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STAPLE }IERE FOR OFFICE USE ONLY
Cycle#
Mail CompletedForm, copyof Sales Book #
Receiptand copyof EnergyGuide
Label to: {d Seq#
TC#
Laurie Anderson
MMED
125High Street;Unit# 2
Mansfield,MA 02048
ELD
MANSFI
MUFIICIHALHLECTRIC ENT
FEPARTM
Refund $
Ref Date

Mansfield Municipal Electric I)epartment

t t"itLt"tf#;ff
ENERGY ncentiveProgram
R:::r
Customer Name: Home Phone:
(asit appearson electricaccount)
Address: Work Phone:

Town: Account Number:

New ENERGY STAR Appliance Information

Appliance purchased: - Central Air Conditioner Refrigerator Clothes Washer
(pleasecheck)
-
Dishwasher _ Dehumidifier Window Air Conditioner Programmable
-
Clock Thermostat

Brand: Model:

Date of Purchase: Store:

If Refrig., size (cubic ft.): Style: _ Top _ Bottom _ Side by Side

lf NC, size@TUs): Energy Efficiency Rating (S)EER):

Information on Appliance New PurchaseIs Replacing

Brand: Model:

ApproximateAge: If NC, size(BTUs):

If Refrigerator, size (cubic ft.): Style: _ Top Freezer Bottom Freezer

Side-by-Side

Please allow 4 to 6 weeksfor processing of Rebate. It will appear as a credit on your Electric bill.

Please remember to attach a copv of vour Ssles Receipt

along with a coov of the EnerwGuide Label