City of Madison and Heartland Consumers Power District

APPLIANCE REBATE

The Power Forward residential

rebate program is provided by
Heartland Consumers Power
District in collaboration with the
City of Madison. Incentives are
provided to residential
customers for replacement or
new appliances with a new
ENERGY STAR model.

Residential customers of the

City of Madison are served
by Heartland and are eligible
for rebates.
Rebates are available only
on ENERGY STAR products
purchased as outlined in this
application and purchased
and applied for in the current
calendar year. Applications
must be submitted by
December 31, 2016.
Rebates are available on a
first-come, first-served basis
and are subject to eligibility
and availability of funds.
This program is subject
to change or termination
without notice.
Each account is eligible
to receive one rebate per
appliance type. Application
must be filled out completely
in order to be considered.
A copy of proof of purchase/
sales receipt along with
ENERGY STAR verification
must be included and will not
be returned. Verification of
disposal (replacement only) is
required for refrigerator and
freezer rebates.
Rebates will be issued by the
City of Madison. Please allow
up to 90 days for delivery of
rebates.

Proof of purchase and ENERGY STAR verification must be included with the application.
Applicant Information
Name: _____________________________________________________________________________
Date of Application: __________________________________________________________________
Address: ___________________________________________________________________________
City: __________________________________________ State: ____________ Zip: _______________
Daytime Phone Number: ______________________________________________________________
Email Address: ______________________________________________________________________
Rebate Information
Check appropriate box. (If applying for more than one appliance rebate, use separate form.)
Replacement

New
Refrigerator Rebate - $100 Replacement/$50.00 New

Verification of disposal of old appliance must be included.

Freezer Rebate - $100 Replacement/$50.00 New

Verification of disposal of old appliance must be included.

Clothes Washer Rebate - $50 Replacement/$25 New

Dishwasher Rebate - $50 Replacement/$25 New
Electric Clothes Dryer Rebate - $50 Replacement/$25.00 New
Programmable Thermostat - $20
Manufacturer: _____________________________________________________________________
Model: ________________________________ Serial Number: ______________________________
Store Name and Location: _ ___________________________________________________________
Purchase Date: ____________Age of appliance being replaced: ______________________________

Signature:_______________________________________Date:_______________________________
Heartland and the City of Madison do not endorse or warrant any equipment funded under this
program or guarantee that a specific level of energy or cost savings will result from products funded
by these rebates.
Please return completed application and all accompanying documentation to the City of Madison

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POWER FORWARD RESIDENTIAL ENERGY STAR REBATES

Verification of Disposal
In order to receive a rebate on a new ENERGY STAR refrigerator or freezer through the Power Forward program, you must provide proof that
the existing appliance has been taken out of service. For your convenience, we have provided a verification of disposal form that your retailer
or recycling center can complete for acceptable documentation. A recycling center receipt or official retailer documentation of recycling is
also acceptable.

Verification of Disposal
I hereby certify that ______________________has purchased a new ________________________to replace an existing appliance. The unit
(customer name) _

(appliance name)

has been taken out of service and disposed of properly.

Name of Retailer/Recycler: ______________________________________________________________________________________________

Authorized Signature: ____________________________________________________________________ Date: _________________________

Submit this form or other proof of disposal to the City of Madison along with your ENERGY STAR rebate application.
Please contact Karen @ (605) 256-7504 with questions about residential rebates.

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