ENERGY STAR® qualified Appliance Package

$50–$100 Rebate
from Minnesota Power and participating utilities
Residential customers can purchase and take delivery of two to three ENERGY STAR qualified
appliances (clothes washer, dishwasher, and refrigerator) from Janaury 1–December 31, 2009.
Valid for customers of Minnesota Power and participating utilities. See back for details.

STEP 1 TO BE COMPLETED BY RETAILER OR PURCHASER (Required for processing)

Store Name Store Salesperson

Store Phone Number City State ZIP

 Appliance must be ENERGY STAR qualified to be eligible for rebate.

 You must purchase all three appliances (clothes washer, dishwasher, and refrigerator) in order to qualify for a $100 rebate.
 Receive a $75 rebate for the purchase of a clothes washer and a dishwasher or refrigerator.
 Receive a $50 rebate for the purchase of a dishwasher and a refrigerator.

Please complete the following information (Required for processing)

Appliance Type Brand Model Number Serial Number

Clothes Washer

Dishwasher

Refrigerator

Please check one:

 TOTAL Cash-Back Rebate $100.00 (all 3 appliances)
 TOTAL Cash-Back Rebate $75.00 (clothes washer and dishwasher or refrigerator)
 TOTAL Cash-Back Rebate $50.00 (dishwasher and refrigerator)

STEP 2 TO BE COMPLETED BY PURCHASER (Required for processing)

Electric Utility Company (required) Customer Name

Street Address City State ZIP

Phone Number Email

Purchase Date

This/these appliance(s) will be used in a:

 Farm  Business  Apartment/Condo bldg (4 or more units)  Single Family Home (1-3 units)

PARTICIPATING UTILITIES Your electric utility must be listed below in order to qualify for Cash-Back Rebates.
Aitkin Public Utilities Gilbert Public Utilities Mountain Iron Public Utility
Brainerd Public Utilities Grand Rapids Public Utility Pierz Public Utility
Ely Public Utilities Minnesota Power Two Harbors Power and Light

Copy of sales receipt must be sent with completed form.

 ENERGY STAR® qualified Appliance Package
$50–$100 Rebate
from Minnesota Power and participating utilities
STEP 3
 This offer available to residential customers of Minnesota Power and participating utilities only.
 Offer may be subject to change without prior notice. Offer may not be used in conjunction with any other utility offer.
 Mail this completed form and a copy of your sales receipt showing model number, and purchase date to:
MN ENERGY STAR Appliance Package Rebate, c/o WECC, 431 Charmany Drive, Madison, WI 53719
 Offer valid January 1–December 31, 2009. Request must be postmarked no later than January 15, 2010. Offer expires December 31, 2009.
 If you do not receive your Cash-Back Reward within eight weeks of mailing, please call the Minnesota ENERGY STAR Program toll-free at 888.509.3247
ext. 303, between 8 a.m. and 5 p.m. Central Standard Time, Monday through Friday.
 Not responsible for lost, late, or undelivered responses. Late submissions will not be accepted. Incomplete forms will not be processed.
 Fraudulent submissions could result in federal prosecution under U.S. Mail Fraud Statute (18 U.S. code, section 1241 and 1242).
 This form has no cash value. Please retain a copy of it for your records.
 Qualifying appliance(s) must be installed within the service area of a participating utility. Minnesota utilities do not warrant the performance of installed
equipment expressly or implicitly.
 This offer is sponsored by Minnesota Power and participating utilities.
 Minnesota Power and participating utilities, in partnership with ENERGY STAR, offer consumers and businesses energy efficient solutions that save money
and help the environment.
 If you have questions on this form or the Minnesota ENERGY STAR Program, call 800.677.8423 or visit us online at www.mnpower.com/energystar.

Confidentiality Statement:
I am providing the requested information solely to be eligible to participate in this program and request that the personal information supplied by me be
treated as confidential.

Sign or Initial here_____________________________________________________

STEP 4

1. When did you become aware of the ENERGY STAR symbol? 7. Is your home:
 before purchase  during purchase  newly constructed  existing (before 2000)
 after purchase  newly purchased  other
8. Your annual household income?
2. How did you hear about the ENERGY STAR symbol?  less than $20,000  $20-49,999  $50-$74,999
 newspaper ad  radio ad  website  $75-99,999  above $100,000
 utility bill insert  news article  in-store
 friend or relative  other _______________ 9. Your occupation?
________________________________________________________________
3. Why did you purchase an ENERGY STAR qualified appliance?
 features  better for environment 10. What type of water heater do you have?
 energy savings  money savings  gas  electric  oil
 Cash-Back Rebate  solar  LP
 certified by independent entity

4. When did you become aware of the Cash-Back Rebate? 11. Are you replacing an existing appliance?
 before purchase  during purchase  yes  no
 after purchase
12. Do you own any other ENERGY STAR qualified products? (check all that apply)
5. How did you hear about the Cash-Back Rebate?  light bulbs  torchieres  light fixtures  electronics
 newspaper ad  radio ad  website  refrigerator  dishwasher  room a/c  dehumidifier
 utility representative  news article  in-store
 friend or relative  other _______________

6. The number of people living in your home, per age category:

___ under 17 years ___ 18-65 yrs. ___ over 65

Copy of sales receipt must be sent with completed form.