Notice. Privacy Act. Klickitat PUD 1313 S. Columbus Ave. Goldendale, WA (509) or (800) Privacy Act Notice:

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1 Notice Privacy Act Privacy Act Notice: Your interest in our conservation program is appreciated. We hope that you will decide to participate in these energy savings activities. If you do, it is necessary for you to provide some information to us, which will enable us to run this program successfully. The information to be collected includes the names and addresses of customers participating in the program technical data about energy use and efficiency. We need this information to determine whether you are eligible for the program. Beyond this, the information collected will be used to evaluate and audit the conservation program. Upon BPA s request, we will provide them with this information. BPA may also wish to make certain site visits to evaluate the installations and the performance of the program. This and the data listed above will then be used to assist us in developing new programs and in assessing energy savings obtained by existing programs in the region. This information will be retained for three years. It may be released to the public, but only in anonymous statistical form.

2 Customer, RE: Rebate on Refrigerators & Freezers Refrigerators and Freezers that qualify for a KPUD rebate must be new ENERGY STAR and 7.75 cubic feet or greater. Rebate for new Refrigerator $10.00 Rebate for new Freezer $15.00 Customer will need to complete a rebate coupon and attach a copy of the sales receipt when it is turned in. Refrigerator and Freezer Decommissioning KPUD will rebate $60.00 for the decommissioning of an existing functional refrigerator or freezer for recycling in s service territory. The refrigerator or freezer must have a minimum capacity of 10 cubic feet. The unit must be decommissioned and its components recycled. KPUD representative will need to verify the unit is in functional condition and minimum cubic feet. Transfer stations will be able to provide you with a receipt of disposal/recycling which will be required for rebate. Anita Clever Energy Services Specialist or x622

3 Residential Energy Efficient Appliance Coupon Refrigerator / Freezer PUD OFFICE USE ONLY G.L. No Total Rebate Customer Name: Account #: Date: Mailing Address: (for rebate check) Installation Address (if different) Phone: RESIDENCE INFORMATION: Put year home built, in box that applies: Site Built Manufactured Home Permanently Installed Multifamily (Mark the box that applies) Occupied Year Round Occupied Seasonally Rental Number of Units Refrigerator / Freezer (This Section for PUD Office use) Number Refrigerators: ENERGY STAR 7.75 cubic ft. or greater Number of Freezers: ENERGY STAR 7.75 cubic ft. or greater x $10.00 = x $15.00 = ENERGY STAR Label Yes No Brand: Model: Qualify for rebate: Yes No Model Verified: Utility Rep. Initials Important! Attach a copy of the original invoice/receipt to this coupon

4 Residential Decommissioning Rebate Coupon For Disposal / Recycling of Refrigerator / Freezer PUD OFFICE USE ONLY G.L. No Total Rebate Customer Name: Account #: Date: Mailing Address: (for rebate check) Installation Address (if different) Phone: RESIDENCE INFORMATION: Put year home built, in box that applies: Site Built Manufactured Home Permanently Installed Multifamily Unit 4 or less (Mark the box that applies) Occupied Year Round Occupied Seasonally Rental Number of Units Refrigerator / Freezer (This Section for PUD Office use) Number Refrigerators: 10 cubic ft or greater Number of Freezers: 10 cubic ft. or greater x $60.00 = x $60.00 = Brand: Model: Qualify for Disposal/Recycle rebate: Yes No Model Verified: Utility Rep. Initials Important! Attach a copy of the original Disposal receipt to this coupon

5 Decommissioning of a Refrigerator or Freezer Inspection & Recycling To qualify for Decommissioning rebate, Refrigerator or Freezer must be an older working inefficient model and be 10 cubic feet or greater. Customer Name: Date: Customer Site Address: Customer Mailing Address: Customer Phone# PUD Account# Item Decommissioning: Cubic Feet: Working Condition: Yes No Verified by PUD Inspector: Recycling Location: Date Recycled: Recycling Agent s Signature: (Please provide copy of invoice from recycler) This section is for KPUD use Qualifies for Rebate? Yes No Date: Rebate Amount: $60.00 Utility Representative: G.L. #