for online submission of water conservation indoor rebate requests.

For more information, rebate amounts, and eligibility requirements regarding all indoor rebates, click on the rebate links below:

Washing Machines

Rebate Requirements

Click Here to download rebate requirements.

Please Note: Form submissions without valid entries, proof(s) of purchase, and/or supporting documents will not be processed. Fields marked with an asterisk (*) are required.

Customer Information

First Name:*

Last Name:*

Account Number:*

Email Address:

Daytime Phone:*

Alternat Phone:

Installation Address Number:*

Street Name:*

City:*

State:*

Zip Code:*

Indoor Rebates

Eligible Indoor Rebates:*

The following is required to process rebate requests:

Proof of purchase for the product or service
Documents showing High Efficiency models for washing machines

Purchase or Service Information

*Proof of purchase is required for processing rebate requests. Please upload proof of purchase and EPA WaterSense documents for High Efficiency documents for washing machines models. Proof of EPA WaterSense and High Efficiency may be on the receipt, owner’s manual, or pulled from the Internet.

Company Store or Name:*

Purchase Price or Service Amount:*

Purchase or Service Date:*

Brand Name or Model:*

Serial Number:

Proof of Purchase and Supporting Documents

Note: Multiple documents can be uploaded at one time by selecting all documents to be uploaded before clicking the "Upload a File" button. Acceptable file formats : .jpg, .jpeg, .gif, .docx, .doc, and .pdf

Proof of Purchase:*

Supporting Documents:

Comments:

Total Estimated Rebate Amount:

Terms of Acceptance and Signature

Full Name:*

Terms and Conditions:*

I agree to the terms and conditions of the rebate.

Checking the box above constitutes a legal signature confirming that you acknowledge and agree to the terms and conditions of the rebate and that you warrant the truthfulness of the information that you provided/submitted in this web form.

Please type the characters*

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WASHING MACHINE REBATE FORM