Application Form for WashWise Clothes Washer Rebate Program

APPLICATIONS WITH MISSING OR INCOMPLETE INFORMATION WILL NOT BE PROCESSED.

Did you remember to:
□ Check that your clothes washer is a qualified product? (No used machines)
□ Read the Terms and Conditions?
□ Check that your electric OR water utility is listed on the back of this page as a participating utility?
□ Include completed application and copy of itemized receipt?
(Receipt MUST include retailer name, address & phone number, purchase date & price, product make and model)
□ Sign and date rebate application AND payment release authorization (if applicable)?
□ Make a copy of the completed application form and all required documentation to KEEP for your records?
□ Mail the completed application and itemized receipt to:
WashWise Clothes Washer Rebate Program
1400 SW 5th Avenue, Suite 700
Portland, OR 97201

For more information and a detailed explanation of the Terms and Conditions,
please visit www.washwiserebate.com or call 1-866-632-4636.

Customer Information
(All information below is REQUIRED for processing. Please print in block letters.)

Full Name: Daytime Phone:

Full Installation Address:

City: State: Zip:

Full Mailing Address (if different):

City: State: Zip:

Email Address (optional):

Name of electric provider: Name of water provider:

Water Heater Fuel is: □ Electric □ Natural Gas □ Propane

Clothes Dryer Fuel is: □ Electric □ Natural Gas □ Propane
Clothes Washer Rebate Information
Date Purchased: Date Installed:
Model Number (required): *Serial Number (required):

* Serial numbers are usually located on the inside of the clothes washer door or on the back of the machine.

Acceptance of Terms & Conditions

I hereby certify that all information is accurate including claims of customer and equipment information. I have read all terms
and conditions on the reverse side of this form and acknowledge that WashWise may verify all the information provided.
Customer Signature: Date:

This information can be made available on request to accommodate people with disabilities and those who need language assistance.
4170 12/2009
Payment Release Authorization
(Complete this section ONLY if payment is to be made to someone other than the participating utility customer.)

I am authorizing this payment of my rebate to the third party [‘Payee’] named below and I understand that I will not be
receiving the rebate check from WashWise. I also understand that my release of the payment to the third party does not
exempt me from the rebate requirements outlined in this application.
Check should be made payable to : (Please print “Payee” name) Telephone number:

Payee mailing address:

Authorized by: (Please print the Participating Utility Customer’s Name and sign) Date:

Terms & Conditions

Please refer to the following terms and conditions prior to signing acceptance on reverse side:
• This form must be received by the WashWise program within 90 days of the clothes washer purchase.
• You have not received a WashWise rebate for this home after January 1, 2003.
• The clothes washer rebated has been installed at the address indicated on other side.
• All information supplied on this form is true and correct.
• WashWise staff has permission to verify any of the information on this form, and inspect the clothes washer installation upon
request.
• The model number and serial number are required for payment.
• The WashWise rebate program and rebate levels may change without prior notice.
• All information must be complete and a copy of an itemized receipt enclosed to be considered for payment.
• Please allow for 6-8 weeks to process a complete rebate application before your check is mailed.
• You are a residential customer of at least one of the participating electric or water utility providers.
Participating utilities have made no implied or express warranties or representations with regard to these products, energy
savings or water savings from these installations. This offer ends December 31, 2010 or when funds are exhausted.

List of Participating Utilities:

Puget Sound Energy Snohomish County PUD
• Puget Sound Energy residential electric • Everett Regional Water System
customers only (Must be a customer of Snohomish County PUD)

• Puget Sound Energy gas-only customers Saving Water Partnership

do not qualify unless they are a member • Cedar River Water and Sewer District
of one of the participating water utilities
• City of Bothell
Seattle City Light • City of Duvall
City of Renton • City of Mercer Island
• Coal Creek Utility District
Tacoma Power
• Highline Water District
Tacoma Water • Northshore Utility District
Cascade Water Alliance • Olympic View Water and Sewer District
• City of Bellevue • Seattle Public Utilities
• City of Issaquah • Shoreline Water District
• City of Kirkland • Soos Creek Water and Sewer District*
• City of Redmond • Water District #20
• City of Tukwila • Water District #45
• Covington Water District • Water District #49
• Sammamish Plateau Water & Sewer District • Water District #90
• Skyway Water & Sewer District • Water District #119
• Water District #125
City of Bonney Lake
• Woodinville Water District
* Note: Must be a water customer,
sewer-only customers do not qualify.

Printed on recycled paper