Energy Efficient Appliance, Water Heater and Lighting

Energy Efficient Commercial* Lighting

Rebate Application

(*non-dwelling unit)

Complete and sign this form. (Please print clearly).

Utility Account Number: ______

Company Name: ______

Contact First Name: ______Last Name: ______

Installation Address: ______Suite: ______

City: ______State: ______Zip: ______

Phone: ( ) ______E-Mail (optional) ______

Mailing Address (if different): ______Apt: ______

City: ______State: ______Zip: ______

Contractor Information

Company Name: Apperson Energy Management Contact Name: Jim Apperson Energy Management

Company Address: P.O. BOX 366

City: Redwood Valley State: CA Zip: 95470

Contractor License Number: 431271 Business Phone: 707-485-5158

Rebate Amount Applying For: $ (From City of Ukiah’s Commercial Lighting Spreadsheet)

Note: Rebates will not exceed 60% of installed job cost. Project must be pre-approved by City of Ukiah Prior to work beginning to assure availability of funds.

Upon signing this agreement, customer acknowledges the following:

This rebate offer may be discontinued at any time by City of Ukiah, and is limited to availability of funds. City of Ukiah disclaims any warranty, whether expressed or implied, regarding the lighting equipment installed, or for any materials or labor associated with its installation, maintenance, repair, or any energy savings associated with its use. I understand the above and certify that I am a customer of City of Ukiah and the above mentioned products will be installed at the location indicated above.

Lighting project must be inspected and approved by City of Ukiah prior to payment of rebates. Call

1-888-883-9879 for availability of funds, and to schedule your inspection when your project is complete.

Customer Signature: ______Date

Please submit this completed form and a copy of your lighting project

proposal (from the City of Ukiah’s Commercial Lighting Spreadsheet) to:

City of Ukiah

Attn: Commercial Lighting Rebates

PO Box 421

Clackamas, OR 97015

Note: Your contractor can acquire a copy of the City of Ukiah’s

Lighting Spreadsheet by calling 1-888-883-9879

Tax Liability Information: You are urged to consult your tax advisor concerning the taxability of rebates. The City of Ukiah is not responsible for any taxes that may be imposed as a result of your receipt of this rebate. Rebates in excess of $600.00 may be reported on IRS Form 1099. A completed W-9 form must accompany this application to help determine if Form 1099 will be issued by the City of Ukiah.